Halting the Progression of Prediabetes

Innovations in Diabetes & Endocrinology | Winter 2023

According to the Centers for Disease Control and Prevention (CDC), one in three American adults has prediabetes. Without intervention, most will go on to develop Type 2 diabetes.

Revital Gorodeski Baskin, MD

Revital Gorodeski Baskin, MD, is determined to stop the cycle. As Director of the Obesity Program within the University Hospitals Diabetes and Metabolic Care Center, she and her team offer patients expert, evidence-based care to make necessary lifestyle changes and improve their health. “The take-home message we share is that there are multiple pathways to success,” she says. “It is important to present varying modalities to determine what works best.”

Prediabetes is defined as fasting plasma glucose between 100 and 125 mg/dL and is associated with overweight or obesity, higher waist circumference and insulin resistance. To prevent or slow progression to Type 2 diabetes, Dr. Gorodeski Baskin has her patients focus on diet, exercise and, in some cases, medication.

Dietary Interventions

The most well-studied dietary intervention shown to improve prediabetes and diabetes is the Mediterranean diet, Dr. Gorodeski Baskin explains. “It is based on the dietary intake of the 22 countries surrounding the Mediterranean Sea,” she says. “The diet has been associated with improvement in metabolic syndrome, specifically high blood pressure, elevated cholesterol, cardiovascular disease and diabetes.” Patients at the UH Diabetes and Metabolic Care Center are encouraged to consider the eating plan a lifestyle change rather than a restrictive diet.

Dr. Gorodeski Baskin also recommends the Dietary Approaches to Stop Hypertension (DASH) diet. It limits added sugars, sodium and saturated fats and has been shown to lower blood pressure and LDL cholesterol. She adds that patients can also find success with vegetarian, vegan and intermittent fasting plans, noting that calorie restriction is the predominant factor in improving glucose levels. “Type 2 diabetes is a consequence of insulin resistance that occurs over time,” she says. “When people lose as little as 5 to 10 percent of their body weight, insulin sensitivity can improve dramatically.”

Exercise Recommendations

Strength training and high-intensity interval training (HIIT) are the primary modes of exercise Dr. Gorodeski Baskin recommends to the patient she sees. “Strength training is too often underutilized in weight loss because the resulting increase in muscle mass speeds metabolism,” she says. HIIT is also associated with improved metabolic markers and can be incorporated into many Types of exercise. “During cardiovascular exercises, individuals can ramp up the speed, resistance or incline in short, repeated bursts to derive much greater benefit,” adds Dr. Gorodeski Baskin. “Studies show just 10 or 20 minutes of quality exercise can bring about measurable health improvements.”

Medication

While weight loss and behavioral modification are Dr. Gorodeski Baskin’s first steps, several medications have been shown to forestall the progression of prediabetes to diabetes. Sulfonylureas work by improving insulin release from beta cells in the pancreas. Metformin and other sodium-glucose cotransporter-2 (SGLT2) inhibitors have been well-studied in patients with impaired glucose tolerance, and thiazolidinediones (TZDs) act on metabolic pathways to increase insulin sensitivity.

However, much of the current conversation around diabetes drugs is focused on glucagon-like peptide 1 (GLP-1) receptor agonists, including the once-weekly injections Ozempic® (semaglutide), Trulicity® and Mounjaro™ (tirzepatide). GLP-1 agonists have been shown to decrease dangerous visceral adipose tissue within the abdominal cavity.

“Mounjaro is also a GIP [glucose-dependent insulinotropic polypeptide] agonist, so the medication works both peripherally to slow gastric emptying and centrally to decrease appetite and improve satiety,” says Dr. Gorodeski Baskin. “It is wonderful for improved glucose control and helps patients lose weight, which is essential for Type 2 diabetes.”

Ozempic is U.S. Food and Drug Administration (FDA)-approved for adults with Type 2 diabetes and known heart disease. Mounjaro received FDA approval as a glucose-lowering therapy for adults with Type 2 diabetes last spring. In October, it was granted “fast track” review for weight management without a co-diagnosis of diabetes. Dr. Gorodeski Baskin is hopeful that the drug may be available as a weight loss medication within the next six months. Though this class of medications is not yet approved for children or teens, a recent study of adolescents in the New England Journal of Medicine1 demonstrated “unbelievably positive weight loss results,” she says.

Despite promising findings, there are hurdles to making these medications widely available. Costs can exceed $1,200 per month, and some health insurers are clamping down on coverage. However, Dr. Gorodeski Baskin believes the future is bright. “Improving diabetes requires the tough task of behavior modification, but it is uplifting to know that medical science continues to offer patients tools that are showing amazing benefits,” she says, adding that studies are already under way for a triple agonist medication.

For more information, contact Dr. Gorodeski Baskin at Revital.GorodeskiBaskin@UHhospitals.org.

¹ Once-Weekly Semaglutide in Adolescents with Obesity. N Engl J Med 2022; 387:2245-2257 DOI: 10.1056/NEJMoa2208601

Contributing Expert:
Revital Gorodeski Baskin, MD
Director of Obesity
Assistant Professor
Case Western Reserve University School of Medicine