Pre-Diabetes, Should I Be Concerned About It?
Before we can review what Pre-Diabetes is, it’s important to understand what the Diabetes diagnosis is. As I often say, there is a lot of fear mongering in the health field. I believe it’s important for us to be aware of the risks associated with our lifestyle decisions; however, I also believe we do a disservice when we provide information and advice that is not always evidence based and only based in fear.
As someone who grew up with a parent with Type I Diabetes, I have always understood the risks and potential complications that can arise with such a diagnosis. My parents did an amazing job of raising my siblings and I with an understanding that Diabetes, especially Type I, is not a death sentence and my father could live a very full life through management tools. Let me be clear, I am not saying it’s a walk in the park. A diagnosis of Diabetes, regardless of type, can be incredibly scary and derail your life for a bit. What I am saying however, is that there are amazing tools nowadays to help manage a Diabetes diagnosis, and manage it in a safe and flexible way. Gone (hopefully) are the days of rigidity and strict rules when it comes to Diabetes care.
Before I dive into the diagnosis portion of this blog, I want to explain a bit about how the body functions without Diabetes. When a non-Diabetes body consumes food, specifically carbohydrates, the blood sugar naturally rises. This is a very normal response to the consumption of glucose, the molecule that carbohydrates break down into. Its building block per say. As the blood sugar rises the pancreas gets alerted to release insulin. Insulin is a hormone that is produced by beta cells in the pancreas. Insulin regulates blood sugar levels by getting glucose out of the blood stream and into the cells to use for energy. On the flip side, Glucagon is another hormone that is produced by the pancreas to increase blood sugar levels when they get too low. It does so by signaling to the liver to release some stored glucose into the blood stream. Both insulin and glucagon work in a “balanced”, give and take kind of relationship. They help maintain homeostasis of the blood sugar levels. And they do a darn good job of it! Diabetes conditions occur when this homeostasis is essentially interrupted.
Type I Diabetes
Type I Diabetes is an autoimmune condition in which the body’s immune system attacks and destroys the beta cells in the pancreas, thus stopping insulin production entirely. Because insulin is important for decreasing blood sugar levels and preventing increased stretches of high blood sugar, an individual cannot survive without supplemental insulin. This is why I am very passionate about access to care, because there are conditions in which individuals cannot live without a specific medication. Up until 1922 insulin was not used for the treatment of Diabetes and ultimately individuals died because of it. It wasn’t purposeful of course, the science just wasn’t there yet to know how to use supplemental insulin. Insulin prices though remain heavily overpriced and a large issue in the healthcare field; forcing providers to come up with different options medically for treatment that are not as effective but are cheaper for insurance companies. Type I Diabetes was previously referred to as Juvenile Diabetes because it most often occurs during the childhood years; however, that is an outdated term as autoimmune conditions can occur at any point. In fact, my father was diagnosed with Type I Diabetes when he was in his early 30s. Imagine my frustration when visiting with a OBGYN and explaining to them my father had Type I Diabetes, to be told only children can have that. Cue eye-roll and insert some statement about us needing to do better at educating clinicians.
Type II Diabetes
Type II Diabetes is a condition in which the body’s cells become resistant to insulin, meaning they, for whatever reason, will not allow the glucose into the cells. Or they just may be really slow at doing so, thus resulting in elevated blood sugar levels. What can also happen is that the pancreas suffers some sort of injury or is overworked in general and therefore stops producing adequate amounts of insulin. Type II Diabetes is mostly seen in adults although there have been more numbers seen in children lately. Many people will blame Type II Diabetes on sugar consumption, when in fact it has much more to do with genetics and hormones. We often see this condition alongside hormonal concerns such as PCOS because there is an issue with insulin resistance stemming from imbalanced hormones. I feel it’s important to also mention that Type II Diabetes has nothing to do with weight. There is this fatphobic narrative in the world that only individuals in large or fat bodies can have Type II Diabetes. This viewpoint is inherently wrong, dangerous, and not proven by fact. In my clinical internship days, I had a rotation with an outpatient diabetes educator who was also a dietitian. She saw at least 6 clients a day, sometimes more, five days a week. And the majority of her clients with Type II Diabetes were in small/straight sized bodies. I’ll leave it at that.
Gestational Diabetes
This is a form of Diabetes that only occurs during pregnancy. This is why the Glucose Tolerance Test is held – any individual who is pregnant or has been pregnant likely has a memory of the orange glucose drink you have to consume. Pregnancy is a very stressful time on the body and high blood sugar can arise because the body simply struggles to manage it. This is important to test because high blood sugar can have an impact on a baby’s development, size, and help determine if induction may be beneficial. My heart goes out to all individuals with Gestational Diabetes as it can be really scary to be given a diagnosis while trying to grow a human.
We need to be very careful at how we approach care in Gestational Diabetes. Unfortunately, weight stigma exists in the research which makes it hard to provide true, good psychoeducation on this condition. There is a lot of shame that can develop for an individual with Gestational Diabetes. The condition can be treated with diet alone, however the rigidity that is required can be very negative for the mental state of someone trying to grow a human. Most nutritional recommendations encourage disordered eating, carb avoidance, and continuous monitoring. It is of utmost importance for this condition to be managed, I do not disagree with that, but I also know that it is a balance that must be kept between not increasing stress levels, shame, or fear and distrust of the provider. To any provider reading this, please tread carefully with your clients that have Gestational Diabetes, and look into weight inclusive care if you haven’t already.
Other Types of Diabetes
There are other types of Diabetes that are not as common, but I have a sneaking suspicion over time with more research people may be given more diagnoses. They are:
Latent Autoimmune Diabetes in Adults (LADA) – Often times described as Diabetes 1.5 since it is similar to both Type I and Type II. Most individuals start off similar to Type II Diabetes, not requiring insulin, but gradually over time the condition increases in severity ending with requiring insulin
Maturity Onset Diabetes of the Young (MODY)
Neonatal Diabetes
Steroid-Induced Diabetes
Monogenic Diabetes Syndromes – includes Cystic Fibrosis and Pancreatitis
Wolfram Syndrome – a rare genetic disorder that causes Diabetes, optic atrophy, and deafness.
Symptoms of Diabetes
Excessive Thirst (A result of frequent urination)
Frequent Urination (The body has increased levels of sugar in the blood and can only decrease them by excreting it via urine)
Fatigue
Weight Loss (The body is getting no energy from glucose since it is not making it into the cells without insulin)
Blurred Vision (high blood sugar levels damage the small blood vessels in the retina causing them to leak fluid)
If you or someone you know is experiencing any of the above it is highly recommended to seek support from an endocrinologist as soon as possible.
In the efforts to avoid fear mongering, I want to express first that despite there being no cure for diabetes, there are many medications nowadays that help manage the condition(s) well. Back when my father was diagnosed in the 80s people believed they would not live long lives, not see their children grow up, die young essentially. Now, we have the scientific research and ability to give those with Diabetes diagnoses life well into their 80s and 90s. I say this all while also knowing that access to these lifesaving medications can be a large barrier still to this day.
If Diabetes conditions are left untreated, or an individual makes the choice to not treat their Diabetes as is their right, they will be at risk for health problems that include heart disease, vision loss, kidney disease, and amputations.
Pre-Diabetes
Okay – now that we’ve gotten through ALL of that. How does Pre-Diabetes get into the mix here? Pre-Diabetes, as its name implies, is the precurser to Diabetes. Diabetes conditions are diagnosed using the Hemoglobin A1C (HbA1C). The A1C is a blood test that measures the average blood sugar levels of the body over the past 3 months. It measures the percentage of red blood cells that have hemoglobin coated in sugar. Red blood cells live for about 3 months so it provides the blood sugar levels for that 3-month length of time.
A normal A1C level is under 5.7%. Levels 5.7-6.4% indicate Pre-Diabetes. And levels 6.5% of higher indicated Diabetes. Each A1C percentage reading has a blood sugar average number that lines up with it.
Factors that Affect A1C
Many factors can affect the accuracy of the A1C test and it’s important that these things are discussed with your healthcare provider.
Alcohol use disorder
Blood transfusions
Chronic kidney disease
Bleeding
Pregnancy
Liver Cirrhosis
Sickle Cell Anemia
Hemolytic Anemia
High Altitude – I’m looking at all you Coloradans out here!
Iron Supplementation
It may come as a shock to many but Pre-Diabetes is not actually a medical diagnosis. The name itself implies it is the step before Diabetes due to the level of the A1C. However, not everyone in the Pre-Diabetes range for their A1C ever goes on to develop Diabetes.
Diagnosis Of Pre-Diabetes
To fully understand Pre-Diabetes, you have to know these two terms/tests:
1. Impaired Fasting Glucose: levels of 100 to 125 mg/dL
2. Impaired Glucose Tolerance: Two-hour glucose levels of 140 to 199 mg per dL on the 75-g oral glucose tolerance test (remember back to reviewing Gestational Diabetes testing)
In 2001, the American Diabetes Association (ADA) Public Relations Department felt like these two terms were not encouraging medical providers and the public to take Diabetes seriously enough. They decided to take these two medical terms/tests and use the term Pre-Diabetes to describe them instead.
Even further, the ADA went on to make claims that having either an Impaired Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT) significantly increased one’s risk for the development of Diabetes. A large number of health organizations rejected this including the World Health Organization (WHO). However, in 2009 the Center for Disease Control (CDC) for reasons unbeknownst to many, dropped the lower limit of the A1C for diagnosis. Literally overnight people became diagnosed with Diabetes.
How to Treat as a Weight Inclusive Provider
There is unfortunately a lot of weight stigma wrapped up in the treatment of Diabetes, and that of Pre-Diabetes. It has been recommended that the best way to “treat” Pre-Diabetes, as a weight inclusive provider, is essentially to ignore it. And maybe ignore is the wrong term because our clients are coming to us to get information. I like to take the approach of educating my clients on their condition. I have found that often times their diagnosing provider has not given them any information on what this condition actually is! I share a lot of the information in this blog post actually with them and we discuss how it may pertain to their situation. Did we get an A1C draw that’s averaging your blood sugar levels during the holidays, or were you on vacation or traveling a lot thus increasing stress? Were you on a certain medication for half those months that could impact this A1C? I see clients come into my office incredibly terrified because their doctor has told them they are Pre-Diabetic off of ONE LAB DRAW RESULT. I usually encourage them we get a repeat A1C in 3 months and see if it’s come back to normal. Often times, it does.
After we get the initial psychoeducation stuff down, let’s talk about lifestyle. Let’s discuss movement in a very flexible and non-obsessive way. Let’s discuss adequate stress management and rest practices. Let’s make sure individuals are taking care of themselves, staying hydrated, eating adequately and enjoying life. And let’s make sure that we are not falling into the trap of continuous glucose monitors (when not necessary), frequent (almost obsessive) monitoring, and feeling the need to knowing numbers (i.e. blood sugar numbers) that we wouldn’t usually be privy to knowing all the time.
As always, it’s a dance we weight inclusive providers do when trying to review true medical conditions with our clients. Managing the inclusivity piece, while also trying to remain steadfast in the goals of our clients for feeling better and being “healthier”. None of us will ever be perfect at this dance. But the more we focus on our clients’ needs, their goals, their overall wellbeing, and calling out fatphobia and weight bias in the field when we see it, then I think we’re on the right track.
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Note to Self Nutrition LLC is an outpatient dietetics practice specializing in the treatment of eating disorders, women’s health and fertility including PCOS, endometriosis, and hormonal imbalances, diabetes and prediabetes, disordered eating, along with other chronic health conditions such as heart health, hypertension, and kidney disease. Owner and dietitian Lauren Hirschhorn-Tieu is passionate about empowering individuals to build trust with their relationship with food and their body. Lauren provides multiple services including nutritional counseling, recovery coaching, supervision and nutrition presentations. In person availability is offered in Denver. Virtual telehealth services are offered in Maryland, Virginia, Washington DC, Colorado, and Florida. We would be honored to join you on your journey to discovering food and body peace!
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