Prediabetes is Linked to Coronary Artery Calcification

 

According to the CDC, nearly 98 million adults in America have prediabetes. Additionally, the majority of people with prediabetes are unaware of their disease. And prediabetes can lead to type 2 diabetes. Prediabetes is a condition that deserves attention not only because it can lead to type 2 diabetes, but because the condition is associated with other diseases. For example, a recent study reveals that there is a link between prediabetes and coronary artery calcification.

The American Diabetes Association and the CDC define prediabetes as follows: 5.7% ≤ HbA1c ≤ 6.4%;  100 mg/dL ≤ FPG ≤ 125 mg/dL;  140 mg/dL  ≤ OGTT≤ 199 mg/dL. Prediabetes is known to be associated with cardiovascular disease, kidney problems and, of course, diabetes. And, as mentioned above, the link to coronary artery calcification has been uncovered.

Coronary artery calcification, or CAC, is a buildup of calcium in the two main arteries of the heart, commonly known as the coronary arteries. This buildup occurs after about five years of plaque (fat and cholesterol) formation in the arteries. CAC is a sign of coronary artery disease and can provide information to your healthcare practitioner to assist them in assessing your cardiovascular risk.

In the CAC study, three groups of participants were established using fasting blood glucose (FBG) and HbA1c. One group was defined by the following prediabetes characteristics: 100 mg/dL ≤ FBG ≤ 125 mg/dL and HbA1c < 5.7%). Another group was defined by the following: FBG < 100 mg/dl and 5.7% ≤ HbA1c ≤ 6.4%. And finally, one group was defined by the following:  100 mg/dL ≤ FBG ≤ 125 mg/dL and 5.7% ≤ HbA1c ≤ 6.4%. Consisting of 1541 participants, the study took place between 2011 to 2019. None of the participants had a history of cardiovascular disease.

The investigators concluded that "CAC risk and CAC progression were consistently highest in individuals meeting both [the] glucose and HbA1c criteria" for prediabetes, while individuals meeting either one of the prediabetes criteria "showed a significantly increased risk of CAC progression."

The study just adds more evidence to the greatly held position that prediabetes should be treated because of its link to more serious health conditions.

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Gut Microbiota, Eating Patterns and Prediabetes

Gut microbiota, which include bacteria, fungi and viruses, have been found to influence obesity and other metabolic diseases. For example, gut bacteria diversity appears to be important for weight management and metabolic health. One study demonstrated that the diversity can influence obesity, because individuals with the least gut bacteria diversity are more prone to be obese. Another study indicated that a low level of gut bacteria diversity can give rise to insulin resistance which can lead to type 2 diabetes. And a more recent study has shown that there is a relationship between gut microbiota abundance, eating patterns, and prediabetes.

The study was done in Sweden. The investigators looked at 1726 subjects ranging in age from 18 to 71 years old. The group was 55% women, and the mean BMI of the group was 25.5. No one in the group had diabetes. Two food patterns were used to determine the relationship between diet, prediabetes prevalence, and gut microbiota composition. One of the food patterns was called the “Health-conscious” pattern, and the other food pattern was called the “Sugar and High-Fat Dairy” pattern. Examining fecal microbiota from the gut was part of the analysis.

The investigators found that for subjects that followed the "Health-conscious" eating pattern, there was a lower level of prediabetes. And there was a higher level of prediabetes for the women who followed the “Sugar and High-Fat Dairy” eating pattern.

For those subjects that followed the “Health-conscious” eating pattern, there was an abundance of gut microbiota that differed in amount from the microbiota found in the subjects that followed the “Sugar and High-Fat Dairy” eating pattern. This was especially true for the type of gut microbiota called Roseburia. For those subjects who followed the “Sugar and High-Fat Dairy” pattern, there was no significant amount of this type of microbiota in the fecal material.

Therefore, the abundance of microbiota -- in this case Roseburia -- is important for good metabolic health, including possibly lowering the risk of prediabetes. So, gut bacteria amount and diversity may be essential for good health.

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Some Fruits and Vegetables May Better Treat Hypertension than Others

Hypertension is very prevalent in the U.S. and worldwide. The condition can increase the risk for stroke and heart disease. Many American adults have hypertension, and it is not under control for a large number of these adults. Hypertension usually has no symptoms, so the only way to determine if a person has hypertension is by measuring their blood pressure. A number of diets that emphasize fruits and vegetables have been found to lower blood pressure. However, not a lot of attention has been paid to determining which fruits and vegetables, and which combinations of fruits and vegetables are most beneficial. And a recent study set out to do just that.

The study was a meta-analysis where the databases PubMed and Embase were searched for relevant studies, by the researchers, using search terms that contained  the keywords “fruits,” “vegetables,” and "hypertension." The researchers ended the search on May 15th 2022. The researchers extracted a total of 17566 articles. And after an exhaustive selection process, the researchers concluded that 18 studies met the inclusion criteria. Some of the elements of the criteria were relevance, case-control, the availability of full text rather than just the abstract, and how the title described the study.

Hypertension was the outcome of most of the studies. And most of the studies used the following hypertension guidelines: SBP ≥140 mm Hg and/or DBP ≥ 90 mm Hg, or SBP ≥ 135 mm Hg and/or DBP ≥85 mm Hg.” Some studies used a medical diagnosis of hypertension or a prescription for hypertension medication as a guideline. If a subject’s SBP was  ≥130 mm Hg, and/or the DBP ≥85 mm Hg, that subject was deemed to have elevated blood pressure

The researchers concluded that the results of this meta-analysis support dietary advice to increase the consumption of fruit and vegetables as part of strategies to prevent hypertension. The results show that a high intake of fruits and vegetables combined and total fruits, but not total vegetables, was associated with a lower risk of hypertension.

A daily intake of up to 800 grams of a combination of fruits and vegetables was associated linearly with hypertension prevention. And for some specific fruits and vegetables, such as cantaloupe, potatoes, and Brussels sprouts, there was an associated increased risk of hypertension, while apples, pears, avocado, blueberries, raisins or grapes, broccoli, carrots, lettuce, and onions appeared to lower the risk. Of course, more studies are needed to ferret out specific fruits and vegetables that are the most helpful in the treatment of hypertension.

Healthcare providers might want to investigate this study and other studies on diet to help the patient decide on the best diet to follow for hypertension.

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Plant-Based Diet Quality is Important for Cardiovascular Health

A leading cause of death and disability in the world is cardiovascular disease (CVD). Food has a vital influence on the development and management of cardiovascular disease. And reducing the consumption of animal products has been shown to have a positive impact on cardiovascular health. However, simply reducing meat intake is not enough. A focus on overall diet quality, including the consumption of a variety of plant-based foods, is essential for reducing cardiovascular risk.

Studies have consistently shown that a diet high in animal products, particularly red and processed meat, is associated with an increased risk of CVD. Animal products are high in saturated fats and cholesterol, which have been linked to an increased risk of CVD.

A diet filled with plant-based foods, like fruits, vegetables, whole grains, legumes, and nuts, has been shown to have a protective effect on cardiovascular health. These foods are high in fiber, antioxidants, and unsaturated fats, and have been linked to improved blood pressure and lipid profiles which can reduce the risk of CVD.

Indeed, individuals should select plant-based foods that are close to natural. The foods should be whole foods. These are foods that have received very little processing or refining. Whole foods typically contain no additives or artificial ingredients. Although individuals can select from animal products infrequently in moderation, individuals should abstain from eating fried foods such as fried poultry and fried fish. Also, when animal products such as low-fat dairy and eggs are consumed, these products should be eaten infrequently and in moderation.

Healthcare providers should discuss the importance of diet quality with their patients when discussion cardiovascular health. This is especially true for patients considering a plant-based diet. Patients should be warned not to assume that all plant-based diets will improve cardiovascular health, just because there is an absence of meat. The patients should be warned to avoid non-meat foods that have been processed or contain additives or artificial ingredients.

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Using Questionnaires to Predict Prediabetes and Diabetes Risk

Since prediabetes often leads to type 2 diabetes, a screening test, in the form of a questionnaire, is often used to identify individuals who are at risk for prediabetes and diabetes. Such a questionnaire, endorsed by the CDC and the ADA (American Diabetes Association), is used in the CDC National Diabetes Prevention Program. The questionnaire consists of five questions, some of which are related to cardiovascular health (CVH). And a recent study, examining the use of a questionnaire similar to the CDC/ADA questionnaire, has shown that there is a positive correlation between a high score on a CVH-related questionnaire and the development of prediabetes or diabetes.

An individual’s risk of prediabetes or diabetes increases with age, so a question requesting the individual’s age is on the CDC/ADA prediabetes-diabetes-risk questionnaire. Men have a higher risk of prediabetes and diabetes than women, so a gender-related question is on the questionnaire.

The risk of prediabetes and diabetes increases for women who experienced gestational diabetes, so a gestational-diabetes question is on the questionnaire. Questions are also asked about immediate family members who have had diabetes, since an immediate-family-history of diabetes can raise a person’s risks of diabetes and prediabetes.

Questions about weight and physical activity are also part of the questionnaire, since excess body fat and a lack of adequate physical activity can raise the risk of prediabetes and diabetes. A question concerning a diagnosis of high blood pressure is also on the questionnaire, since people with hypertension are at a high risk of diabetes.

The CDC/ADA questionnaire is a good predictor of prediabetes and diabetes risk. It is derived from a questionnaire the ADA published in 1995. And a recently developed questionnaire, using slightly different CVH metrics, also gives good indications of prediabetes and diabetes risk.

The more recent questionnaire is based on a CVH-related study investigating the use of a questionnaire to identify individuals with a high risk of acquiring prediabetes or diabetes. The study consisted of 403,857 participants who were 18-71 years of age. The researchers looked at fasting plasma glucose (FPG) data over a period of five consecutive years. And the researchers concluded that a group of CVH markers can be used to predict prediabetes and diabetes. Researchers, using the questionnaire, asks questions to determine if a person smokes, engages in physical activity, is overweight or obese, has untreated total cholesterol, high blood pressure or eats breakfast infrequently.

The researchers concluded that “The ideal CVH metrics were as follows: BMI of <25 kg/m2; non-smoking; 30 min of physical activity ≥twice weekly or ≥1 h of walking per day; ... skipping breakfast <3 times per week; systolic untreated blood pressure/diastolic blood pressure of <120/80 mmHg; and total cholesterol of <200 mg/dL”

Furthermore, the probability of acquiring prediabetes or diabetes increased as the number of non-ideal CVH metrics increased over a period of one year. And the association between a non-ideal BMI and the likelihood of prediabetes or diabetes was the strongest among the metrics.

Hence, healthcare providers should consider the use of questionnaires to help identify clients or patients who are at a high risk of prediabetes and diabetes.

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Healthcare Cost for Type 2 diabetes

The National Diabetes Prevention Program (National DPP) services can prevent or delay type 2 diabetes for individuals with prediabetes. The National DPP services include help with healthy diet, physical activity, and lifestyle modification. In delaying or preventing type 2 diabetes, the National DPP services can reduce healthcare costs.

Reducing healthcare costs is a significant concern with respect to diabetes. And since older people incur more healthcare costs, in general, one recent study looked at the cost of providing healthcare services to people with type 2 diabetes who were over 65. The CMS version of the National DPP, called the Medicare Diabetes Prevention Program, or MDPP, addresses diabetes prevention for Medicare beneficiaries, the majority of which are over 65 years of age.

In research conducted in Finland, investigators looked at "electronic patient records" to find people over 65 who had been told they had diabetes. After a selection process, 187 people with diabetes and 176 people without diabetes were chosen for the study. Information on how often primary care was used by the chosen participants was taken from electronic patient records for a one-year period.

It was found that, after a year, individuals with diabetes had more doctor's appointments, nurse's appointments, lab work done, and inpatient care at the community hospital than patients without a diagnosis of type 2 diabetes.

The older persons with type 2 diabetes who participated in these healthcare activities paid more for healthcare. In fact, the CDC reports that the average person with diabetes spends $16,750 a year on medical expenses. That is roughly 2.3 times what someone without diabetes would spend on medical care.

The National DPP and the MDPP (to some extent) are public-private arrangements that offer type 2 diabetes prevention services in healthcare and community settings. The National DPP and MDPP have been shown to decrease healthcare cost by delaying or preventing type 2 diabetes. To adequately address diabetes and type 2 diabetes prevention, healthcare providers should either offer treatment services or refer patients to community or healthcare organizations offering the services. 

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Handgrip Strength as a Predictor for Prediabetes

The commonly accepted definition of prediabetes, in general, is as follows: prediabetes is when an individual has abnormally high blood glucose, but the blood glucose is not high enough to be called diabetes. Prediabetes may affect the body in many ways. For example, according to a study done in India, prediabetes is associated with unwanted changes in handgrip strength. And a change in handgrip strength may come before the prediabetes. Indeed, one study, looking at subjects in Japan, indicates that handgrip strength could be an independent predictor of prediabetes.

In the India study, 200 subjects were examined. One hundred of the subjects had prediabetes and 100 had normal blood glucose. The researchers measured the handgrip strength of all subjects.

After crunching the data, the researchers found that the handgrip strength was approximately 12% less for the subjects with prediabetes compared to the subjects who had normal blood glucose.  So, handgrip strength decreased with prediabetes.

In the Japanese study, mentioned above, decreasing handgrip strength was shown to be a possible predictor of prediabetes. In the study, the researchers investigated 1075 subjects who had no prediabetes or diabetes. The researchers measured the handgrip strength of the subjects to obtain baseline measurements.  And the researchers used the handgrip strength measurements to calculate the relative handgrip strength. The relative handgrip strength is defined as "absolute handgrip strength (kg) divided by BMI (reported as kg/BMI)."

After two years of follow-up, the researchers concluded "that lower baseline relative handgrip strength predicted a higher risk of prediabetes incidence among the participants." The researchers stated that "relative handgrip strength predicted a lower and significant risk of prediabetes incidence among individuals with normal weight" as defined by a BMI between 18.4 and 25.

Therefore, handgrip strength measurements could be taken in healthcare settings. Those individuals who have low handgrip strength measurements could be examined for other indicators of prediabetes. And for those with prediabetes or a high risk for diabetes, appropriate interventions could be made.  

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