The Road to
Selda Tekiner
Family Medicine Department
ınternational Diabetes Federation. IDF Diabetes, 7 ed. Brussels, Belgium: International Diabetes Federation, 2015. http://www.diabetesatlas.org
What is Diabetes Mellitus
• “Diabetes” is a disorder that affects the way your body uses food for energy
• Normally the sugar in foods that you eat is digested and broken down to a simple sugar known as “glucose”.
• Glucose circulates in your blood where it waits to enter cells to be used as fuel.
What is Diabetes Mellitus
• Glucose provides the energy for the body that needs for daily activities.
• The blood vessels and blood are the highways that transport sugar from where it is either taken in (the stomach) or manufactured (in the liver) to the cells where it is used (muscles) or where it is stored (fat).
• Sugar cannot go into the cells by itself. The pancreas releases insulin into the
blood, which serves as the helper, or the "key," that lets sugar into the cells for use as energy.
• When sugar leaves the bloodstream and enters the cells, the blood sugar level is lowered. Without insulin, or the "key," sugar cannot get into the body's cells for use as energy. This causes sugar to rise.
• Too much sugar in the blood is called hyperglycemia (high blood sugar).
Insulin
• “Insuline” a hormone, produced by the
pancreas, helps move the glucose into cells
• A healthy pancreas adjusts the amount of insulin based on the level of glucose
• If you have diabetes, this process breaks
down, and blood sugar levels become too high
Insulin
• Insulin is a hormone made by the pancreas that
helps glucose in your blood enter cells in your muscle, fat, and liver, where it’s used for energy.
• Glucose comes from the food you eat. The liver also makes glucose in times of need, such as when you’re fasting. When blood glucose, also called blood sugar, levels rise after you
eat, your pancreas releases insulin into the blood. Insulin then lowers blood glucose to keep it in the normal range.
• Insulin resistance is when cells in your muscles, fat, and liver don’t respond well to insulin (start resisting or ignoring the signal that the hormone insulin is trying to send out) and can’t easily take up glucose from your blood.
• As a result, your pancreas makes more insulin to help glucose enter your cells. As long as your pancreas can make enough insulin to overcome your cells’ weak response to insulin, your blood glucose levels will stay in the healthy range.
What is Insulin Resistance?
How Insulin Resistance Develops
• While genetics, aging and ethnicity play roles in developing insulin sensitivity, the driving forces behind insulin resistance are
– excess body weight, too much belly fat, a lack of exercise, smoking, and even skimping on sleep
What is prediabetes?
• Prediabetes means your blood glucose levels are higher than normal but not high enough to be diagnosed as diabetes.
• Prediabetes usually occurs in people who already have some insulin resistance or whose beta cells in the pancreas aren’t making enough
insulin to keep blood glucose in the normal range. Without enough insulin, extra glucose stays in your bloodstream rather than entering your cells.
• Over time, you could develop Type 2 diabetes.
How common is prediabetes?
• More than 84 million people ages 18 and older have prediabetes in the United States.
• That’s about 1 out of every 3 adults.
• More alarming, if not treated, will advance to diabetes within five years.
Who is more likely to develop insulin resistance or prediabetes?
• People who have genetic or lifestyle risk factors are more likely to develop insulin resistance or prediabetes.
RISK FACTORS:
– age 45 or older
– overweight or obesity
– a parent, brother, or sister with diabetes
– African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, Native Hawaiian, or Pacific Islander American ethnicity
– physical inactivity
– health conditions such as high blood pressure and abnormal cholesterol levels – a history of gestational diabetes
– a history of heart disease or stroke – Polycystic ovary syndrome (PCOS)
• People who have metabolic syndrome—a
combination of high blood pressure, abnormal cholesterol levels, and large waist size—are
more likely to have prediabetes.
other things that may contribute to insulin resistance
• certain medicines, such as glucocorticoids, some antipsychotics, and some medicines (HIV..)
• hormonal disorders
• sleep problems, especially sleep apnea
RISK FACTORS
UNCHANGABLE
• family history,
• age,
• ethnicity,
CHANGABLE/ lifestyle risk factors
• eating
• physical activity
• weight
Excess weight
• Experts believe obesity, especially too much fat in the abdomen and
around the organs, called visceral fat, is a main cause of insulin resistance.
• A waist measurement of 40 inches (101cm)(1 inch=2.54cm) or more for men and 35 inches (88.9cm) or more for women is linked to insulin
resistance.
• This is true even if your body mass index (BMI)* falls within the normal range.
• However, research has shown that Asian Americans may have an increased risk for insulin resistance even without a high BMI.
– * Body Mass Index (BMI) is a person's weight in kilograms divided by the square of height in meters.
• Healthy weight : Your BMI is 18.5 to 24.9
• Overweight: Your BMI is 25 to 29.9
• Obese: Your BMI is 30 or higher
• It is used to think that fat tissue was only for energy storage.
However, studies have shown that belly fat makes hormones and other substances that can contribute to chronic, or long- lasting, inflammation in the body.
• Inflammation may play a role in insulin resistance, type 2 diabetes, and cardiovascular disease
• Excess weight may lead to insulin resistance, which in turn may play a part in the development of fatty liver disease.
Physical inactivity
• Not getting enough physical activity is linked to insulin resistance and prediabetes.
• Regular physical activity causes changes in your body that make it better able to keep your blood glucose levels in balance.
What are the symptoms of insulin resistance and prediabetes?
• Insulin resistance and prediabetes usually have no symptoms.
Some people with prediabetes may have darkened skin in the armpit or on the back and sides of the neck, a condition called acanthosis nigricans. Many small skin growths called skin tags often appear in these same areas.
• Even though blood glucose levels are not high enough to cause symptoms for most people, a few research studies have shown that some people with prediabetes may already have early
changes in their eyes that can lead to retinopathy.
– This problem more often occurs in people with diabetes.
How do we diagnose insulin resistance and prediabetes?
• We use the blood test to find out if someone has prediabetes, but they don’t usually test for insulin resistance. The most accurate test for insulin resistance is complicated and used
mostly for research.
• The fasting plasma glucose (FPG) test or the HbA1c test are used to diagnose prediabetes.
• Less often, we use the oral glucose tolerance test (OGTT), which is more expensive and not as easy to give.
• The Hb A1c test reflects the average blood glucose over the past 3 months.
• The FPG and OGTT show your blood glucose level at the time of the test.
• The A1C test is not as sensitive as the other tests. In some people, it may miss prediabetes that the OGTT could catch.
The OGTT can identify how your body handles glucose after a meal—often before your fasting blood glucose level becomes abnormal.
– Often doctors use the OGTT to check for gestational diabetes, a type of diabetes that develops during pregnancy.
• People with prediabetes have up to a 50
percent chance of developing diabetes over the next 5 to 10 years.
• You can take steps to manage your
prediabetes and prevent Type 2 diabetes.
The following test results show Prediabetes
• Hb A1c: 5.7 to 6.4 percent
• FPG : 100 - 125 mg/dL (milligrams per deciliter)
• OGTT : 140 to 199 mg/dL
• You should be tested for prediabetes if you are
overweight or have obesity and have one or more other risk factors for diabetes, or if your parents, siblings, or children have type 2 diabetes.
• Even if you don’t have risk factors, you should start getting tested once you reach age 45.
• If the results are normal but you have other risk
factors for diabetes, you should be retested at least every 3 years.
The tests:
• Fasting plasma glucose test (FPG): You don’t eat anything for eight hours leading up to an FPG test. That's why this test is often done in the
morning.
If blood glucose level is between 100 - 125mg/dL, this means prediabetes.
“Impaired fasting glucose” or IFG, which is another term for prediabetes.
When FPG is above 126mg/dl this means that “diabetes”.
Oral Glucose Tolerance Test (OGTT)
• It is the test used to diagnose prediabetes.
• The patient doesn’t eat anything for eight hours before the test
• First fasting blood glucose level is tested; then patient drinks 75g of a very sugary mixture.
• Two hours later, blood glucose level is measured
• If the blood glucose level is between 140 and 199mg/dL two hours after drinking the sugary mixture, you have pre-diabetes = “impaired glucose tolerance” or IGT, which is another term for pre-diabetes
If blood glucose level is above 200mg/dL with the oral glucose tolerance test, it means diabetes.
How can I prevent or reverse insulin resistance and prediabetes?
• Physical activity and losing weight if you need to may help your body respond better to
insulin.
• Taking small steps, such as eating healthier foods and moving more to lose weight, can help reverse insulin resistance and prevent or delay type 2 diabetes in people with
prediabetes.
Evaluation of Food Choices
A registered dietitian (RD) or certified diabetes educator (CDE) can help you create a meal plan respects your preferred foods and also reflects good-for-your-blood- glucose-level foods.
The goal of the healthy food plan is to assure that you are controlling your blood glucose level by keeping it in a healthy, normal range. Your meal plan should be adjusted to be comfortable and satisfying to you, taking into account your overall health, physical activity, and what you like to eat. There are no diets out there that will work nearly as well as one that has been worked out with your likes and
dislikes, cultural preferences,
• making lifestyle changes that may prevent or reverse insulin resistance and prediabetes.
Exercise
• When we exercise, our body uses more glucose, so exercising can lower blood glucose level.
• Also when we exercise, our body doesn’t need as much insulin to transport the glucose; our body becomes less insulin resistant.
• Since the body doesn’t use insulin well when the person has prediabetes, lower insulin resistance is better.
• And of course, there are all the traditional benefits of exercise: it can help you lose weight, keep your heart healthy, make you sleep better, and even improve your mood.
• The National Institutes of Health-funded research study, the Diabetes Prevention Program (DPP),
showed that for people at high risk of developing diabetes, losing 5 to 7 percent of their starting
weight helped reduce their chance of developing the disease.
• That’s 10 to 14 pounds (4,5-6,5kg) (1 pound=0,45kg) for someone who weighs 200 pounds (90kg). People in the study lost weight by changing their diet and being more physically active.
• The DPP also showed that taking metformin, a medicine used to treat diabetes, could delay diabetes.
• Metformin works best for women with a history of gestational diabetes, younger adults, and people with obesity.
Two main types of diabetes
Type 1 :
• Type 1 diabetes occurs because the insulin-producing cells of the pancreas (beta cells) are damaged. The pancreas makes little or no insulin, so sugar cannot get into the body's cells for use as energy.
• People with type 1 diabetes must use insulin injections to control their blood glucose.
• Type 1 is the most common form of diabetes in people who are under age 30.
• 10% of people with diabetes are diagnosed with type 1.
Type 2:
• Adult onset diabetes; the pancreas makes insulin, but it either doesn't produce enough, or the insulin does not work properly.
• 90% of people with diabetes, have type 2.
• Mostly in people who are over 40 years old. (but can occur even in childhood if there are risk factors present).
• Type 2 diabetes may sometimes be controlled with a combination of diet, weight management and exercise.
• However, treatment also may include oral glucose-lowering medications (taken by mouth) or insulin injections (shots).
• Type 2 diabetes has several causes: genetics and lifestyle are the most important ones. A combination of these factors can cause insulin
resistance, when your body doesn’t use insulin as well as it should. Insulin resistance is the most common cause of type 2 diabetes.
• Genetics Play a Role in Type 2 Diabetes
• Type 2 diabetes can be hereditary. That doesn’t mean that if your mother or father has (or had) type 2 diabetes, you’re guaranteed to develop it;
instead, it means that you have a greater chance of developing type 2.
Lifestyle Is Very Important !!!
• Genes do play a role in type 2 diabetes, but lifestyle choices are also
important. You can, for example, have a genetic mutation that may make you susceptible to type 2, but if you take good care of your body, you may not develop diabetes.
• Say that two people have the same genetic mutation. One of them eats well, watches their cholesterol, and stays physically fit, and the other is overweight (BMI greater than 25) and inactive. The person who is
overweight and inactive is much more likely to develop type 2 diabetes because certain lifestyle choices greatly influence how well your body uses insulin.
Differences between Type 1 and Type 2
• The most important difference is the role of insulin.
– Insulin is a hormone made by the pancreas that allows your body to use sugar (glucose) from carbohydrates in the food that you eat for energy or to store for future use. Insulin helps keeps your blood sugar level from getting too high (hyperglycemia)or too low (hypoglycemia).
• People with type 1 diabetes are unable to produce any insulin at all.
People with type 2 diabetes still produce insulin, however, the cells in the muscles, liver and fat tissue are inefficient at absorbing the insulin and cannot regulate glucose well. As a result, the body tries to compensate by having the pancreas pump out more insulin. But the pancreas slowly loses the ability to produce enough insulin, and as a result, the cells don’t get the energy they need to function properly.
• So, Type 2 diabetes is a progressive condition, meaning that the longer someone has it, the more “help” they will need to manage blood glucose levels.
– This may require more medications and eventually, injected insulin could be needed.
• People with T2D produce insulin, but their bodies don’t use it correctly;
this is referred to as being insulin resistant.
• People with type 2 diabetes may also be unable to produce enough insulin to handle the glucose in their body. In these instances, insulin is needed to allow the glucose to travel from the bloodstream into our cells, where it’s used to create energy.
• Type 2 diabetes is usually associated with being overweight (BMI greater than 25), and is harder to control when food choices are not adjusted, and if the person get no physical activity.
• And while it’s true that too much body fat and physical
inactivity (being sedentary) does increase the likelihood of developing type 2, even people who are fit and trim can develop this type of diabetes
Symptoms Develop Gradually with Type 2 Diabetes
• The symptoms of type 2 diabetes develop gradually
• It’s possible to miss them or to not connect them as related symptoms.
• Some people are actually surprised when they are diagnosed with Type 2 diabetes, because they’ve gone to the doctor for something else (eg, fatigue or increased urination).
• because, if you have the insulin resistant form of type 2, it takes time for the effects of insulin resistance to show up.
• Your body doesn’t become insulin resistant (unable to use insulin properly) overnight
• If you’re not insulin resistant—and instead your body doesn’t produce enough insulin to
process glucose well—the symptoms also develop gradually. Your body will be able to
“make do” with lower insulin levels for awhile, but eventually, you will start to notice the
following symptoms.
• Here are some of the common symptoms of type 2 diabetes:
• Fatigue: Your body isn’t getting the energy it needs from the food you’re eating, so you may feel very tired.
• Extreme thirst: No matter how much you drink, it feels like you’re still dehydrated. Your tissues (such as your muscles) are, in fact, dehydrated when there’s too much glucose
(sugar) in your blood. Your body pulls fluid from the tissues to try to dilute the blood and counteract the high glucose, so
your tissues will be dehydrated and send the message that you need to drink more. This is also associated with increased urination.
• Frequent urination: This is related to drinking so much more in an attempt to satisfy your thirst. Since you’re drinking more, you’ll have to urinate
more. Additionally, the body will try to get rid of the excess glucose through urination.
• Extreme hunger: Even after you eat, you may still feel very hungry. That’s because your muscles aren’t getting the energy they need from the food;
your body’s insulin resistance keeps glucose from entering the muscle and providing energy. Therefore, the muscles and other tissues send a
“hunger” message, trying to get more energy into the body
• Weight loss: You may be eating more but still losing weight. Since your body isn’t getting energy from food, it turns to muscles and fat and starts to break them down in order to create energy. That will cause you to lose weight.
• Infections: The effects of type 2 diabetes make it harder for your body to fight off an infection, so you may experience frequent infections. Women may have frequent vaginal (yeast) and/or bladder infections. That’s
because bacteria can flourish when there are high levels of glucose in the blood.
• Slow wound healing: Similar to the body’s inability to fight off infections, it might take longer for wounds (even small cuts) to heal. The high blood glucose level affects how well the white blood cells (which are in charge of healing wounds) work.
• Blurry vision: In an attempt to get more fluid into the blood to counteract the high blood glucose level, your body may pull fluid from the eyes. You may have trouble focusing then, leading to blurry vision
Lifestyle Is Very Important
• Genes do play a role in Type 2 diabetes, but lifestyle choices are also important.
– You can, for example, have a genetic mutation that may make you susceptible to type 2, but if you take good care of your body, you may not develop diabetes.
• Say that two people have the same genetic mutation. One of them eats well, watches their cholesterol, and stays physically fit, and the other is overweight (BMI greater than 25) and inactive. The person who is
overweight and inactive is much more likely to develop type 2 diabetes because certain lifestyle choices greatly influence how well your body uses insulin.
Lifestyle choices that affect the
development of type 2 diabetes include
• Lack of exercise: Physical activity has many benefits—one of them being that it can help you avoid type 2 diabetes, if you’re susceptible.
• Unhealthy meal planning choices: A meal plan filled with high-fat foods and lacking in fiber (which you can get from grains, vegetables, and fruits) increases the likelihood of type 2.
• Overweight/Obesity: Lack of exercise and unhealthy meal planning
choices can lead to obesity, or make it worse. Being overweight makes it more likely that you’ll become insulin resistant and can also lead to many other health conditions.
• The American Diabetes Association (ADA) recommends at least 150
minutes of moderate activity a week—that’s 30 minutes five days a week.
– You can get that through activities such as walking, bike riding, or swimming.
• Lose weight: If you’re overweight, you should get started on a weight loss program as soon as you’re diagnosed with prediabetes. Losing just 5 to 10% of your weight can significantly reduce your risk of developing type 2 diabetes. The combination of eating well and exercising more is a great way to lose weight—and then maintain your new, healthy weight.
• Metformin: For people who are at very high risk of developing type 2 diabetes after being diagnosed with prediabetes, we (the doctors) may recommend medication. ADA says that metformin should be the only medication used to prevent T2D. It keeps the liver from making more
glucose when you don’t need it, thereby keeping your blood glucose level in a better range
Type 2 diabetes risk factors
• mostly related to lifestyle choices !!!
• Type 2 diabetes develops when glucose—
which our bodies need for energy—stays in the blood and can’t get into the cells.
• This occurs when the pancreas either doesn’t make enough insulin or the body doesn’t use the insulin as it should, leading to insulin
resistance.
About Insulin Resistance
• Insulin resistance means that;
– body cannot use the insulin which it makes.
– Our body may produce sufficient amounts of insulin to transport glucose to the cells, but the body resists the insulin.
– As a result, glucose builds up in the blood and
causes symptoms associated with type 2 diabetes.
Type 2:
• Adult onset diabetes; the pancreas makes insulin, but it either doesn't produce enough, or the insulin does not work properly.
• 90% of people with diabetes, have type 2.
• Mostly in people who are over 40 years old. (but can occur even in childhood if there are risk factors present).
• Type 2 diabetes may sometimes be controlled with a combination of diet, weight management and exercise.
• However, treatment also may include oral glucose-lowering medications (taken by mouth) or insulin injections (shots).
RISK FACTORS?
• Family history of diabetes
– African-American, Hispanic, Native American, or Asian-American race, Pacific Islander or ethnic background
• Overweight
• Physical stress (such as surgery or illness)
• Use of certain medications, including steroids
• Injury to the pancreas (such as infection, tumor, surgery or accident)
• Autoimmune disease
• High blood pressure
• Abnormal blood cholesterol or triglyceride levels
• Age (risk increases with age)
• Smoking
• History of gestational diabetes
• sugar itself does not cause diabetes. Eating a lot of sugar can lead to tooth decay, but it does not cause diabetes.
The symptoms
• Increased thirst
• Increased hunger (especially after eating)
• Dry mouth
• Frequent urination
• Unexplained weight loss (even though you are eating and feel hungry)
• Weak, tired feeling
• Blurred vision
• Numbness or tingling in the hands or feet
• Slow-healing sores or cuts
• Dry and itchy skin
• Frequent yeast infections or urinary infections
How to prevent prediabetes from becoming type 2 diabetes
• Prediabetes is a “pre-diagnosis” of diabetes—you can think of it as a warning sign. This condition arises
when your blood glucose level (blood sugar level) is higher than normal but it’s not high enough to be considered diabetes.
• Why might this matter? Prediabetes is an indication that you could develop type 2 diabetes (T2D) if you don’t make some immediate and lasting lifestyle changes.
• It is very possible to prevent prediabetes from developing into Type 2 diabetes.
• Eating healthy whole food, addressing overweight and staying at a healthy weight, and committing to some physical activity
—which can be a walk or two daily—is enough to help get your blood glucose level back into the normal range.
• That's the key to assuring you avoid not only the onset of diabetes but all the related complications including heart disease, vision, loss, nerve damage, and kidney failure.
Know the Common Symptoms that Indicate a Higher Risk of Diabetes
• Diabetes develops very gradually,
• when blood glucose level is higher than it should be, the person may not have any symptoms at all
– however, he/she may notice that:
• hungrier than normal
• losing weight, despite eating more
• thirstier than normal
• have to go to the bathroom more frequently
• more tired than usual
Recognizing Prediabetes: Common Causes and Risk Factors
• Prediabetes develops when your body begins to have trouble using the hormone insuline. Insulin is necessary to transport glucose—what your body uses for energy—into the cells via the bloodstream. In pre-diabetes, your body either doesn’t make enough insulin or it doesn’t use it well (that’s called insulin resistance).
• If you don’t have enough insulin or if you’re insulin resistant, you can build up too much glucose in your blood, leading to a higher-than-normal blood glucose level and perhaps
prediabetes.
•
• Researchers aren’t sure what exactly causes the insulin process to go away in some
people. There are several risk factors, though, that make it more likely that you’ll develop
pre-diabetes. These are the same risk factors related to the development of type 2 diabetes:
• Weight: If you’re overweight (have a body mass index—a BMI—of higher than 25), you’re at high risk for developing prediabetes, especially if you carry a lot of extra weight in your abdomen, you may develop prediabetes. The extra fat cells can cause your body to become more insulin resistant.
• Lack of physical activity: This often goes hand-in-hand with being overweight. If you aren’t physically active, you’re more likely to develop prediabetes.
• Family history: Prediabetes has a hereditary factor. If someone in your close family has (or had) it, you are more likely to develop it.
• Race/ethnicity: Certain ethnic groups are more likely to develop prediabetes, including African-Americans, Hispanic Americans, Native Americans, and Asian Americans.
• Age: The older you are, the more at risk you are for developing prediabetes. At age 45, your
risk starts to rise, and after age 65, your risk increases exponentially.
• Gestational diabetes: If you developed diabetes while you were pregnant, that increases your risk for developing prediabetes later on.
• Other health problems: High blood pressure (hypertension) and high
cholesterol (the “bad” LDL cholesterol) increase your risk of getting type 2 diabetes.
Polycystic ovary syndrome (PCOS) also raises the risk of prediabetes
because it’s related to insulin resistance. In PCOS, many cysts form in your ovaries, and one possible cause is insulin resistance. If you have PCOS, that means you may be insulin resistant and therefore at risk for developing prediabetes
• If you have hypothyroidism (low thyroid function; not enough circulating thyroid hormone), and you have prediabetes, then your risk of developing T2D more than doubles in comparison to individuals with normal thyroid function..
How Is Prediabetes Diagnosed?
• Your doctor may want to test your blood glucose levels if you’re
overweight (have a body mass index—BMI—of over 25) and if you have one or more of the risk factors listed above.
•
• Even if you aren’t overweight and don’t have any of the risk factors, your doctor may want to start testing your blood glucose level every three years beginning when you’re 45. That’s a smart thing to do because the risk of developing prediabetes (and therefore type 2 diabetes) increases with age. Because there are so many possible complications of diabetes (e.g., heart problems and nerve problems), it’s a good idea to be vigilant about detecting blood glucose abnormalities early.
The tests:
• Fasting plasma glucose test (FPG): You don’t eat anything for eight hours leading up to an FPG test. That's why this test is often done in the
morning.
If blood glucose level is between 100 - 125mg/dL, this means prediabetes.
“Impaired fasting glucose” or IFG, which is another term for prediabetes.
When FPG is above 126mg/dl this means that “diabetes”.
Oral Glucose Tolerance Test (OGTT)
• It is the test used to diagnose prediabetes.
• The patient doesn’t eat anything for eight hours before the test
• First fasting blood glucose level is tested; then patient drinks 75g of a very sugary mixture.
• Two hours later, blood glucose level is measured
• If the blood glucose level is between 140 and 199mg/dL two hours after drinking the sugary mixture, you have pre-diabetes = “impaired glucose tolerance” or IGT, which is another term for pre-diabetes
If blood glucose level is above 200mg/dL with the oral glucose tolerance test, it means diabetes.
• Type 2 diabetes used to be called adult-onset diabetes or non-insulin
dependent diabetes because it was diagnosed mainly in adults who do not require insulin to manage their condition.
• People with type 2 diabetes still produce insuline however, the cells in the muscles, liver and fat tissue are inefficient at absorbing the insulin and cannot regulate glucose well. As a result, the body tries to compensate by having the pancreas pump out more insulin. But the pancreas slowly loses the ability to produce enough insulin, and as a result, the cells don’t get the energy they need to function properly.
The Lifestyle Recommendations for Taking Control of Prediabetes
• The American Diabetes Association (ADA) says that serious lifestyle changes are effective in preventing type 2 diabetes after you’ve been diagnosed with pre-diabetes.
