What goals and treatment modalities should be the focus of the management of pre-diabetes? Does early intervention make a difference?

Scott Grundy (Dallas, TX) and Christie Ballantyne (Houston, TX) discussed aspects of the nonglycemic goals of pre-diabetes treatment, addressing obesity, blood pressure, and lipid management, as well as goals of thrombus prevention. Ballantyne discussed the concept of the metabolic syndrome, pointing out that a number of commonly measured clinical variables may be used in predicting diabetes (such as waist circumference, hypertension, family history of diabetes, ethnicity, age, fasting glucose, and lipids [1]) and suggesting that the metabolic syndrome thus offers a practical means of allowing physicians to integrate many of these factors rather than itself adding to risk. For cardiovascular disease prediction, Ballantyne suggested, blood glucose is less important than blood pressure and HDL cholesterol, which are particularly important, as metabolic syndrome components (2); and, of course, LDL cholesterol and cigarette use are additional factors that must be taken into account. Other measures, such as microalbuminuria, retinal abnormalities, A1C, C-reactive protein, lipoprotein-associated phospholipase A2, carotid ultrasound, and coronary calcium score, may be useful as well. Recognizing that 98% of women have a Framingham risk score below 10%, Ballantyne proposed redefining intermediate risk as between 5 and 20% per decade.

Grundy described metabolic syndrome as a subtype of obesity, caused by environmental (increased dietary calories and lack of exercise) and genetic factors, resulting in atherogenic dyslipidemia, hypertension, a prothrombotic state, and many other conditions, as well as pre-diabetes. The National Health and Nutrition Evaluation Survey II, carried out from 1988 to 1994, showed substantial overlap between pre-diabetes and metabolic syndrome (3), which Grudy termed the cardiovascular disease–centric and …