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Type 2 Diabetes Mellitus Case Study

Contributors:

Kayleigh Fagert

Melissa Gramajo

Rose Mantel

Emily Stallings

Rationale: We chose this topic because type 2 diabetes mellitus is a chronic disease that many of us will encounter as future healthcare providers.

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• Clinical Medicine General
• Complications of Pregnancy
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Two Cases of Successful Type 2 Diabetes Control with Lifestyle Modification in Children and Adolescents

Seon hwa lee.

1 Department of Pediatrics, Konkuk University Medical Center, Seoul, Korea

Myung Hyun Cho

Yong hyuk kim.

2 Department of Pediatrics, Wonju College of Medicine, Yonsei University, Wonju, Korea

Sochung Chung

Obesity and obesity-related disease are becoming serious global issues. The incidence of obesity and type 2 diabetes has increased in children and adolescents. Type 2 diabetes is a chronic disease that is difficult to treat, and the accurate assessment of obesity in type 2 diabetes is becoming increasingly important. Obesity is the excessive accumulation of fat that causes insulin resistance, and body composition analyses can help physicians evaluate fat levels. Although previous studies have shown the achievement of complete remission of type 2 diabetes after focused improvement in lifestyle habits, there are few cases of complete remission of type 2 diabetes. Here we report on obese patients with type 2 diabetes who were able to achieve considerable fat loss and partial or complete remission of diabetes through lifestyle changes. This case report emphasizes once again that focused lifestyle intervention effectively treats childhood diabetes.

INTRODUCTION

Obesity and obesity-related diseases are serious public health issues worldwide, and the increased incidence of type 2 diabetes in children and adolescents is associated with the increased incidence of obesity. 1 , 2 Excess weight gain is a risk factor for both type 2 diabetes and insulin resistance. Obesity refers to excessive fat accumulation and may affect the clinical course of diabetes in terms of insulin resistance. Therefore, the accurate assessment of obesity is important. 3 Body mass index (BMI) is used as an indicator to evaluate weight excess or obesity. 4 However, BMI is limited in that it is the sum of fat-free mass index (FFMI) and fat mass index (FMI) and does not only reflect excess fat. 5 , 6 Therefore, it may be helpful to use body composition analysis that measures fat mass (FM) without fat-free mass (FFM) as a tool to evaluate obesity. Although type 2 diabetes is considered a chronic disease that is difficult to completely cure 7 , 8 , studies have reported complete remission of type 2 diabetes in adults after intensive lifestyle modification. 9 Here we report two cases of type 2 diabetes with partial or complete response to lifestyle modification, particularly FM decrease. Our findings emphasize that lifestyle modifications including dietary treatment and exercise therapy comprise the first-line treatment in obese patients with type 2 diabetes. 10

CASE REPORT

Ms. L, 17 years and 5 months, female

Polydipsia, polyuria

Family history

Mother with hypertension, father with heart failure.

Past medical/social history

No significant history

History of present illness

This 17-year-old girl was diagnosed with diabetes at another hospital after a 1-month history of persistent polydipsia and polyuria. She presented to Konkuk University Medical Center for further diagnosis and treatment of her persistent symptoms.

Physical examination

On admission, her height was 173.1 cm (>97th percentile), weight was 107.2 kg (>97th percentile), and BMI was 35.8 kg/m 2 (>97th percentile) ( Table 1 ). She appeared obese but did not look ill and her mental status was intact. Her vital signs were normal except for a blood pressure of 137/81 mmHg (95–99th percentile). Her skin was warm and no dry mucous membranes were observed. A chest examination was unremarkable. No enlargement of the liver or spleen was appreciated on an abdominal examination. The rest of the physical exam was unremarkable.

Anthropometric data and patient body composition profiles of adolescent girls with type 2 diabetes who achieved remission after stopping medications

BMI, body mass index; FFM, fat free mass; FM, fat mass; FFMI, fat free mass index; FMI, fat mass index; FFMIZ, fat free mass index Z score; FMIZ, fat mass index Z score; PBF, percent body fat.

Lab findings

Labs on admission revealed a glycated hemoglobin (HbA1c) of 11.1%, fasting plasma glucose level of 102 mg/dL, insulin level of 23.12 μIU/mL, and C-peptide level of 4.13 ng/mL. Liver function tests revealed an elevated serum aspartate transaminase (AST) level of 115 IU/L and serum alanine transaminase (ALT) level of 141 IU/L. A lipid panel demonstrated a total cholesterol level of 133 mg/dL, triglycerides of 71 mg/dL, and high-density lipoprotein cholesterol (HDL-C) of 49 mg/dL ( Table 2 ). The total protein and albumin level was 7.0 g/dL and that of albumin was 4.5 g/dL. The free fatty acid level was elevated at 1214 μEq/L.

Biochemical profiles of adolescent girls with type 2 diabetes who achieved remission after stopping medications

HbA1c, glycated hemoglobin A1c; HDL, high lipoprotein; AST, aspartate transaminase; ALT, alanine transaminase.

Radiologic findings

There were no abnormal findings on a chest radiograph. An abdominal ultrasound showed severe fatty infiltration of the liver.

Treatment and progress

For glycemic control, the patient was started on oral medications (metformin 500 mg BID, glimepiride 1 mg QD) as well as a diet and exercise program as a lifestyle modification. Her dietary and nutritional knowledge were evaluated, and she was counseled to have regular meals with 70–75 g of proteins per day and maintain daily nutritional requirements of approximately 1,800 kcal. She was recommended to consume a low-carb, low-fat diet, limit high saturated fats, track her intake, and attend outpatient appointments every 1–2 months. She was instructed to perform aerobic and weight exercises that improve muscle strength for more than 1 hour at least 3 times per week. For 1 year, she did aerobic and anaerobic exercises for an hour or more per day. After 1 year, she incorporated a 7 km walk daily and Pilates more than 3 times per week to her exercise program. In the outpatient setting, we assessed her adherence to therapy at 1–2 month intervals, offered motivational support, and advised her to gradually increase her exercise duration rather than intensity. We measured her height and weight every year and used InBody720, a type of bioelectrical impedance analysis (BIA), to accurately evaluate her obesity. On diagnosis, the patient’s BMI was 35.8 kg/m 2 (FMI, 18.0 kg/m 2 ; FFMI, 17.8 kg/m 2 ), scoring >97th percentile, and percent body fat (PBF) was 50.4%. During the 2 years of outpatient monitoring, she had no difficulty controlling her blood sugar level using the combination of oral medication and lifestyle modification. However, the dose of metformin was increased to 1,000 mg BID due to difficulty maintaining her HbA1c <7.0% on the previous regimen; at that time, she was still considered obese with a BMI of 35.1 kg/m 2 (FMI, 17.2 kg/m 2 ; FFMI, 17.9 kg/m 2 ) and PBF of 48.9%. Her weight and body composition during treatment are shown in Fig. 1 .

Plot of changes in FFMI and FMI in two adolescent girls with T2DM who achieved remission. T2DM, type 2 diabetes; BMI, body mass index; PBF, percent body fat; FFMI, fat free mass index; FMI, fat mass index.

Three years later, the patient’s dietary therapy and exercise program resulted in an increased FFMI at 18.3 kg/m 2 and reduced FMI at 14.9 kg/m 2 , leading to discontinuation of the glimepiride and a reduction in the metformin dose to 500 mg BID.

Four years later, her HbA1c decreased to 5.4% and the metformin was discontinued due to her successful glycemic control. At that time, her fasting blood glucose level was 97 mg/dL, insulin level was 5.62 μIU/mL, and C-peptide level was 2.13 ng/mL. Her BMI was 27.1 kg/m 2 (FMI, 10.3 kg/m 2 ; FFMI, 16.8 kg/m 2 ) and PBF was 38.2%, which is still considered obese based on the World Health Organization diagnostic criteria for Asian adults; however, it was 8.7 kg/m 2 less than her BMI prior to treatment and her FMI had decreased by 7.7 kg/m 2 . Her FFMI was also reduced by 1.0 kg/m 2 , but still belonged to the 90–95th percentile; thus, her nutritional status was not a concern ( Table 1 ). Liver function tests and a lipid panel revealed AST 20 IU/L, ALT 12 IU/L, total cholesterol 114 mg/dL, triglycerides 59 mg/dL, and HDL-C 51 mg/dL ( Table 2 ). Her HbA1c has remained at <5.7% for more than a year without oral medications and will continue to be followed.

Ms. A, 12 years and 10 months, female

Hyperglycemia

Father with type 2 diabetes under treatment

12-year-old female who presented to Konkuk University Medical Center with post-prandial hyperglycemia of 330 mg/dL measured by her father one day prior to admission. Menarche occurred 1 year prior and her menstrual cycles were regular.

On admission, the patient’s height was 158.9 cm (25–50th percentile), weight was 75.5 kg (>97th percentile), and BMI was 29.9 kg/m 2 (>97th percentile) ( Table 1 ). Her vital signs were within the normal range with a blood pressure of 112/68 mmHg, pulse of 72 beats/min, respiratory rate of 20 breaths/min, and temperature of 36.6°C. She had a clear mental status, warm skin, and moist mucous membranes. A chest examination revealed no specific findings, while an abdominal examination revealed no hepatomegaly or splenomegaly. The rest of the physical examination was unremarkable.

Laboratory findings

Laboratory tests at the time of admission revealed an HbA1c level of 9.9%, fasting blood glucose level of 202 mg/dL, insulin level of 15.85 μIU/mL, and C-peptide level of 2.97 ng/mL. Liver function tests showed an elevated AST level at 47 IU/L and ALT level at 69 IU/L. A lipid panel and comprehensive metabolic panel showed a total cholesterol level of 165 mg/dL, triglyceride level of 104 mg/dL, HDL-C of 50 mg/dL, total protein of 7.6 g/dL, and albumin of 4.8 g/dL ( Table 2 ). The free fatty acid level was elevated at 671 μEq/L.

Radiologic finding

There were no significant findings on a chest radiograph. An abdominal ultrasound showed moderate fatty liver.

For glycemic control, combination therapy of oral medication (metformin 500 mg BID) and lifestyle modification through adjustments in dietary habits was prescribed. We evaluated her dietary and nutritional knowledge and then counseled her to consume regular meals with 70–90 g of protein per day, maintain daily nutritional requirements of approximately 1800 kcal, and eat a low-carb, low-fat diet. She was recommended to modify her habitual preference of salty and spicy foods, reduce her salt intake, track her meals, and attend outpatient monitoring appointments every 1–2 months.

For an exercise program, she was instructed to include aerobic and weight exercises that improve muscle strength. She was advised to walk >1 hour at least 5 days per week and visit a health training center for ≥1 hour of strength exercises at least 3 times per week. We measured her height and weight every 2 months, and used InBody720, a type of BIA for accurate assessment of obesity. On diagnosis, patient’s BMI was 29.9 kg/m 2 (FMI, 12.7 kg/m 2 ; FFMI, 17.2 kg/m 2 ) and PBF was 42.5%. Two years later after the diagnosis, an abdominal ultrasound showed improvements in her fatty liver and her HbA1c was successfully reduced to 6.0%. The oral medication was discontinued due to the successful glycemic control. At the time, her fasting blood sugar was 97 mg/dL, insulin level was 5.62 μIU/mL, and C-peptide level was 2.79 ng/mL. Her BMI (FMI+FFMI) was 23.2 kg/m 2 (7.0 kg/m 2 +16.2 kg/m 2 ), which was within the overweight range (85–90th percentile), and her PBF was 30.2%. Her BMI at that point was 6.7 kg/m 2 lower than that prior to therapy, with a 5.7 kg/m 2 reduction observed in her FMI ( Table 1 ). Liver function tests and a lipid panel revealed the following: AST, 20 IU/L; ALT, 34 IU/L; total cholesterol, 115 mg/dL; triglycerides, 70 mg/dL; and HDL-C, 30 mg/dL ( Table 2 ). The changes in the patient’s weight and body composition during treatment are shown in Fig. 1 . Since discontinuing the oral medication, the patient has maintained an HbA1c level <6.5%.

The prevalence of type 2 diabetes is increasing with changes in dietary habits and increases in the incidence of obesity among children and adolescents. Although it is already known that a reduced caloric intake and weight loss through lifestyle modifications can treat diabetes, few cases demonstrating such an effect have been reported to date. 9 As discussed previously in two cases, a notable reduction in FM resulted in an HbA1c level <6.5% and improved glycemic control as well as successful maintenance of HbA1c at goal level without medications. According to the 2009 consensus statement reported by the American Diabetes Association, a complete response is defined as blood sugar in the normal range for >1 year without any medications (fasting blood sugar <100 mg/dL, HbA1c <5.7%). Partial response is defined as a blood sugar level below the diabetes range for >1 year without any medications or medical procedures (HbA1C <6.5%; fasting blood sugar, 100–125 mg/dL). 11 In the two cases presented above, significant decreases in BMI and PBF were observed as well as subsequent improvements in HbA1c and fasting blood sugar level. In developing children, weight gain occurs with increasing age, and increases in BMI are common. However, such increases in BMI are due to increases in FFM, not FM. 6 Appropriate growth is one of the important objectives of pediatric diabetes management and treatment. Since proper nutrition and hormonal balance are essential for growth, it is more important to achieve a reduction in FM than a reduction in weight by having regular meals that are low in carbs and fat with a normal protein intake.

Weight loss through lifestyle modification generally affects FFM. In the cases discussed above, both patients had elevated FM and FFM on admission. By balancing appropriate dietary changes with aerobic and anaerobic exercises, the patient was able to maintain FFM and incur no significant effect on growth. In the present case, the patient was instructed to spend 1 hour exercising at least 3 times per week, assessed for compliance as an outpatient every 1–2 months, offered continuous motivational support, and told to gradually increase her exercise duration.

A recent study reported that oral medication was eventually needed to control hyperglycemia in patients with diabetes refractory to management with proper lifestyle modification. 12 However, lifestyle modification is important, and is a cornerstone in the treatment of diabetes, and it should be a mandatory treatment for type 2 diabetes. In females, it is common to see an increase in PBF with progression of puberty. 13 , 14 However, here we report cases of complete remission of diabetes in teenage girls with lifestyle modification and emphasize once again that intensive lifestyle improvement is an effective early treatment for diabetes. 15

Our results demonstrate that intensive lifestyle modification including regular exercise and dietary changes is very effective in the treatment of obese patients with type 2 diabetes.

CONFLICTS OF INTEREST

The authors declare that there are no conflicts of interest.

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Correlation between overweight, obesity, gestational diabetes mellitus, adipokines (adipolin and adiponectin), and adverse pregnancy outcomes: a pilot study.

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Share and Cite

Mihai, M.; Vladut, S.; Sonia-Teodora, L.; Laura Mihaela, S.; Victoria, N.; Irina Elena, M.; Claudiu, M. Correlation between Overweight, Obesity, Gestational Diabetes Mellitus, Adipokines (Adipolin and Adiponectin), and Adverse Pregnancy Outcomes: A Pilot Study. Medicina 2024 , 60 , 1544. https://doi.org/10.3390/medicina60091544

Mihai M, Vladut S, Sonia-Teodora L, Laura Mihaela S, Victoria N, Irina Elena M, Claudiu M. Correlation between Overweight, Obesity, Gestational Diabetes Mellitus, Adipokines (Adipolin and Adiponectin), and Adverse Pregnancy Outcomes: A Pilot Study. Medicina . 2024; 60(9):1544. https://doi.org/10.3390/medicina60091544

Mihai, Muntean, Săsăran Vladut, Luca Sonia-Teodora, Suciu Laura Mihaela, Nyulas Victoria, Muntean Irina Elena, and Mărginean Claudiu. 2024. "Correlation between Overweight, Obesity, Gestational Diabetes Mellitus, Adipokines (Adipolin and Adiponectin), and Adverse Pregnancy Outcomes: A Pilot Study" Medicina 60, no. 9: 1544. https://doi.org/10.3390/medicina60091544

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Clinical pearls, case study: screening and treatment of pre-diabetes in primary care.

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Richard J. Shrot , Frances M. Sahebzamani , H. James Brownlee; Case Study: Screening and Treatment of Pre-Diabetes in Primary Care. Clin Diabetes 1 April 2004; 22 (2): 98–100. https://doi.org/10.2337/diaclin.22.2.98

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J.M., a 48-year-old Hispanic man, was seen in the primary care clinic for routine follow-up of hypertension, for which he had been treated for the past 8 years. His only medication was lisinopril, 20 mg/day. Home blood pressure monitoring averaged 128/82 mmHg. He had a family history for hypertension, type 2 diabetes, and coronary artery disease. J.M. reported a 20-lb weight gain over the past year, along with a sedentary lifestyle with no regular exercise routine. Other medical history was negative, including symptoms of fatigue, polyuria, or polydipsia. He denied past or current tobacco use.

J.M. presented with a waist size of 42 inches, BMI of 34 kg/m 2 , and blood pressure of 125/80 mmHg. A subsequent lipoprotein profile demonstrated the common pattern associated with pre-diabetes, including a low HDL cholesterol (30 mg/dl) and a high triglyceride level (185 mg/dl). The LDL was mildly elevated (132 mg/dl), and total cholesterol was 199 mg/dl. His fasting glucose was 111 mg/dl, with a repeat value of 115 mg/dl one week later.

Does this patient have pre-diabetes?

When should patients be screened for pre-diabetes?

How should pre-diabetes be treated in primary care settings?

Type 2 diabetes is a significant cause of death, disability, and health care burden in the United States, affecting an estimated 16 million Americans. A prodromal phase of this disease, in which patients manifest impaired glucose metabolism, has recently been identified as “pre-diabetes” by the U.S. Secretary of Health and Human Services. 1 Pre-diabetes is also a major health care burden estimated to affect at least an additional 16 million Americans, 2 and possibly as many as 43 million with the new criteria for impaired fasting glucose (IFG) being reduced to 100 mg/dl. 3 Pre-diabetes is highly associated with concomitant cardiovascular risk factors and has been found to confer an increased risk of cardiovascular complications including myocardial infarction, stroke, and death. 1  

Pre-diabetes is clinically defined by either an IFG between 100 and 125 mg/dl or by a 2-hour oral glucose tolerance test (OGTT) result of 140–199 mg/dl, indicating impaired glucose tolerance (IGT), or both 4 ( Table 1 ). The normal fasting glucose level was recently adjusted downward from 110 to 100 mg/dl, after analysis by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. 5 (This report is reprinted in full in this issue starting on p. 71 .) The committee recognized that IGT was more common in most populations by the older criteria. Lowering the impaired fasting level to 100 mg/dl should make the predictive value of future diabetes more concordant, regardless of whether IFG or IGT is used.

With the favorable results of the Diabetes Prevention Program for Type 2 Diabetes (DPP) published in 2002, 6 a recent position statement of the American Diabetes Association proposes screening recommendations for pre-diabetes to be done as part of a health care visit and suggests screening in individuals age ≥ 45 years, especially those who are overweight (BMI ≥ 25 kg/m 2 ) 1 ( Table 2 ). Screening should also be considered in individuals who are < 45 years old and overweight in the presence of other risk factors, such as a first-degree relative with diabetes, history of gestational diabetes, high-risk ethnicity, hypertension, or dyslipidemia. Asian Americans may be screened at a lower BMI (≥ 23 kg/m 2 ).

Based on these screening recommendations, J.M. was a candidate for screening with age, ethnicity, BMI, dyslipidemia, family history, sedentary lifestyle, and hypertension as prevailing risk factors. His low HDL, high triglyceride level, waist circumference, and hypertension made him a likely candidate for the diagnosis of pre-diabetes. These four risk factors, along with impairment of glucose tolerance, were established as clinical markers for insulin resistance by the National Cholesterol Education Program, Adult Treatment Panel III, and are used to confirm a diagnosis of the metabolic syndrome 7 ( Table 3 ).

J.M.’s fasting glucose results of 111 and 115 mg/dl confirmed the diagnosis of pre-diabetes. To exclude a diagnosis of diabetes, a 2-hour OGTT was ordered. Its result of 173 mg/dl indicated that J.M. had IGT in addition to IFG. A recent analysis of glucose progression over several decades in the Baltimore Longitudinal Study of Aging suggests that IFG and IGT may represent different phenotypes in the natural history of progression to type 2 diabetes. 8 This suggestion, however, was based on the older definition of IFG.

The results of recent clinical trials to prevent or delay progression to type 2 diabetes demonstrate the benefit of identifying patients at risk and implementing early aggressive intervention. Although intensive lifestyle and selected pharmacological interventions have demonstrated effective outcomes in preventing or delaying progression to diabetes, many questions, including that of cost-effectiveness, persist in the translation of these interventions into primary care settings. Based on the DPP and the Finnish study, 9 successful treatment of pre-diabetes requires thorough patient education, counseling, and support in lifestyle changes targeting a 5–7% reduction in total body weight and an exercise goal of 150 minutes/week. J.M. was provided with the necessary counseling for dietary intervention, and, following a pre-exercise treadmill stress test, a titrated exercise program was initiated.

Aggressive management of J.M.’s comorbidities may also help slow progression to diabetes. Studies of selected angiotensin-converting enzyme inhibitors (ramipril) and statins (pravastatin) have suggested that these drugs may delay the progression of pre-diabetes to diabetes. 10 , 11 Results of studies such as the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medications (DREAM) trial are needed to confirm these findings. J.M.’s blood pressure was well controlled with lisinopril, 20 mg/day. A statin was added to treat his dyslipidemia. Both of these interventions may help to delay the progression to diabetes. Aspirin therapy was initiated to reduce cardiovascular risk.

The use of the insulin sensitizers—metformin and the thiazolidinediones (TZDs)—has been shown to be beneficial in delaying the progression from pre-diabetes to diabetes. 6 , 12 In the DPP, metformin, 850 mg twice daily, reduced the relative risk of progression to type 2 diabetes by 31%. Metformin may additionally improve outcomes by inducing weight loss. Although conducted in women with a history of gestational diabetes, the Troglitazone in the Prevention of Diabetes (TRIPOD) study demonstrated a 56% reduction in relative risk in progression of pre-diabetes to diabetes. Although treatment was discontinued because of the withdrawal of troglitazone from the U.S. market, persistent protective treatment effects were observed more than 8 months after discontinuation. Long-term clinical trial data are not yet available for the newer TZDs, but there is a reasonable expectation that the currently available medications in this drug class may provide similar benefits. Until further clinical trial data become available, clinician judgment–based individualized patient characteristics will determine the use of insulin sensitizers in pre-diabetes. However, lifestyle modifications are first-line treatment for pre-diabetes ( Table 4 ).

J.M. met with a dietitian and a physical therapist for initial instruction. Brisk walking was the starting baseline exercise for 30 minutes each day, 5 days per week, with the use of a pedometer to measure distances. Calorie counting and knowledge of healthy choices from the food pyramid were discussed, but the intensive case management approach, as used in the DPP, was not possible because of insurance reimbursement issues and a lack of availability of individual case managers.

After a 6-month trial of diet and exercise, J.M. was only able to exercise for 20 minutes or less each week, had gained 7 lb, and had an increase in fasting glucose to 117 mg/dl. Although not approved by the Food and Drug Administration for this indication or recommended by the American Diabetes Association, metformin remains an alternative.

Pre-diabetes is diagnosed by a fasting glucose between 100 and 125 mg/dl (IFG) or a 2-hour OGTT result between 140 and 199 mg/dl (IGT), or both, confirmed.

The onset of type 2 diabetes can be prevented or delayed.

Screening for pre-diabetes should be considered for patients at age 45 years, especially for overweight or obese patients, and earlier for patients with a BMI of 25 kg/m 2 or more with additional risk factors such as hypertension or dyslipidemia.

A dyslipidemic pattern of low HDL cholesterol and high triglycerides, in addition to hypertension and large waist size, are clinical markers for insulin resistance and impaired glucose metabolism.

Aggressive management of concomitant comorbidities, such as hypertension and dyslipidemia, may delay progression of pre-diabetes to diabetes.

Aggressive lifestyle modification has delayed the progression of diabetes by about 60%, while medications such as metformin have reduced progression by about 30%.

Efforts should be made to secure insurance reimbursement for intensive lifestyle modification, including classes and case managers such as those used in the DPP.

Definition of Pre-Diabetes

Routine Screening Recommendations for Pre-Diabetes

Definition of Metabolic Syndrome from National Cholesterol Education Program Adult Treatment Panel III

Successful Treatment of Pre-Diabetes

Richard J. Schrot, MD, CDE, is an associate professor, Frances M. Sahebzamani, PhD, ARNP, is an assistant professor, and H. James Brownlee, Jr., MD, is a professor and chairman in the Department of Family Medicine at the University of South Florida (USF) School of Medicine in Tampa, Fla. Dr. Schrot is a member of the research working group, and Dr. Sahebzamani and Dr. Brownlee are co-directors of the USF Pre-Diabetes Treatment and Research Center. Dr. Schrot has been director of the Ambulatory Care Diabetes Clinic at the James A. Haley VA Hospital in Tampa, Fla.

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