From the Guidelines
For a patient with an A1c of 6.1%, the management plan should focus primarily on lifestyle modifications rather than medications, aiming to lose 7% of body weight and increase moderate-intensity physical activity to at least 150 min/week. This approach is supported by the most recent and highest quality study 1, which recommends referring patients with prediabetes to an intensive behavioral lifestyle intervention program. The patient should aim to reduce caloric intake, limit refined carbohydrates and added sugars, increase fiber intake, and follow a Mediterranean or DASH-style eating pattern. Physical activity should include at least 150 minutes of moderate-intensity exercise weekly, such as brisk walking, swimming, or cycling, ideally spread across multiple days. Some key points to consider in the management plan include:
- Regular monitoring with A1c testing every 6-12 months to track progress 1
- Consideration of metformin therapy for high-risk patients, such as those with BMI >35, age <60, or history of gestational diabetes, but not as first-line therapy for most prediabetic patients 1
- The use of technology-assisted tools, including Internet-based social networks, distance learning, and mobile applications, to support lifestyle modification 1
- Screening for and treatment of modifiable risk factors for cardiovascular disease, as suggested by the evidence 1. The goal of these interventions is to improve insulin sensitivity, reduce hepatic glucose production, and preserve beta-cell function, thereby preventing or delaying progression to type 2 diabetes and reducing the risk of developing diabetes within 10 years.
From the Research
Management Plan for Prediabetes
The management plan for a patient with an A1c level of 6.1, indicating prediabetes, involves:
- Lifestyle modification, including calorie restriction, increased physical activity (≥150 min/wk), self-monitoring, and motivational support, which has been shown to decrease the incidence of diabetes by 6.2 cases per 100 person-years during a 3-year period 2
- Metformin, which decreased the risk of diabetes among individuals with prediabetes by 3.2 cases per 100 person-years during 3 years, and is most effective for women with prior gestational diabetes and for individuals younger than 60 years with body mass index of 35 or greater, fasting plasma glucose level of 110 mg/dL or higher, or HbA1c level of 6.0% or higher 2
- Close follow-up and consideration of metformin introduction only when diabetes is diagnosed, as approximately two-thirds of people with prediabetes do not develop diabetes, and one-third return to normal glucose regulation 3
Risk of Cardiovascular Disease
Prediabetes is associated with an increased risk of cardiovascular events and mortality, with an excess absolute risk of 8.75 per 10 000 person-years for cardiovascular disease during 6.6 years 2
- Maintaining systolic blood pressure < 130 mmHg or LDL cholesterol < 100 mg/dL is significantly associated with reduced cardiovascular disease hospitalization risk, especially when both risk factors are well controlled 4
- The association between prediabetes and cardiovascular disease is due to associated nonglycemic risk factors, not the slightly increased glycemia 3
A1c Level and Future Risk of Diabetes
An A1c level of 6.1 is associated with a highly increased risk of incident diabetes, with an annualized diabetes incidence of 54.1% 5