Prediabetes: An Opportunity to Prevent Diabetes

Course #94192 - $60 • 15 Hours/Credits


Self-Assessment Questions

    1 . What percentage of the adult population in the United States has prediabetes, according to estimates from the Centers for Disease Control and Prevention?
    A) 71%
    B) 15.4%
    C) 33.9%
    D) 50.5%

    SIGNIFICANCE OF THE PROBLEM

    Prediabetes is a remarkably common health problem that has been vastly underdiagnosed. The Centers for Disease Control and Prevention (CDC) estimate that 33.9% of the adult population in the United States has prediabetes, with nearly half (48.3%) of adults 65 years of age and older having blood glucose values that meet the criteria [3]. About one in six adolescents in the United States has prediabetes [4]. In spite of the high prevalence of prediabetes, only 11.6% of people with this condition are told of their diagnosis [3].

    Click to Review



    2 . Which of the following is a health risk of untreated prediabetes?
    A) It can cause early onset of retinopathy.
    B) It can rapidly progress to acute hyperglycemia.
    C) It is associated with decreased risk for neuropathy.
    D) It makes the person twice as likely to develop type 2 diabetes.

    SIGNIFICANCE OF THE PROBLEM

    Although it is underdiagnosed, prediabetes is a serious condition that significantly increases the risk for major health problems. People with prediabetes are approximately 5 to 15 times more likely to develop diabetes than those who have normal blood glucose levels [5]. Furthermore, the harmful effects of high blood glucose begin to occur at much lower levels than currently define diabetes. In other words, complications of diabetes begin early in the course of glucose intolerance, often before diabetes is diagnosed. Studies suggest that when blood glucose is higher than normal and remains untreated, patients have a greater risk for developing the microvascular and macrovascular complications associated with diabetes [6,7,8]. For example, characteristics of diabetic retinopathy may be detected in people with no history of diabetes who have elevated fasting blood glucose or impaired glucose tolerance (IGT) [9]. Impaired glucose tolerance is also common in nondiabetic patients with peripheral neuropathy [10]. This data emphasize the importance of prompt detection and intervention of prediabetes. In fact, research suggests that restoring blood glucose levels to normal, rather than maintaining prediabetic levels, is necessary to prevent complications [7,8]. When preventive efforts delay the onset of diabetes, there is less disease exposure and lower risk for the adverse consequences of high blood glucose over time. This results in better quality of life for the individual and lower healthcare costs for society.

    Click to Review



    3 . What is a normal fasting blood glucose level?
    A) Less than 50 mg/dL
    B) Less than 70 mg/dL
    C) Less than 100 mg/dL
    D) Less than 120 mg/dL

    EVALUATION AND CLASSIFICATION OF HIGH BLOOD GLUCOSE

    There are many tests available to assess patients suspected of having diabetes or prediabetes. These include [14,15]:

    • Fasting plasma glucose (FPG): Blood is collected after the patient has had no dietary intake for eight hours or more. Normal fasting plasma glucose is less than 100 mg/dL.

    • Casual plasma glucose: This is sometimes referred to as "random" or nonfasting blood glucose, as blood is collected without regard to the time of last caloric intake.

    • Oral glucose tolerance test (OGTT): Blood is taken two hours after the person has ingested a glucose load of 75 grams. This is also known as a "glucose challenge." Normal nonfasting plasma glucose taken two hours following glucose challenge is less than 140 mg/dL.

    • Hemoglobin A1c (A1c): This laboratory test uses venous blood to show the average blood glucose concentration over the previous two to three months. The test measures the amount of glucose that is chemically attached to the red blood cells (RBCs). RBCs that have been exposed to high amounts of glucose over their lifespan, which is about 90 days, will have more glucose attached to them. This will result in a higher A1c reading. A1c levels greater than 7.0% are associated with an increased risk for eye, kidney, and nerve damage and cardiovascular disease. Historically, A1c was not used as a test for the diagnosis of diabetes or prediabetes. However, in 2010 the ADA revised its criteria for the diagnosis of diabetes to include use of A1c for diagnosis. A1c of less than 5.7% is considered normal.

    Click to Review



    4 . Which test measures blood glucose two hours after the person has ingested a glucose load of 75 grams?
    A) Hemoglobin A1c
    B) Fasting blood glucose
    C) Casual plasma glucose
    D) Oral glucose tolerance test (OGTT)

    EVALUATION AND CLASSIFICATION OF HIGH BLOOD GLUCOSE

    There are many tests available to assess patients suspected of having diabetes or prediabetes. These include [14,15]:

    • Fasting plasma glucose (FPG): Blood is collected after the patient has had no dietary intake for eight hours or more. Normal fasting plasma glucose is less than 100 mg/dL.

    • Casual plasma glucose: This is sometimes referred to as "random" or nonfasting blood glucose, as blood is collected without regard to the time of last caloric intake.

    • Oral glucose tolerance test (OGTT): Blood is taken two hours after the person has ingested a glucose load of 75 grams. This is also known as a "glucose challenge." Normal nonfasting plasma glucose taken two hours following glucose challenge is less than 140 mg/dL.

    • Hemoglobin A1c (A1c): This laboratory test uses venous blood to show the average blood glucose concentration over the previous two to three months. The test measures the amount of glucose that is chemically attached to the red blood cells (RBCs). RBCs that have been exposed to high amounts of glucose over their lifespan, which is about 90 days, will have more glucose attached to them. This will result in a higher A1c reading. A1c levels greater than 7.0% are associated with an increased risk for eye, kidney, and nerve damage and cardiovascular disease. Historically, A1c was not used as a test for the diagnosis of diabetes or prediabetes. However, in 2010 the ADA revised its criteria for the diagnosis of diabetes to include use of A1c for diagnosis. A1c of less than 5.7% is considered normal.

    Click to Review



    5 . Which of the following is a correct diagnostic criterion for diabetes?
    A) A1c greater than or equal to 5.7%
    B) Fasting plasma glucose of 126 mg/dL or greater
    C) Oral glucose tolerance test result of 150 mg/dL or greater
    D) Casual or random plasma glucose 140 mg/dL or greater accompanied by symptoms of hyperglycemia

    EVALUATION AND CLASSIFICATION OF HIGH BLOOD GLUCOSE

    A diagnosis of diabetes is established when a person has any or all of the following blood glucose values [14]:

    • FPG: 126 mg/dL or greater

    • Casual or random plasma glucose: 200 mg/dL or greater accompanied by symptoms of hyperglycemia, (i.e., polyuria, polydipsia, and/or unexplained weight loss)

    • OGTT: 200 mg/dL or greater

    • A1c: Greater than or equal to 6.5%

    Click to Review



    6 . The risk for retinopathy and nephropathy may begin to increase when two-hour postprandial blood glucose levels reach
    A) 70 mg/dL.
    B) 102 mg/dL.
    C) 162 mg/dL.
    D) 240 mg/dL.

    HEALTH RISKS ASSOCIATED WITH PREDIABETES

    Evidence suggests that the microvascular damage from high blood glucose begins early in the progression from normal glucose tolerance to frank diabetes. Studies of people with prediabetes indicate that risk for retinopathy, nephropathy, and neuropathy are all increased [6]. Retinal microaneurysms and microalbuminuria, the hallmarks of diabetic retinopathy and nephropathy respectively, have been detected in a significant number of nondiabetic people with IGT [9]. IGT is common in patients with peripheral neuropathy, and a causal relationship has been assumed, though not adequately studied. The risk for retinopathy and nephropathy may begin to increase when two-hour postprandial blood glucose levels reach 162 mg/dL [10].

    Click to Review



    7 . Which of the following is considered a risk factor for prediabetes and diabetes?
    A) White race
    B) Age younger than 30 years
    C) A family history of diabetes
    D) High-density lipoprotein (HDL) cholesterol greater than 40 mg/dL

    RISK FACTORS FOR DIABETES AND PREDIABETES

    Risk factors for diabetes and prediabetes include [6]:

    • Age older than 45 years

    • Family history of diabetes (in a parent, brother, or sister)

    • Previously identified as having IGT, IFG, and/or metabolic syndrome

    • Belonging to certain racial and ethnic groups, including non-Hispanic blacks, Hispanic/Latino Americans, Asian Americans, Pacific Islanders, American Indians, and Alaska Natives

    • History of gestational diabetes

    • Women who have delivered a baby weighing 9 pounds or more

    • Polycystic ovary syndrome (PCOS)

    • Overweight

    • Sedentary lifestyle

    • High blood pressure (140/90 mm Hg or more) or being treated for high blood pressure

    • HDL cholesterol less than 35 mg/dL

    • Triglyceride level greater than 250 mg/dL

    • A history of cardiovascular disease

    • Receiving antipsychotic therapy for schizophrenia or bipolar disorder

    Click to Review



    8 . Insulin resistance refers to
    A) excessive insulin secretion by the pancreas.
    B) insufficient insulin secretion by the pancreas.
    C) inappropriate glucose production by the liver.
    D) impairment of the body's ability to utilize available insulin.

    AN OVERVIEW OF TYPE 2 DIABETES

    Insulin resistance, or the impairment of the body to effectively utilize available insulin, is the hallmark of both metabolic syndrome and type 2 diabetes. In people with early stage type 2 diabetes, insulin resistance reduces glucose uptake by 35% to 40%. With insulin resistance, the pancreas may produce normal or greater than normal amounts of insulin, but receptor sites for it are not available. For some people, the pancreas is temporarily able to make enough additional insulin to overcome the insulin resistance and produce normal blood glucose levels. Hyperinsulinemia is usually the case in early stages of type 2 diabetes and is associated with macrovascular risk factors of the metabolic syndrome, such as dyslipidemia and hypertension. High levels of insulin in the blood increase sympathetic activity that can raise blood pressure.

    Click to Review



    9 . Which of the following is a potential macrovascular complication of diabetes?
    A) Retinopathy
    B) Nephropathy
    C) Coronary artery disease
    D) All of the above

    AN OVERVIEW OF TYPE 2 DIABETES

    The chronic complications of diabetes are usually classified as microvascular or macrovascular according to the type of blood vessel damage that underlies the problem. Microvascular complications of diabetes include retinopathy, nephropathy, and neuropathy. Prolonged hyperglycemia leads to changes in the structure of the microscopic vessels that supply the eye, the kidney, and the nerves.

    Macrovascular complications of diabetes are coronary artery disease, cerebral artery disease, and peripheral vascular disease. Heart disease is the foremost cause of death in people with diabetes [13]. Moreover, people with diabetes are prone to developing both coronary and cerebral vascular disease at an earlier age than people who do not have diabetes.

    Click to Review



    10 . The results of the Diabetes Prevention Program (DPP) indicate that the greatest reduction in diabetes risk was associated with
    A) a 2% reduction in hemoglobin A1c levels.
    B) a 3- to 5-inch reduction in waist circumference.
    C) improvements in triglyceride and HDL cholesterol levels.
    D) lifestyle changes that resulted in a 5% to 7% body weight reduction.

    DIABETES PREVENTION PROGRAM

    The DPP was a landmark study on the prevention of diabetes. The results, published in the New England Journal of Medicine in 2002, reported that diabetes could be prevented or delayed in people with IFG and IGT [2]. Using subjects with prediabetes who were overweight, the study compared the results of treatment with the diabetes medication metformin versus lifestyle changes that led to weight loss. Importantly, the DPP showed that the greatest reduction in diabetes risk was associated with lifestyle changes that resulted in a 5% to 7% loss of body weight. Ten-year follow-up of DPP subjects has shown that diet and exercise, resulting in weight loss, could keep diabetes at bay for at least a decade in those at high risk [33].

    Click to Review



    11 . According to the DPP, diabetes risk reduction with the use of metformin was found to be most effective for people
    A) 25 to 44 years of age.
    B) older than 60 years of age.
    C) less than 50 pounds overweight.
    D) not engaged in lifestyle changes.

    DIABETES PREVENTION PROGRAM

    The results of the DPP also showed that diabetes could be prevented with the use of metformin in people with prediabetes, with risk reduction of about 31% [34]. Risk reduction with use of metformin was found to be most effective for people 25 to 44 years of age and in those who were at least 60 pounds overweight [34]. After 10 years, the incidence of type 2 diabetes was decreased by 18% in the metformin group as compared to placebo [33].

    Click to Review



    12 . General evidence-based dietary guidelines for the prevention and treatment of diabetes include all of the following, EXCEPT:
    A) Limit salt intake to 2,400 mg/day.
    B) Avoid eating meats and dairy products.
    C) Limit food high in saturated fat, trans fatty acids, and cholesterol.
    D) Limit alcohol intake to not more than two drinks per day for men and one drink per day for women.

    NUTRITIONAL INTERVENTIONS TO PREVENT DIABETES

    General evidence-based dietary guidelines for the prevention and treatment of diabetes are to:

    • Consume a variety of foods, including fruits, vegetables, grains, low-fat and fat-free dairy products, and lean meats.

    • Limit food high in saturated fat, trans fatty acids, and cholesterol. Emphasize fruits, vegetables, and low-fat dairy products.

    • Limit salt intake to 2,400 mg/day.

    • Limit alcohol to no more than two drinks per day for men and one drink per day for women in people who choose to drink alcohol.

    Click to Review



    13 . Safe weight loss, a main tenet in the prevention of diabetes, is defined by the American Dietetic Association and the American Diabetes Association as a target of
    A) 0.5 to 1 pound every two weeks.
    B) 1 to 2 pounds per week.
    C) 2 to 4 pounds per week.
    D) 5 or more pounds per week.

    NUTRITIONAL INTERVENTIONS TO PREVENT DIABETES

    Reducing calories and increasing physical activity are the cornerstones of healthy weight loss [46]. As their position on weight management, the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) states "…successful weight management to improve overall health for adults requires a lifelong commitment to healthful lifestyle behaviors emphasizing sustainable and enjoyable eating practices and daily physical activity" [46]. For safe weight loss, the Academy of Nutrition and Dietetics and the ADA recommend a reduction of 500 to 1,000 calories per day to achieve a target weight-loss rate of 1 to 2 pounds per week [46].

    Click to Review



    14 . Excess waist circumference with associated health risk is identified as greater than
    A) 34 inches in men and women.
    B) 35 inches in men and greater than 30 inches in women.
    C) 37 inches in men and women.
    D) 40 inches in men and greater than 35 inches in women.

    NUTRITIONAL INTERVENTIONS TO PREVENT DIABETES

    Excess waist circumference with associated health risk is identified as greater than 40 inches in men or greater than 35 inches in nonpregnant women [52]. The proper way to measure abdominal circumference is to place a tape measure around the bare abdomen, just above the hipbone. The tape should be parallel to the floor and snug, but not compressing the skin. Instruct the patient to exhale and relax for the measurement [52].

    Click to Review



    15 . Which of the following interventions may NOT be effective in helping patients better control portion sizes?
    A) Use larger plates, bowls, and utensils.
    B) Avoid eating directly out of a bag or bowl.
    C) Weigh and measure foods to ensure appropriate serving size.
    D) Practice the "plate method" of portion control (i.e., using a plate with portion dividers).

    NUTRITIONAL INTERVENTIONS TO PREVENT DIABETES

    Studies indicate that portion control is a valid component of a healthy and effective weight loss plan. Based on these studies, the Academy of Nutrition and Dietetics recommends that portion control be integrated into the weight-loss plan. To help patients with portion control, advise them to:

    • Weigh and measure foods to ensure appropriate serving sizes (Table 1).

    • Visualize appropriate serving sizes. Teach patients to compare food serving sizes to the size of everyday objects as a frame of reference (Table 2). Artificial food models of appropriate size may be useful to demonstrate serving sizes.

    • Use premeasured, calorie-controlled foods, such as reduced-calorie frozen dinners or 100-calorie packages. Use smaller plates, bowls, and utensils for eating.

    • Avoid eating directly out of a bag or bowl. Put one serving on a plate or dish.

    • Be aware of large serving sizes in restaurants. Place half of a large portion in a take-home container before starting the meal or share an entree with another person.

    • Practice the "plate method" of portion control.

    Click to Review



    16 . As part of counseling for weight loss, patients should be advised to eat
    A) whenever hungry.
    B) at least every 2 to 3 hours during waking hours.
    C) at least every 4 to 5 hours during waking hours.
    D) at most every 6 hours during waking hours.

    NUTRITIONAL INTERVENTIONS TO PREVENT DIABETES

    The Academy of Nutrition and Dietetics recommends that total caloric intake be "distributed throughout the day, with the consumption of four to five meals/snacks per day, including breakfast" [46]. An important counseling strategy is to help the person find a meal pattern that prevents times of heightened hunger. Advise patients to eat at least every four to five hours during waking hours. They should also try to avoid hunger in situations in which high-calorie food choices are readily available. For example, helping the patient plan healthy sack lunches and snacks may prevent overeating at vending machines or fast food establishments during working hours. Consuming a greater proportion of calories during the day, as opposed to the evening, may also prove to be beneficial to patients' weight loss goals [46].

    Click to Review



    17 . Reading food labels is an essential part of a weight loss or management plan. The first step in examining the nutrition facts on a food label is to note the
    A) total fat content.
    B) number of calories.
    C) serving size and servings per package.
    D) percent daily values of various vitamins and minerals.

    NUTRITIONAL INTERVENTIONS TO PREVENT DIABETES

    For weight management and diabetes prevention, patients may be instructed to examine the nutrition facts on a food label (Figure 3) [70,71]. The first step is checking serving size and servings per package. Note that even small packages may have more than one serving. This can be misleading, as many people would expect to eat the entire package in one sitting. If the person eats the entire package of a container having two servings, all of the nutritional values on the label must be doubled. Eating just one serving is essential. A 2016 redesign of the nutrition facts label bolds serving size and number of servings to address this issue [72].

    Click to Review



    18 . The percent daily values that appear on food labels are based on a daily intake of
    A) 1,000 calories.
    B) 1,500 calories.
    C) 1,750 calories.
    D) 2,000 calories.

    NUTRITIONAL INTERVENTIONS TO PREVENT DIABETES

    The percent daily value is also a useful tool. If a food has 5% or less of fat, cholesterol, and sodium, it is a good choice [71]. Foods that are high in fiber, vitamins A and C, calcium, and iron will have 20% or more of the recommended daily value; these are good foods to incorporate into one's diet. Note that percent daily values are average levels of nutrients for a person eating 2,000 calories per day, and a person trying to lose weight will usually require less than 2,000 calories per day. Use these values only as a guide for evaluating the relative nutrient content of foods [71,72].

    Click to Review



    19 . Which of the following is a good source of omega-3 fatty acids?
    A) Poultry
    B) Walnuts
    C) Olive oil
    D) Fatty fishes, such as salmon

    NUTRITIONAL INTERVENTIONS TO PREVENT DIABETES

    Polyunsaturated fatty acids, such as omega-3 fatty acids, improve insulin sensitivity and may help reduce risk for cardiovascular disease by reducing triglycerides, increasing HDL cholesterol, and lowering blood pressure [22]. Good sources include salmon, sardines, herring, trout, and other fatty fish, as well as fish oil supplements. Dietary guidelines recommend consuming at least two servings of non-fried fatty fish per week. Dietary supplements of omega-3 fatty acids may be recommended for people who cannot meet this requirement from diet alone. People using anticoagulant medications should be medically supervised when taking these supplements.

    Click to Review



    20 . In addition to a healthful diet and modest calorie restriction, the American Diabetes Association recommends a minimum of how much physical activity for the prevention of type 2 diabetes?
    A) 60 minutes of moderate intensity aerobic activity five or more days per week
    B) 75 minutes of moderate-to-vigorous intensity aerobic activity per week
    C) 150 minutes of moderate-to-vigorous intensity aerobic activity per week
    D) 300 minutes of moderate-to-vigorous intensity aerobic activity per week

    EXERCISE TO PREVENT DIABETES

    As noted, for the prevention of type 2 diabetes, the ADA recommends a minimum of 150 minutes of moderate-to-vigorous intensity aerobic activity per week, along with a healthful diet and modest calorie restriction. Aerobic exercise is defined as "rhythmic, repeated, and continuous movements of the same large muscle groups for at least 10 minutes at a time" [36]. Examples include walking, bicycling, dancing, water aerobics, and many sports [36]. Because the effect of exercise on insulin sensitivity does not last longer than 72 hours, patients will experience the most benefit to blood glucose if aerobic sessions are no more than two days apart [36,80].

    Click to Review



    21 . Which of the following is an example of a resistance exercise?
    A) Weight lifting
    B) Walking briskly
    C) Stationary bike riding
    D) Cross-country distance running

    EXERCISE TO PREVENT DIABETES

    Experts recommend resistance exercise be a component of the complete fitness program for healthy adults. Resistance exercise is defined as, "activities that use muscular strength to move a weight or work against a resistive load" [36]. Examples include weightlifting, working with resistance bands, and using weight machines.

    Click to Review



    22 . When considering the initiation of an exercise routine with greater intensity than activities of daily living, an exercise stress test with electrocardiogram is recommended for all individuals with diabetes who
    A) have a history of asthma.
    B) are older than 40 years of age.
    C) have a body mass index greater than 30.
    D) have symptoms of microvascular complications.

    EXERCISE TO PREVENT DIABETES

    While there are no specific recommendations for evaluating the person with prediabetes for exercise clearance, guidelines do exist for people with diabetes and other chronic conditions. The ADA recommends that people with diabetes should be assessed before beginning a program of physical activity if it is going to be more vigorous than brisk walking. This assessment should include looking for conditions that may be associated with increased likelihood of cardiovascular disease. However, the circumstances under which a graded electrocardiogram (EKG) stress test should be considered are not well defined. Cost analysis studies have indicated that the widespread use of this test is cost-prohibitive, partly due to high risk of false-positive results, which trigger subsequent invasive testing procedures. The recommendation is that medical providers weigh the potential benefits of this type of testing against risks and costs in each individual case. In general, it is advised that anyone with diabetes older than 40 years of age be considered for an exercise stress test with EKG monitoring before undertaking aerobic physical activity with an intensity greater than the demands of everyday living, which is defined as more intense than brisk walking [83].

    Click to Review



    23 . Which of the following is NOT a factor that has been found to influence maintenance of exercise behavior?
    A) Exercising alone
    B) Setting realistic goals
    C) Setting and sticking to a schedule
    D) Identifying alternatives to reduce boredom

    EXERCISE TO PREVENT DIABETES

    It is also important to help patients select a program that will have the greatest chance for long-term maintenance. The ACSM has identified factors that influence maintenance of exercise behavior [80]:

    • Setting realistic goals

    • Setting an exercise schedule in advance and sticking to it

    • Using an exercise partner

    • Encouraging self-rewards

    • Identifying alternatives to reduce boredom

    • Accepting off days and being able to return to the program after backsliding

    Click to Review



    24 . Which of the following is a strategy to help patients overcome a time barrier to participating in an exercise program?
    A) Scheduling exercise
    B) Waking earlier to exercise
    C) Including exercise in a regular daily routine
    D) All of the above

    EXERCISE TO PREVENT DIABETES

    After barriers to exercise have been identified, steps can be taken to help patients overcome them. For each barrier, ask the patient what he or she thinks could help; this will allow the patient to be actively involved in resolving the barriers. Then, provide suggestions to supplement the patient's problem-solving activity. Common barriers to exercise and suggestions for helping patients overcome them include:

    • Not enough time: Strategies may include scheduling time for exercise, walking on lunch break, waking 30 minutes earlier, and/or including exercise in the regular daily routine, such as on the way home from work.

    • Too out of shape: Suggest starting slowly and gradually increasing both duration and intensity of exercise. Explore the feasibility of using a pedometer, and reinforce that even a little bit of activity is better than none at all.

    • Too tired: Propose exercising at times of day when energy level is higher. Educate that many people feel more energetic overall when they are active on a regular basis.

    • Not motivated: Recommend getting social support and/or finding an exercise partner. Ask the patient to identify what would help him or her get and stay motivated. Explore which types of activities would be most appealing.

    Click to Review



    25 . Which of the following exercises may be recommended to the individual who enjoys watching television?
    A) Gardening
    B) Workout video
    C) Home exercise equipment
    D) Treading water while talking

    EXERCISE TO PREVENT DIABETES

    Evaluating one's "exercise personality" is a way of identifying the type of activity that is most suitable for an individual. Examples of personality factors and corresponding types of exercise may include [91]:

    • Likes to be outside: Walking, gardening with a shovel or rake, hiking, bicycling, swimming

    • Likes to watch television: Treadmill, aerobic programs on television, stationary bicycle, other home exercise equipment

    • Likes social events: Mall walking, walking for a cause (e.g., diabetes, breast cancer), taking a class, treading water while talking with friends, dancing

    • Likes to be alone: Workout video, swimming, solitary walk in a safe environment, cardiovascular exercise equipment (e.g., treadmill)

    • Needs direction: Exercise classes, walking partner or group, guided hikes, a personal trainer

    • Family oriented: Active outings, ball games

    Click to Review



    26 . Which of the following medications is approved by the U.S. Food and Drug Administration for the prevention of diabetes?
    A) Orlistat
    B) Glucagon
    C) Metformin
    D) None of the above

    PHARMACOTHERAPY FOR PATIENTS WITH PREDIABETES

    As of 2018, no drug is approved by the FDA to prevent diabetes or treat insulin resistance. However, metformin is recommended by the ADA for the prevention of diabetes in certain patients [14,93]. Consensus criteria for considering the use of metformin in addition to lifestyle intervention are [14]:

    • Very high risk, defined as combined IFG and IGT, plus another risk factor, such as:

      • A1c 5.7% to 6.4%

      • Hypertension

      • Low HDL cholesterol

      • Elevated triglycerides

      • Family history of diabetes in a first-degree relative

    • Obesity

    • Age younger than 60 years

    • Women with prior gestational diabetes

    Click to Review



    27 . The American Diabetes Association consensus criteria for considering the use of metformin in addition to lifestyle intervention for the prevention of diabetes includes
    A) low body mass index.
    B) age older than 60 years.
    C) a family history of diabetes with no other risk factors.
    D) impaired fasting glucose, impaired glucose tolerance, and elevated triglycerides.

    PHARMACOTHERAPY FOR PATIENTS WITH PREDIABETES

    As of 2018, no drug is approved by the FDA to prevent diabetes or treat insulin resistance. However, metformin is recommended by the ADA for the prevention of diabetes in certain patients [14,93]. Consensus criteria for considering the use of metformin in addition to lifestyle intervention are [14]:

    • Very high risk, defined as combined IFG and IGT, plus another risk factor, such as:

      • A1c 5.7% to 6.4%

      • Hypertension

      • Low HDL cholesterol

      • Elevated triglycerides

      • Family history of diabetes in a first-degree relative

    • Obesity

    • Age younger than 60 years

    • Women with prior gestational diabetes

    Click to Review



    28 . Although acarbose has been studied for use in the prevention of diabetes, its efficacy and practicality in actual clinical practice have been questioned due to significant
    A) hepatic side effects.
    B) pulmonary side effects.
    C) cardiovascular side effects.
    D) gastrointestinal side effects.

    PHARMACOTHERAPY FOR PATIENTS WITH PREDIABETES

    Another drug, acarbose, was found to reduce the progression of IGT to type 2 diabetes by 25% over 3.3 years in one study [97]. Because this medication can cause significant gastrointestinal side effects, many subjects discontinued the study medication [96]. This raises questions about the efficacy and practicality of using acarbose to prevent type 2 diabetes in actual clinical practice [97].

    Click to Review



    29 . In a 2010 study, what percentage of gastric banding patients with type 2 diabetes experienced a return to normal glycemia after the procedure?
    A) 24%
    B) 53%
    C) 73%
    D) 99%

    METABOLIC SURGERY

    Reviews and meta-analyses of publications concerning metabolic surgery have consistently found improvement or resolution of diabetes in the majority of patients. A 2010 study demonstrated that gastric banding surgery could induce a remission of existing type 2 diabetes, with 73% of the study group returning to normal glycemia. Another study indicated that gastric banding induced prolonged satiety and resulted in improved glycemic control. Of those who did not achieve euglycemia, glycemic control was improved [97]. This suggests that surgical intervention may be an appropriate approach for preventing diabetes in select patients who are unable to lose weight by other means. The ADA recommends considering metabolic surgery for adults with a BMI of 40 or greater (37.5 or greater in Asian Americans) regardless of the level of glycemic control and in adults with a BMI greater than 35 (32.5–37.4 in Asian Americans) who have type 2 diabetes or associated comorbidities when lifestyle interventions are unsuccessful [14]. After metabolic surgery, patients should receive ongoing lifestyle support and medical monitoring [14].

    Click to Review



    30 . The American Diabetes Association recommendation is
    A) not to screen children for prediabetes.
    B) to screen for prediabetes in children with body mass indices greater than 30.
    C) to consider screening for prediabetes in children born to mothers with gestational diabetes.
    D) to screen for prediabetes in children and adolescents who are overweight and who have one or more additional risk factors for diabetes.

    PREVENTING DIABETES IN CHILDREN

    More research is necessary to determine how to address prediabetes in children. It is unknown whether children with prediabetes have the same degree of risk for developing type 2 diabetes as adults with prediabetes, or if the predictors for long-term risks of diabetes are the same for children [106,107]. The ADA recommends screening for prediabetes in children and adolescents younger than 18 years of age who are overweight or obese and who have one or more of the following risk factors for diabetes [14]:

    • Maternal history of diabetes or gestational diabetes during the child's gestation

    • Family history of type 2 diabetes in first- or second-degree relative

    • Race/ethnicity (e.g., Native American, African American, Latino, Asian American, Pacific Islander)

    • Signs of insulin resistance or conditions associated with insulin resistance (i.e., acanthosis nigricans, hypertension, dyslipidemia, PCOS, or small-for-gestational-age birth weight)

    Click to Review



    31 . The Centers for Disease Control and Prevention recommend that children and adolescents participate in
    A) 15 to 20 minutes of physical activity every day.
    B) 30 minutes of physical activity on most days.
    C) 60 minutes of physical activity every day.
    D) 120 minutes of physical activity every week.

    PREVENTING DIABETES IN CHILDREN

    The CDC recommends that children and adolescents participate in at least 60 minutes of physical activity every day [109]. A study presented at the 2010 ADA annual meeting revealed that obese boys who engaged in aerobic and resistance exercise decreased their total body fat, visceral fat, and insulin resistance, even without any changes in diet [110]. The study also indicated that resistance exercise training is appealing to boys and that it expends similar energy to aerobic training in this population.

    Click to Review



    32 . Tips for the family working to become more active include all of the following, EXCEPT:
    A) Assign children to active chores.
    B) Have children walk or ride their bikes to school when possible.
    C) Have active family outings, such as walks, ball games, and swimming.
    D) Limit television, computer, or video game time to no more than four hours per day.

    PREVENTING DIABETES IN CHILDREN

    Tips for the family working to become more active include:

    • Limit television, computer, or game "screen time" to less than two hours per day.

    • Assign children to active chores, such as raking leaves or carrying grocery bags.

    • Have children walk or ride their bikes to school when possible.

    • Have active family outings, such as walks, ball games, and swimming.

    • Encourage sports. If the child is not competitive, look for team activities that focus on fun and participation rather than winning.

    • Parents can be good roles models by being active themselves.

    Click to Review



    33 . Hispanic adults are
    A) 1.2 times more likely than non-Hispanic white adults to be diagnosed with diabetes.
    B) 1.3 times more likely than non-Hispanic white adults to be diagnosed with diabetes.
    C) 1.5 times more likely than non-Hispanic white adults to be diagnosed with diabetes.
    D) 1.7 times more likely than non-Hispanic white adults to be diagnosed with diabetes.

    ETHNIC VARIABILITY AND CULTURAL CONSIDERATIONS

    Diabetes is an urgent issue in the Latin American/Hispanic communities. Hispanic adults are 1.7 times more likely than non-Hispanic white adults to be diagnosed with diabetes [117]. Rates of complications of diabetes are also higher among this group. Abdominal obesity and insulin resistance greatly increase the risk for metabolic syndrome in this population.

    Click to Review



    34 . Which of the following is a traditional part of the Hispanic diet?
    A) Cabbage
    B) Pineapple
    C) Butter beans
    D) Turnip greens

    ETHNIC VARIABILITY AND CULTURAL CONSIDERATIONS

    The traditional Hispanic diet is high in fruits, vegetables, and fiber, and low in fat. However, acculturation to the American diet has changed traditional preferences and practices to a less healthy style of eating. Healthy choices most likely to appeal to this population include [115]:

    • Vegetables: Cabbage, carrots, cassava, jicama, nopales, peppers, tomatoes (salsa)

    • Fruits: Açaí, agave, banana, cherimoya, guava, mango, passion fruit, starfruit

    • Grain/starch: Amaranth, bread, corn, pasta, quinoa, rice, tortilla

    • Legumes, nuts, seeds: Pine nuts, black, garbanzo, kidney, and pinto beans

    • Protein: Abalone, crab, sea bass, cod, chicken, eggs, beef, pork

    • Dairy: Asadero cheese, yogurt, milk

    Click to Review



    35 . Which of the following modifiable cardiovascular risk factors occurs at a high prevalence in the African American community?
    A) Obesity
    B) Hypertension
    C) Sedentary lifestyle
    D) All of the above

    ETHNIC VARIABILITY AND CULTURAL CONSIDERATIONS

    African Americans have a high prevalence of cardiovascular risk factors that may be reduced with lifestyle modification. These include obesity, hypertension, sedentary lifestyle, and tobacco use [114,118]. Unfortunately, studies have indicated that African Americans are less likely to participate in health screening programs. This is due in part to poor access, but may also stem from cultural and historical factors, such as mistrust in the healthcare system stemming from a history of inequitable treatment [114].

    Click to Review



    36 . Use of body mass index to predict diabetes risk is not as reliable among Asian Americans because
    A) they tend to have much lower body fat percentages.
    B) central adiposity is the only reliable predictive factor.
    C) they tend to develop insulin resistance and type 2 diabetes at much lower indices.
    D) they tend to develop insulin resistance and type 2 diabetes at much higher indices.

    ETHNIC VARIABILITY AND CULTURAL CONSIDERATIONS

    The incidence of diabetes among Asian Americans has increased more rapidly among those who have lived in the United States for a longer period of time than among new immigrants or those living in Asia [114]. Japanese individuals living in Seattle have diabetes prevalence four to five times that of those living in Tokyo [114]. Use of BMI is not as reliable a tool for predicting diabetes risk in Asian populations, as they tend to develop insulin resistance and type 2 diabetes at much lower indices [121]. The International Diabetes Federation has determined lower measures of waist circumference for determining health risk in Asian populations [121].

    Click to Review



    37 . The first construct of the Health Belief Model is
    A) self-efficacy.
    B) cues to action.
    C) perceived barriers.
    D) perceived susceptibility.

    BEHAVIOR CHANGE

    Perceived susceptibility is the first construct of the HBM. This may be reflected by the patient considering "What is the likelihood that I will get diabetes?" Patients who believe the risk is low will be less likely to make changes to prevent diabetes. Educating patients about the risk factors for diabetes will help them understand their susceptibility.

    Click to Review



    38 . Which of the following is NOT one of the U.S. Preventive Services Task Force's Five A's protocol?
    A) Agree on patient goals.
    B) Advise patient about what to change.
    C) Analyze effectiveness of interventions.
    D) Assess current practices, barriers, and readiness to change.

    BEHAVIOR CHANGE

    The U.S. Preventive Services Task Force has developed the Five A's protocol, a widely used framework for supporting behavior change in clinical settings [128]. The Five A's protocol can help structure an approach to help patients make health behavior changes. The Five A's are [128]:

    • Assess current practices, barriers, and readiness to change.

    • Advise patient about what to change.

    • Agree on patient goals (negotiate).

    • Assist with change strategies and overcoming barriers.

    • Arrange for resources and referral, follow-up, and support.

    Click to Review



    39 . According to Prochaska's Stages of Change model, a patient who acknowledges the need for change but remains acutely ambivalent and procrastinates would be the
    A) precontemplation stage.
    B) contemplation stage.
    C) preparation stage.
    D) action stage.

    BEHAVIOR CHANGE

    The contemplation stage begins when a patient becomes less resistant to the idea of behavior change. However, he or she remains acutely ambivalent about change and continues to procrastinate. At this time, the person acknowledges the need for change but is held back by his or her reasons for staying the same. A typical contemplative statement would be, "I would really like to exercise, but I just don't have the time." Although the prospect of change within the next six months is characteristic of this stage, people can remain in contemplation for an extended period of time. Patients may be assisted through this stage by promoting their self-efficacy and supporting their efforts to gather information. Specific interventions include reflective listening, providing empathic feedback, and offering information and resources as appropriate. Motivational interviewing, to be discussed in more detail later, is a powerful method for helping precontemplative and contemplative people move further along in the process of change.

    Click to Review



    40 . All of the following should be included in diabetes prevention programs, EXCEPT:
    A) Healthy eating behaviors
    B) Assessing readiness to change
    C) Identifying nonmodifiable risk factors
    D) Overcoming barriers to lifestyle change

    HEALTH EDUCATION FOR DIABETES PREVENTION

    Topics included in diabetes prevention programs include [70,140]:

    • Definition of prediabetes

    • Health risks associated with prediabetes

    • Identifying modifiable risk factors

    • Lifestyle interventions to prevent progression to type 2 diabetes

    • Significance of cardiovascular health and risk reduction

    • Healthy eating behaviors

    • Exercise recommendation

    • Weight-loss strategies

    • Assessing readiness to change

    • Overcoming barriers to lifestyle change

    • Goal setting and action planning

    • Medical follow up to monitor blood glucose, lipids, weight, and blood pressure

    • Signs and symptoms of hyperglycemia and when to call a healthcare provider

    Click to Review