Tag: blood sugar

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Exercise Is Our Jam

brisk walking

Eat less, move more, yadda, blah blah, harrumph.

We’ve heard it. We know we should do it. If for no other reason than because it’s a healthy way to live. And, if we’re prediabetic, it helps to reduce our chance of developing full-blown diabetes.[1]

In this post, let’s focus on the “move more” part.

We want to move more, we just want the right to complain about it along the way.

But bonus, they say that once we start exercising, endorphins will race through our bodies and make us happy. Plus they’re supposed to numb the pain. (Looking forward to that.)

A position statement[2] from the American Diabetes Association says that diabetics and prediabetics should participate in physical activity and exercise. So there’s that, for an added bit of motivation.

Before you leap off the couch and start running in place, talk to your healthcare provider to get guidance on what type and how much exercise you should try.

Moderate exercise[3] appears to be more than adequate in combating the elevated blood sugar of prediabetes. Moderate means you have enough breath to chat while exercising, but not enough to sing. No need to practice sprinting when brisk walking will do.

Exercise loosely falls into four categories: aerobic, strength, balance, and flexibility. Ideally, your week will include all of these types of exercise.

Aerobic, or endurance, exercise cranks up our heart rate and breathing. Brisk walking, hopping on the elliptical, dancing (not slow dancing, the other kind), quick marching in place—whatever activity you want to try that gets your heart rate up will be fine.

Strength training is good for all ages, but as we get older, we lose muscle mass. If you’re middle-aged or older, this means you. Resistance training with bands or weights, push-ups against the wall (or floor, if that’s your preference), squats and lunges—they all help rebuild muscle.

Balance exercises are key to preventing falls as we age. Practicing Tai Chi, standing on one foot or walking heel to toe, side-stepping across a room—there are lots of ways to improve balance, but remember, it’s generally safer to work with a partner.

Flexibility exercises keep our body limber. Without flexibility, it gets hard to bend down and pick up money off the floor. Reason enough to stay loose. Stretching each muscle group, yoga, shoulder rolls, using stretch bands—aging muscles get shorter and lose elasticity, but stretching regularly counters the aging effect.

We need to get off our rears and move. If you find that you’re sitting for a few hours each day, make it a habit to get up every 30 minutes and stretch, do a household chore, just move.

Remember, this is for a healthier body and, more specifically, to knock our blood sugar into normal range. In other words, it’s important!

Thirty minutes each day, move at a moderate pace. Get your heart rate up. If you don’t have time to do this for a 30-minute block of time, then break it up into three 10-minute blocks. As long as you get the minutes in and your heart rate is increased for 30 minutes every day, that’s the important bit.

If your lifestyle has been sedentary for a few years, plan a slow but definite path to moderate exercise for 30 minutes each day.

Start out with three minutes of stretching and don’t worry about increasing your heart rate. Do this for four days, then add three minutes of walking as fast as you feel comfortable. And so on.

Keep adding in minutes of activity every few days until you are active for 30 minutes each day. Once you’ve reached that threshold, take a few of those minutes and exercise at a moderate level. Build from there, and within a few weeks, you’ll be exercising at a moderate level for 30 minutes each day.

The timeframe for building a healthy exercise routine will be individual. The only person we need to compare ourselves to is . . . ourself.

How Zen is that?!

[1] Cochrane Library, Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus, https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003054.pub4/full, (February 3, 2020).

[2] American Diabetes Association, Diabetes Care, Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association, https://care.diabetesjournals.org/content/39/11/2065, (February 3, 2020).

[3] Duke Health, Is Moderate or Vigorous Exercise Best for Glucose Control?, https://physicians.dukehealth.org/articles/moderate-or-vigorous-exercise-best-glucose-control, (February 3, 2020).

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Relationships: Insulin and Blood Sugar

Who cares about insulin? Or blood sugar? And what are they, anyway?

Most of us have heard the words, but we’re not clear on the roles that insulin and blood sugar play in our bodies.

We need to learn, because they matter. Especially if we’re prediabetic and have too much blood sugar (glucose) floating around inside.

Here’s how the insulin/blood sugar relationship works:

Let’s say we’re having shrimp, some white rice, and an avocado for lunch. We’ll skip the green vegetable because we don’t need it for this example.

Once eaten, all three food items will break down and provide energy (food) to our body.

The shrimp provides proteins, which become amino acids.

The rice provides carbohydrates, which become sugars (also known as blood sugar, or glucose).

The avocado provides fats, which become fatty acids and glycerol.

Because we’re prediabetic, we’ll focus on the carbohydrates.

The cells in our body are clamoring for their lunch. And since we’re made up of cells, it’s important to feed the little guys. They want a boost to get them through a long afternoon. They want a sugar boost because that’s what most of the cells prefer for energy. Come on, carbs!

The sugar, which is what the rice became after it was digested, is floating around in the blood and the body notices that there’s extra sugar (food) ready to be transported to the hungry cells.

An alert is sent to the pancreas, a gland which is tucked down behind the tummy and next to the spine.[i] The alert goes to the islets of Langerhans – which sounds straight out of Lord of the Rings – and these little floating islands of cells in the pancreas start squirting out hormones called insulin.

The majority of the body’s cells aren’t going to let the sugar just walk in. Our cells are like hotel rooms requiring a key to open.

This is where the insulin shines. The insulin is the key. It attaches to the cell and unlocks it, letting the sugar in to feed the cell. You’d think the cell wouldn’t require coaxing to be fed, but that’s how it works.

Insulin also shepherds extra blood sugar into the liver where it’s stored until the body needs it. Maybe it’ll get called out if you haven’t eaten for several hours, or you’re exercising and need the extra food for your cells.

All of this happens when the body is working as it should, but what happens if your body isn’t cranking out enough insulin? Or what if your cells don’t want to open up when insulin comes knocking?

If your body can’t control the amount of sugar (glucose) floating around in your blood, that’s when trouble starts.

Too much blood sugar floating around and not doing its job of feeding cells, or simply sitting in storage until it’s needed, can cause damage to the body.

There’s a window of time where our body’s in trouble but not yet in full type 2 diabetes. That’s where we are – in prediabetes land.

If we don’t do something about the insulin problem, we’ll cross the border into type 2 diabetes land.

Once we’re living with type 2 diabetes, we’re at a much higher risk of stroke, heart disease, kidney failure, nerve damage and vision loss.[ii] For starters.

But, if we’re lucky enough to find out we’re prediabetic, and that’s a big if since 90% of those living with prediabetes don’t know it[iii], we have a good chance of successfully making the changes necessary to avoid type 2 diabetes, leave prediabetes behind, and get our bodies back to being efficient at the whole insulin/blood sugar relationship.

[i] Johns Hopkins Medicine/Pathology, The Pancreas, http://pathology.jhu.edu/pc/BasicOverview1.php?area=ba, (March 5, 2019).

[ii] Centers for Disease Control and Prevention, Diabetes Quick Facts, https://www.cdc.gov/diabetes/basics/quick-facts.html, (March 5, 2019).

[iii] Centers for Disease Control and Prevention, Prediabetes: Your Chance to Prevent Type 2 Diabetes, https://www.cdc.gov/diabetes/basics/prediabetes.html, (March 5, 2019).

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Medications and Blood Sugar

As prediabetics, the number we look at on a daily basis is our fasting blood sugar level.

We can do that at home with a monitor. Knowing that number, as well as the numbers pre- and post-meal, helps us to track our prediabetes. These numbers give us the information we need to not eat this or eat more of that, with the end result (we hope) of reducing our blood sugar levels.

A sneaky enemy of blood sugar levels that most of us don’t think about is medicine.

Some of the prescription or over-the-counter medications we take raise our blood sugar. This can blow a big hole in our how-to-beat-prediabetes game plan.

It’s tricky if the medication that raises our blood sugar is one we absolutely must take!

Some blood pressure medications, like beta-blockers or thiazide diuretics[i], raise our blood sugar.

Steroids in oral (pill) form can bump our blood sugar level up, but if used in the form of a cream or inhaler, they’re generally not an issue[ii].

Other drugs can also affect blood sugar levels, such as niacin, which is a B vitamin, some antipsychotic drugs, and a sprinkling of others.

Because you’re prediabetic, you should have a quick conversation with your pharmacist about any prescription or over-the-counter drugs you’re taking, to see which might have an effect on your blood sugar. Then work with your provider to decide if the trade-off is worth it.

Sometimes, medications are the reason we’re prediabetic, which puts us in a real pickle if we can’t get off the meds.

We can’t ignore anything that affects our blood sugar. If we do our homework and make changes where we can, it will help us stay on the road that leads out of prediabetes land!

[i] Diabetes Self-Management, Drugs That Can Worsen Diabetes Control, https://www.diabetesselfmanagement.com/managing-diabetes/blood-glucose-management/drugs-that-can-worsen-diabetes-control/, (March 7, 2019).

[ii] WedMD, What Medicines Can Make Your Blood Sugar Spike?, https://www.webmd.com/diabetes/medicines-blood-sugar-spike, (March 7, 2019).

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Prediabetes: FAQ

What is prediabetes?

You have prediabetes when your blood sugar is higher than normal, but not high enough to be in the type 2 diabetes range. This condition puts you at increased risk of developing type 2 diabetes or other health problems, such as heart disease and stroke. Prediabetes should be taken seriously, but it’s not necessarily permanent, as it can be reversed in many cases.

What causes prediabetes?

Many cells in our body like to eat sugar for energy. Carbohydrates turn into sugar when we eat them. In response, the pancreas produces a hormone called insulin, which goes to the cells wanting energy and “unlocks” them, allowing the sugar to enter. If there’s more sugar than insulin, the sugar has nowhere to go and builds up in your blood.

Will I develop type 2 diabetes if I am prediabetic?

You have an excellent chance of stopping the progression to type 2 diabetes. It is not a one-way path, although if you do nothing to combat it, you may develop type 2 diabetes at some point.

What are the risk factors for prediabetes?

Most specialists agree that these are the primary risk factors:

Age 45 and older: Prediabetes can come on at any age, but the older you get the more at risk you are.

Affected family members: If your parents or siblings have type 2 diabetes, that increases your chance of becoming prediabetic.

Weight: Are you chubby, obese, fat? Do you carry that extra weight around the middle? This is one of the biggest risks for prediabetes.

Exercise: Actually, the lack of exercise. If you’re not active at least three times a week, this puts you at risk.

Ethnicity/Race: Although it’s not clear why, if you’re Latinx, African American, Native American, Asian American, or Pacific Islander, you may be at higher risk of developing prediabetes.

PCOS: Polycystic Ovary Syndrome. If you have it, it is a risk factor.

Gestational Diabetes: Developing this during pregnancy, or giving birth to a baby weighing more than nine pounds, increases your risk of developing prediabetes.

Sleep: If your sleep is interrupted or just not good, this is a risk factor.

How do I know if I have prediabetes?

Not everyone has symptoms. The best way to determine if you’re prediabetic is to get a blood test done. There are exceptions to how blood test results are interpreted. Your provider will let you know what they mean for you, but the following is a general picture of what testing is done, and what the results indicate.

The first test snaps a picture of what your blood sugar has been doing for the last two or three months. It’s called the Hemoglobin (A1C) test and is usually the first one providers use when diagnosing prediabetes.

A1C below 5.7 percent is normal

A1C between 5.7 and 6.4 percent is prediabetes

A1C 6.5 percent or higher in tests done on two different days is type 2 diabetes

Next is the Fasting Blood Sugar test. Blood is taken after you’ve been fasting for eight hours or overnight.

Fasting blood sugar below 100 mg/dL is normal

Fasting blood sugar between 100 and 125 mg/dL is prediabetes

Fasting blood sugar 126 mg/dL or higher (in tests done on two different days) is type 2 diabetes

The third test is not used for everyone. It’s called the Oral Glucose Tolerance test. After fasting for eight hours or overnight your blood is tested. You then drink a sugary concoction and two hours later your blood is tested again.

Blood sugar below 140 mg/dL is normal

Blood sugar between 140 and 199 mg/dL is prediabetes

Blood sugar 200 mg/dL or higher is type 2 diabetes

Is prediabetes reversible?

The answer is yes, prediabetes is reversible for some. Three factors play a big part for the majority who reverse their prediabetes diagnosis: weight loss, exercise, and a change in eating habits. Work with your provider and a nutritionist to develop a common-sense plan of action.

Is there treatment for prediabetes?

In addition to weight loss, exercise, and a change of eating habits, healthcare professionals will sometimes recommend metformin, a drug that helps your body control its high blood sugar levels. If you are able to reverse your prediabetes, you’re typically taken off of metformin.

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Eat to Your Meter

Diabetics test their blood sugar several times a day. They do this to check that medications are working as they should, and to see if their blood sugar is too high or too low.[1]

If blood sugar levels are too far outside the norm for a diabetic, that can be a serious health risk.

Why would someone diagnosed with prediabetes choose to self-monitor? It’s not a standard recommendation, but maybe it should be.

If you’ve been diagnosed as prediabetic, you probably get your A1C[2] tested every few months or annually to see if you’ve developed type 2 diabetes. You go to the lab, get a blood draw, and you’re done.

Kind of important to know if you’ve moved from prediabetes to type 2 diabetes.

But, the A1C test is not the only test that is used to diagnose diabetes.

After all, according to the experts, you only need two days of fasting plasma glucose at or greater than 126 mg/dL to be diagnosed diabetic.[3]

It’s possible to be prediabetic and develop full-blown diabetes between those occasional A1C tests.

Self-monitoring your blood sugar can alert you to full-blown diabetes, or that you’re dangerously close to it. This awareness gives you time to immediately stop what you’re doing and try to correct course.

It also helps you to learn what your body tolerates in the way of food and drink, and it shows you what exercise does to your blood sugar levels.

Self-monitoring allows you to learn at a granular level just what’s happening with your blood sugar, and what you can do to affect it.

Use a blood sugar monitor (also called a meter) to discover exactly where your blood sugar is – if you’re prediabetic, normal, or officially a type 2 diabetic.

If you believe you have developed full-blown diabetes, you’ll want to have that confirmed by your healthcare provider, and a medical plan will be put into place.

“Eat to your meter” is a phrase you may hear when chatting to other prediabetics. It means you use the meter to guide you away from foods that make your blood sugar levels go up. Or conversely, toward foods that sustain you and don’t throw your blood sugar out of whack.

Since the goal is to get your blood sugar to stay down in the normal range, rather than the prediabetic range (and definitely not in the diabetic range), it’s necessary to eat more of this and less of that. What “this” and “that” is depends on your body, and that’s what eating to a meter can help you figure out.

Some prediabetics can eat carbs from, say, a carrot or even a carrot cake, and their blood sugar blips up then back down. Other prediabetics will get a big long-lasting bounce in their blood sugar if they eat carbs from the same sources.

Because prediabetes can cause some of the same problems as full-blown diabetes, it’s time to get aggressive in the fight against elevated blood sugar.

According to a thoroughly unscientific interview process performed through an online support group, prediabetics who choose to use a meter seem to find that they use it a lot early on. After a few months, they don’t use it as much because they’ve learned what works for them and what doesn’t.

Changes in lifestyle (food choices, exercise levels, weight control) based on what the meter is saying help them move toward normal levels of blood sugar, and soon they find they don’t need to use a meter to know what they should be eating and how much they should be exercising.

If you decide to start using a meter, you can buy one over the counter in your local pharmacy.

Be aware that insurance doesn’t always cover the cost of the meter and the strips.

Each meter will be slightly different so read the instructions before use, but these are the basic steps to using a meter:

  • Wash and dry your hands and then, if possible, use an alcohol wipe on the pad and sides of a fingertip. This is for infection control and to remove any substance which might affect the test results.
  • Insert a strip into the meter.
  • Use the included needle to poke the pad or side of your fingertip. No need to aggressively stab yourself. Keep it shallow, just enough to draw a tiny bit of blood. Squeeze around the hole to get a drop of blood if it isn’t immediately evident.
  • Touch the strip as indicated to the drop of blood, and your meter should tell you your blood sugar level after a few seconds.

Talk with your healthcare provider about what numbers you should be looking for, but generally speaking, as prediabetics our goal is to have numbers in the normal (rather than prediabetic) range:

  • before a meal the meter should read between 70 and 99 mg/dl (3.9–5.5 mmol/L) for normal blood sugar levels
  • two hours after a meal the meter should read less than 140 mg/dl (7.8 mmol/L) for normal blood sugar levels

It’ll be helpful to note what you’re eating. This makes it easier for you to remember foods and amounts that work for you.

Using apps such as the popular Carb Manager (free) or Carb Manager Premium (not free) is a common way to do this. (We are not associated with Carb Manager, but we do use the app.)

There are dozens of helpful apps, so choose one that makes the process of tracking foods and whatever else you want to track the easiest for you.

If you check your blood sugar before eating and it is 105 (a little higher than normal because you’re prediabetic) and two hours after you start eating a banana it is 145, then next time, try eating half a banana. Or cut bananas from your list of foods. For now.

Remember, the goal is to identify how individual foods affect your blood sugar levels, and to stay away from those that make it stay elevated.

[1] Mayo Clinic, Blood sugar testing: Why, when and how, https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/blood-sugar/art-20046628, (May 20, 2019).

[2] National Institute of Diabetes and Digestive and Kidney Diseases, Diabetes Tests & Diagnosis, https://www.niddk.nih.gov/health-information/diabetes/overview/tests-diagnosis, (May 20, 2019).

[3] https://www.niddk.nih.gov/health-information/diabetes/overview/tests-diagnosis.

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The Harm in Prediabetes

Your doctor says you’re prediabetic.

So what? What does it mean?

Is it like preseason baseball (which is really just practice)?

Maybe it’s like preschool, which is all-day recess with a few rules. Not really school with homework and a teacher who can chill your bones with one glance.

Or, maybe it’s a preview of what’s going to happen to your sorry self if you don’t wake up and take care of business before you’re into full-blown diabetes.

Too harsh? Too bad.

High blood sugar speeds up cognitive decline[1]. It doesn’t have to be a super high level of blood sugar. What are classified as prediabetic levels will do it.

Our ability to reason, remember, use good judgment—all of those can start to slip when we live with high blood sugar for too long a period.

Prediabetes also increases our risk of having a stroke or heart attack or (simply) cardiovascular disease[2].

One of the most common complications of diabetes is also a complication of prediabetes. Nerve damage, or diabetic neuropathy[3]. And guess what? Nerve damage can happen not just in the feet, but throughout the body, affecting, well, pretty much everything.

Prediabetes isn’t benign. It’ll throw you to the ground and stomp on you.

It’s not OK to cruise along in a prediabetic state and just hope we don’t develop full-blown diabetes. High blood sugar is hurting us. We all need to act now to get that blood sugar down to normal levels.

[1] Science Direct, Prediabetes and diabetes accelerate cognitive decline and predict microvascular lesions: A population-based cohort study, https://www.sciencedirect.com/science/article/pii/S1552526018332497, (April 15, 2019).

[2] BMJ, Association between prediabetes and risk of cardiovascular disease and all cause mortality: systematic review and meta-analysis, https://www.bmj.com/content/355/bmj.i5953, (April 15, 2019).

[3] Science Direct, Deep phenotyping neuropathy: An underestimated complication in patients with pre-diabetes and type 2 diabetes associated with albuminuria, https://www.sciencedirect.com/science/article/pii/S0168822718307575, (April 15, 2019).

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Highlights of the Prediabetes Consensus Statement

In 2008, endocrinologists got together and came out with a consensus statement on prediabetes,[1] which seems to be the most current prediabetes consensus statement from this group.

Not much has changed over the years, except for the number of people affected by prediabetes. That figure continues to grow.

You can read the statement online, but who doesn’t love the highlights-only version of pretty much anything that has 33 words in the title?

Here goes:

Introduction

There are hundreds of millions of people around the world with prediabetes.

The scary side of diabetes (stroke, nerve damage, heart disease, and so much more) seems to begin before full-blown diabetes sets in. If you’re prediabetic, you’re at risk for many of the medical complications that affect diabetics.

There are no FDA-approved medications for prediabetes. It was true in 2008, and is still true today.[2]

The Tests

The endocrinologists agree on what the blood work looks like for those who have normal blood sugar, those who have high blood sugar but aren’t yet diabetic (aka prediabetics), and those who are diabetic.

In the statement, they don’t mention using the A1C test as a first measurement of prediabetes, but it’s common to do so now. Therefore, it’s included here.

This test snaps a picture of what your blood sugar has been doing for the last two or three months. It’s called the Hemoglobin (A1C) test and is usually the first one providers use when diagnosing prediabetes.

  • A1C below 5.7 percent is normal.
  • A1C between 5.7 and 6.4 percent is prediabetes.
  • A1C 6.5 percent or higher in tests done on two different days is type 2 diabetes.

Next is the Fasting Blood Sugar test, or Impaired Fasting Glucose test.

Blood is taken after you’ve been fasting for eight hours or overnight. You should not be active or drink anything, such as coffee, before the test that would affect carb metabolism.

  • Fasting blood sugar below 100 mg/dL is normal.
  • Fasting blood sugar between 100 and 125 mg/dL is prediabetes.
  • Fasting blood sugar 126 mg/dL or higher (in tests done on two different days) is type 2 diabetes.

The third test is called the Oral Glucose Tolerance test, or the Impaired Glucose Tolerance test.

After fasting for eight hours or overnight your blood is tested. You then drink a sugary concoction and two hours later your blood is tested again. You shouldn’t be active or smoke prior to this test.

Note that the endocrinologists consider this test to be the more important one because it 1) identifies those who have undiagnosed diabetes and 2) indicates those who have a greater risk of becoming diabetic.

Two hours after drinking the sugary concoction:

  • Blood sugar below 140 mg/dL is normal.
  • Blood sugar between 140 and 199 mg/dL is prediabetes.
  • Blood sugar 200 mg/dL or higher is type 2 diabetes.

Another note: The statement suggests the possibility that the higher end of “normal” is actually prediabetic because, in large population studies, physical abnormalities associated with prediabetes/diabetes are cropping up in those with high “normal” numbers.

And one more note: the endocrinologists say that prediabetes is diagnosed by either the fasting blood sugar test, the oral glucose tolerance test, or diagnosed metabolic syndrome, which is considered to be the same as prediabetes.

Get tested for prediabetes if you have one or more of these risk factors, as listed in the statement:

  • Family history of diabetes
  • Cardiovascular Disease
  • Being overweight or obese
  • Sedentary lifestyle
  • Non-white ancestry
  • Previously identified IGT, IFG, and/or metabolic syndrome
  • Hypertension
  • Increased levels of triglycerides, low concentrations of high-density lipoprotein cholesterol, or both
  • History of gestational diabetes
  • Delivery of a baby weighing more than 9 lb (4 kg)
  • Polycystic ovary syndrome
  • Receiving antipsychotic therapy for schizophrenia and severe bipolar disease

Treatment

The goal is to get blood sugar back to the normal range and treat high blood pressure and excess lipids (cholesterol and other fats in the blood) through medication. Controlling the blood sugar alone won’t automatically prevent heart disease or stroke associated with prediabetes and diabetes.

Meet with your healthcare provider to talk about where you are and where you want to be. Agree on the lifestyle changes you need to make to get you off the path to diabetes.

It boils down to:

Eat less, move more.

Cut calories, eat more fiber, go for healthy choices rather than simple carbs, which include fries, donuts, bread . . . and the list goes on. A nutritionist will lay it all out for you and help you figure out the crazy world of carbs.

You and your healthcare provider should decide if, in addition to cutting calories, drug therapy or other medical treatment is needed to help with weight loss.

Exercise, but don’t start out thinking you have to run a marathon. Your provider will suggest a safe level of exercise for you.

There is no FDA-approved drug therapy to prevent type 2 diabetes or to treat prediabetes, but your provider may decide to try some drugs off-label, depending on your risk factors. That’s another conversation you’ll need to have as you’re working on changing your lifestyle.

There’s more information in the consensus statement. A lot more, for those who love tackling sciencey jargon.

For those who prefer the CliffsNotes® version, we’re done!

[1] American Association of Clinical Endocrinologists, Diagnosis and Management of Prediabetes in the Continuum of Hyperglycemia—When Do the Risks of Diabetes Begin? A Consensus Statement From the American College of Endocrinology and the American Association of Clinical Endocrinologists, https://www.aace.com/files/prediabetesconsensus.pdf, (April 25, 2019).

[2] Medscape, What are the FDA-approved drugs for treatment of prediabetes or prevention of type 2 diabetes mellitus (DM)?, https://www.medscape.com/answers/117853-6619/what-are-the-fda-approved-drugs-for-treatment-of-prediabetes-or-prevention-of-type-2-diabetes-mellitus-dm, (April 29, 2019).