The Problem with the PRE in Prediabetes for Women in Midlife and Beyond

A diagnosis of “prediabetes” is worrisome for many women, because it’s believed to be a sign of poor health and the inevitability of developing diabetes. However, screening and identifying whether you are at risk for type 2 diabetes is an opportunity for education, lifestyle assessment, and health-promoting behavior modification to help prevent or delay the onset of type 2 diabetes.

Aging and Menopause

As we age, cells and tissues in the body may not function as robustly as they used to. We visibly see this with changes in the skin and hair. We may also notice these changes with the onset of arthritis in joints and soft tissue injuries (i.e. tendonitis).

There are many paths to the progressive loss of function associated with aging and disease that are driven by genetic and environmental factors. For women, estrogen provides a protective benefit for many tissues and cellular functions throughout the body. Therefore, the loss of estrogen during menopause is associated with notable physiological changes and increased disease risk.

So, that brings us to “prediabetes” or impaired blood glucose as one example of the impact of aging, and the changes that can occur with glucose homeostasis as we age and in the transition to menopause.

Unfortunately, diabetes has been stigmatized as a disease that is characterized by poor health, “unhealthy” lifestyle choices, eating too many carbs, and weight gain, which is not a true story. This shame-based messaging, especially for midlife women who are trying to maintain some sense of control at this stage of life, can be more damaging than the health concern itself.

What is “Prediabetes”?

Prediabetes, more accurately referred to as “impaired glucose tolerance” or “impaired fasting glucose,” is when blood glucose levels are above normal ranges but below the limit of diagnosing type 2 diabetes. However, the way this is defined varies by organization around the world.

The American Diabetes Association (ADA) defines “prediabetes” as a fasting blood glucose from 100 mg/dL to 125 mg/dL and a hemoglobin A_1c (HbA_1c) from 5.7% to 6.4% (a 3-month marker of blood glucose levels).

This differs from what researchers and medical advisors with the World Health Organization (WHO), the International Diabetes Federation (IDF), and the UK’s National Institute for Health Care Excellence (NICE) have determined as necessary for screening those at risk for the development of type 2 diabetes. The chart below highlights these differences.

A 2-hour oral glucose tolerance test (OGTT) is also a screening tool (the only measurement agreed on the health authorities), but is generally not used in clinical practice.

The argument for lower criteria is that early detection of diabetes helps prevent microvascular complications by implementing strict control on blood glucose levels. Others contend that when the ADA lowered the threshold with their definition of “prediabetes”, millions of Americans became “diagnosed” overnight with something that is merely a risk factor versus a condition to be treated. Consequently, a large number of “false positives” have been associated with these criteria, as demonstrated in a 2018 Cochrane review showing that between 60% and 30% of those “diagnosed” using the ADA criteria reverted to normal glucose levels within 1 to 5 years, respectively (Richter et al, 2018).

What’s the problem? Isn’t early detection a good thing?

Of course, early detection of disease is important and helps improve treatment outcomes! However, in the case of “prediabetes,” when adults, especially older adults, are told they have prediabetes, they are often subjected to undue stress and anxiety about their “diagnosis.” This often comes with a sense of urgency to lose weight or treat their “condition” with medication and consequently they may suffer personally and economically. Age-related changes in glucose metabolism can affect many older people but are often over-diagnosed by the ADA criteria  (Decode Study Group, 1998).

Treating “prediabetes” as a disease exposes middle-aged and older women to potentially harmful interventions, including weight-biased treatments that emphasize restricted diets and a cycle of weight loss and weight regain. Many women are prescribed unnecessary, unregulated supplements. Also disappointing is when providers dismiss menopause hormone therapy for eligible women, especially for those who report sleep disturbances, hot flashes, and night sweats, when this may be a meaningful intervention for addressing bothersome symptoms and potentially resolving blood glucose disturbances.

Compelling evidence for lifestyle interventions that emphasize physical activity and nutrient-dense foods for adults with impaired glucose tolerance comes from the Diabetes Prevention Program (DPP). Unfortunately, these recommendations also emphasize weight loss rather than simply addressing meaningful behavior change, when in fact, the DPP also showed improvements in glucose control when adults who did not lose weight engaged in physical activity.

Moreover, a study of more than 3.8 million adults found that individuals with body weight fluctuations (weight loss and weight gain) were more likely to develop diabetes within a 4-year follow-up period. Even for adults with normal glucose tolerance at baseline, a large fluctuation in body weight was associated with an increased risk of diabetes (Park et al, 2019).

What is the Risk of Diabetes?

Keep in mind that impaired glucose tolerance and type 2 diabetes occur in people with genetic susceptibility due to defects in beta-cell function and insulin sensitivity. Therefore, many women in different body sizes have elevated fasting blood sugars and insulin resistance and do not develop diabetes because their beta cells can keep up with the demand (yes – including women in larger bodies). However, even with the best nutrition and lifestyle interventions, diabetes may not be avoidable for some individuals.

Of course, addressing environmental factors that are within one’s control may help prevent or delay diabetes. However, eating disorders also have a significant genetic component, and environmental factors, such as dieting, and weight loss can increase a person’s risk for all types of eating disorders, including anorexia, bulimia, and binge eating disorder in midlife.

The point is that panicking and mindlessly engaging in weight control measures to manage a risk factor like hyperglycemia sets a person up for increased risk of other diseases, including compromised muscle and bone health.

Weight-neutral recommendations if you are told you have “prediabetes”:

1. Don’t panic. Take a breath and keep in mind that greater health awareness can be a good thing. No different than any other “risk factor” for potential health concerns, this is an opportunity for assessment, taking steps toward prevention or delaying onset, and annual monitoring.
2. Ideally, have an assessment with a qualified registered dietitian who can help you assess nutrition and activity and determine whether there are changes you could make that would improve your blood glucose levels.
3. A variety of eating patterns have been identified as helpful. Most importantly is to eat regular meals and snacks and avoid fasting, which can negatively affect blood sugars and contribute to overeating or binge eating – more on intermittent fasting coming in part 2!
4. Include nutritious carbohydrate foods, including fiber-containing plant foods, such as whole grains, oats, beans, legumes, fruit, and vegetables. A keto diet is not recommended for many reasons – we will discuss this in part 3!
5. Eat high-quality protein and fats together with carbohydrates which can help regulate blood glucose levels.
6. Practice mindful eating which is based on developing awareness of physical and psychological cues for hunger and fullness.
7. Incorporate regular physical activity that you enjoy.
8. Try to get support and treatment for other factors, such as sleep disturbances, managing midlife stressors, and smoking, that can all affect risk.
9. Evaluate alcohol intake and other recreational drug use.
10. Discuss the possibility of Menopause Hormone Therapy with your GP or Gynecologist who can take into account your medical history and whether it would be helpful for you. If they say you should work on losing weight first, I’d suggest finding a “weight-neutral” physician who can provide a more balanced approach to your care.

In terms of macronutrient recommendations, which are often misunderstood and debated when it comes to blood sugar control, “Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes; therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals” (Evert AB, 2019).

Finally, seek out positive messages about food choices that align with your personal and cultural preferences. Avoid messages that demonize and label foods as “bad” or “unhealthy”, including sugar and carbohydrate foods. Only when adequate scientific evidence dictates should a person consider limiting a particular food or food group – or calorie intake.

In part 2, we will unpack the messaging and misinformation about intermittent fasting for weight loss and improving blood sugar levels.