Experts Recommend Two-Pronged Approach to Treating Prediabetes

“In an ideal world, you want to diagnose high-risk people early in order to prevent progression to full-blown diabetes and its associated complications,” Glenn Matfin, MD, clinical associate professor at New York University and senior staff physician at the Joslin Diabetes Center, told Endocrine Today.

Whether prediabetes progresses to diabetes depends on a number of variable factors, including lifestyle changes, genetics and treatment practices, which have some physicians supporting the use of medication and others vehemently against it.

“We draw lines in order to differentiate between normal glucose tolerance, prediabetes and diabetes, but it is an interlinked, continuous chain,” Matfin said. “The clock is ticking, and the health risks rise significantly as prediabetes goes untreated.”

To examine the current state of prediabetes treatment, Endocrine Today spoke with a number of experts to best understand how lifestyle and pharmacological approaches should be utilized to reverse glucose functions to normal levels. The issue is also examined from a financial aspect, as the ability to keep patients with prediabetes from turning into patients with diabetes translates into hundreds of millions of dollars saved in health care costs.

Perhaps due to its subtle set of symptoms, the identification and diagnosis of patients with prediabetes has proved to be a challenge. Research has shown that although 30% of the U.S. population had prediabetes in 2005 to 2006, only 7.3% were aware that they had it.

A consensus from diabetes and metabolic disorder experts at the American College of Endocrinology and American Association of Clinical Endocrinologists define prediabetes as impaired fasting glucose (100 mg/dL-125 mg/dL); impaired glucose tolerance (2-hour postglucose load, 140 mg/dL-199 mg/dL); or both. These intermediate levels of glucose constitute inherent disease risk, experts said. AACE also identified metabolic syndrome as a prediabetes equivalent.

AACE guidelines recommend screening for prediabetes in individuals with the following characteristics: family history of diabetes; cardiovascular disease; overweight or obesity; a sedentary lifestyle; non-white ancestry; previously identified IGT, IFG and/or metabolic syndrome; hypertension; high triglycerides; low HDL; history of gestational diabetes; delivery of a baby weighing more than 9 lb; polycystic ovary syndrome; antipsychotic therapy for schizophrenia; and severe bipolar disease.

Selective screening for prediabetes in high-risk individuals and subsequently enrolling them in Diabetes Prevention Program (DPP) lifestyle intervention has been shown to have an adjusted cost-effectiveness ratio of $9,511 per quality-adjusted life-year compared with no screening.

“To me, you can easily sort out the people who you would like to treat with screening,” Ralph DeFronzo, MD, professor of medicine and chief of the diabetes division, University of Texas Health Science Center and the Audie L. Murphy Memorial VA Hospital, said in an interview.

Numerous studies, most notably the DPP, have lauded the benefits resulting from a lifestyle modification of diet and exercise, finding that it is the ideal first-line treatment to halt the progression of diabetes.

The ACE/AACE consensus statement recommends a two-pronged approach to treating prediabetes: intensive lifestyle intervention, followed by the prevention of CV complications using CV risk reduction medications for abnormal blood pressure and cholesterol, independent of glucose control medications.

Guidelines from the American Diabetes Association (ADA) suggest that patients who are diagnosed with prediabetes be referred to an effective ongoing support program, with a weight loss goal of 5% to 10% of their current body weight, as well as a call for an increase in physical activity of at least 150 minutes per week of a moderate activity such as walking. According to DPP findings, patients who lose weight often regain normal glucose regulation.

“Clinical data suggest that if a patient is able to adhere to it, then lifestyle intervention has broader benefits than drug therapies, and without the side effect profile,” John B. Buse, MD, PhD, professor of medicine and endocrinology chief at the University of North Carolina, Chapel Hill, told Endocrine Today.

Although many physicians cite the patient compliance issues inherent in lifestyle change, others reference the financial burden that the changes can place on patients — in the form of costly gym memberships, fitness equipment, diet foods, and fresh fruits and vegetables. However, the long-term cost-savings of a successful lifestyle modification program are significant.

“The most expensive one-on-one DPP care was $1,000 per person, annually,” Robert E. Ratner, MD, senior scientist at MedStar Health Research Institute, Hyattsville, Md., said in an interview. “The reduction of medical costs that resulted from this had offset the cost of the lifestyle intervention within 3 years.

Sunder Mudaliar, MD, clinical professor of medicine, University of California, San Diego, said there are difficulties in relying solely on lifestyle changes.

“Clearly, a diet and exercise regimen is the first option for anyone with prediabetes, and it seems to work in almost everyone who actually follows it,” he said. “The problem is that we give people diet and exercise recommendations and they come back in 3 or 6 months and nothing happens. Making intensive lifestyle changes requires a lot of institutional support and individual attention, and this often does not occur.”

For some physicians, lifestyle change is just one aspect of prediabetes treatment. At present, although not FDA approved, pharmacological intervention is widely used in the United States as a prediabetes treatment; however, a number of questions remain regarding which medications are most effective and when, or if, they should even be initiated.

“Obesity is driving this epidemic,” DeFronzo said. ”The fact is diet and exercise trials do not work on a long-term basis in the real world, and people regain the weight. I believe that, particularly in high-risk people, the treatment of choice, optimally with combination with diet and exercise, should be pharmacologic therapy.”

For other prediabetic patients, lifestyle changes, even when adhered to, do not provide the results needed to avoid progression to diabetes.

“With a 60-year-old with a BMI of 30 who has made lifestyle changes and either cannot lose weight or despite losing some weight their HbA1c starts to rise, then it makes sense to initiate drug therapy,” Ratner said. “If a patient’s HbA1c has risen from 6% to 6.4%, do you wait until it reaches 6.5%?

“If a patient is either unable to accomplish the lifestyle goals or despite accomplishing the lifestyle goals has deterioration in glycemia, then it is reasonable to add pharmacological therapy,” he said.

According to DeFronzo, much of the resistance to treating prediabetes with medication stems from people not understanding that prediabetes is diabetes.

“People do not often understand the pathophysiology; they do not understand that prediabetes is associated with all of the same problems as diabetes, including severe insulin resistance and loss of beta cell function. If you blindfolded a physician and said, ‘I have a patient who has lost 80% of beta cell function and he/she is maximally insulin resistant. Do I treat?’ Most would say treat.”

The ACE/AACE prediabetes consensus statement recommends that lipid and BP goals be the same for those with prediabetes as those with full-blown diabetes. The experts recommend statins to achieve lipid treatment goals of 100 mg/dL for LDL; 130 mg/dL for non-HDL; and 90 mg/dL for apolipoprotein B. Other adjunctive therapies may be useful, such as fibrates, bile acid sequestrants and ezetimibe. For BP, the goals should be less than 130 mm Hg systolic and less than 80 mm Hg diastolic, using first-line angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or second-line calcium antagonists.

After a patient has been verified as a candidate for pharmacological treatment, the proper medication to prescribe must be addressed.

Metformin is currently the only medication recommended by the ADA for the treatment of prediabetes. According to the ADA, it is typically prescribed for patients who are at high risk for developing diabetes, including those who have an HbA1c greater than 6%; hypertension; low HDL; elevated triglycerides; family history of diabetes in a first-degree relative; are obese; and are younger than 60 years.

“If people fail at lifestyle modification therapy and their glucose is progressing, I think that metformin is a reasonable second choice,” Buse said.

“Metformin has been around for nearly 50 years, its side effect profile is reasonably predictable, it can be used in a large majority of people and it is extremely inexpensive,” he said.

With the sheer number of potential patients, this familiarity is essential, Matfin said: “There is a lot of experience with it. So when you’re talking about a population this size of millions and millions and a health care system that is straining, then metformin after diet and exercise would be a good candidate.”

However, despite metformin’s widespread use, the medication is not for all patients.

“An important caveat for metformin to point out is that its efficacy to prevent diabetes in the DPP in a patient over the age of 60 with a fasting glucose of 109 mg/dL or lower or a BMI under 30 was basically zero. Metformin clearly is not for patients who fall in this category,” Buse said.

Overall, metformin was shown to be “moderately efficacious” in the DPP, DeFronzo said.

“My problem with it is that it does not preserve beta cell function,” he said. “I don’t think it is the best drug from the standpoint of pathophysiology in correcting the underlying disturbances.”

Until the FDA approves any drug for prediabetes or IGT, physicians may be nervous using a drug off-label, DeFronzo said.

According to AACE guidelines, any decision to implement pharmacologic therapy for prediabetes, specifically in children and adolescents, is off-label and requires careful judgment regarding the risks and benefits of each specific agent in each individual patient.

Some physicians are not hesitant to prescribe pharmacotherapy, based on the patient’s decision.

“If a patient has an HbA1c of 6% and wants to take drugs, I have absolutely no problem prescribing them,” Buse said. “The higher the risk for developing diabetes, the more reasonable it is to treat the patient with a drug.

“But, if it is an 85-year-old with an HbA1c of 6%, then it doesn’t make a lot of sense to treat.”

Because of the vast number of Americans with prediabetes and recent reports of adverse events attached to diabetes medications, policymakers have not changed existing policies.

“If you are treating millions of people, costs aside, you have a lot of serious complications that are going to occur, which I believe is one reason that the FDA has not approved drugs specifically for prediabetes,” Matfin said.

A number of programs are in development and have been implemented to decrease the prevalence of prediabetes and stop the progression to diabetes.

“The promotion of healthy lifestyles needs to begin at a young age to start healthy habits early in life,” Mudaliar said.

The U.S. Department of Agriculture (USDA) has proposed an investment of $10 billion during the next 10 years to improve childhood nutrition programs. It announced several improvements in school nutrition, including improved meal quality; increased eligibility for free or reduced price meals; diversified food service programs; school meal report cards for parents to help guide their child’s food choices; and a stronger farm-to-school link.

“A major issue for both medication and lifestyle modification is cost, particularly among the lower socioeconomic groups who have the highest incidences of prediabetes and diabetes,” DeFronzo said.

Neighborhood programs that encourage lifestyle change at an affordable price, such as 16-week health and exercise programs sponsored by area YMCAs, may play a role in improving adherence.

Utility Power Tools – Provide Protection to and Embellish Just About Any Cell Phone Utilizing These Items.

For many individuals, cell phone accessories are as vital as the phone itself. Honestly, we can’t blame them; in fact, cellular phone accessories are irreplaceable. A telephone without accessories is definitely missing something.

There are 2 different varieties of accessories, a type which a cell phone cannot function without, along with the other type of accessories that are not essential but necessary.

A mobile phone cannot function with out a battery plus a charger. Even though it still can perform without headphones, car chargers, protective cases, and other sorts of non-essential cell phone accessories.

Overall, accessories will make your phone much powerful, entertaining, simple to use, and functional.

Accessories also be determined by the kind of phone; smartphone manufacturers have become racing time and energy to provide huge stacks of accessories for his or her customers to help make their smartphones more associated with their lives than anytime before.

This is a list of the most commonly used cellphone accessories:


One of the most widely used accessory within the background of cellphones. It really makes it much simpler to apply your phone especially for folks who speak excessive on their own phones. You don’t need to secure your phone for your ears for an hour or two, a headset can do the do the job. Also, playing music hasn’t been any easier. There are many types of headphones that offer the most effective quality of sound and ear safety.

Bluetooth Headset

Well, headphones had an annoying flaw, the wire. It is definitely annoying especially to tall persons, they need a taller wire or perhaps to place their phones in the higher position. Bluetooth headsets solved the trouble. Now, you can nevertheless be speaking on you phone without carrying it around. Taller people can feel great and relieved. Most significantly, car drivers can now speak on the phones with no need to be on the loud speaker in the car or maybe the crazy option of wearing headphones while driving. One additional thing, the elegant look it gives you.

Car Chargers

One of the most important Wiko accessories any traveler guarantees it’s there. Sometimes, or might be always, your battery fails you. Being of such great importance, car chargers have invariably been an important component of accessory that accompanies, nearly, any phone.

USB Cables

They are necessary nowadays. These are necessary to connect your phone to the computer. One can use them for charging, moving data, software installation and maintenance, and even more important uses.

Phone Cases

A mobile phone case is definitely a important accessory especially for folks who are typically less careful because of their phones. They may protect your phone effectively from the majority of the daily situations that may break or damage it. A protective case and screen are sufficiently good to provide 99% protection to your phone.

Power Banks

The need for power banks is increasing lately. Smartphone has always had disappointing batteries. In fact, a smartphone without overwhelming battery issues has changed into a dream for most people. Phone companies dexmpky38 attempting to do their best to resolve this matter, but it seems that the technology remains somewhat limited. Ideally, power banks provide a temporary solution for this problem. If you’re out of your home rather than with your car, you can use a power bank to re-charge your phone.

Buying Soundcloud Plays – Ideas About Locating a Soundcloud Social Networking Sites Marketer.

Some of the best ideas are also the simplest. There are few things more simple than free soundcloud plays, which in the seven year existence has sneakily become one of the better things online. How’d it get there? Slowly, surely, together with a cadre of artists as diverse as being the internet itself.

SoundCloud would be to music in 2014 what MySpace ended up being to bands in 2004. Except, you already know, without all the blingee bullshit. It is possible to upload all of the sounds you want, follow people to listen for the sounds they’re posting, and save or repost them. It’s music interaction and discovery distilled to its purest form, home to equally as many famous artists as ones that can be soon. It’s as near to indispensable as you grow on the web today.

That’s why it was so troubling when rumors started to circulate that Twitter was thinking about buying SoundCloud. Fortunately those purported talks were suspended, because SoundCloud is generally one of many rare pure and positive things online how the world, within an artistic sense, can be worse off without.

SoundCloud is more than just backyard indie musicians planning to be discovered. Want to discover a new track out of your favorite underground rapper? A lot more often, you’ll think it is first SoundCloud. Would like to hear the latest from Beyonce or Drake? Also SoundCloud. It’s where music lands before it lands on Spotify, before it hits iTunes, before anywhere else at all. It’s house to multi-platinum recording artists, random kids recording beats within their bedroom, and everyone between.

Why is SoundCloud so special is delivers a tool for musicians to create and distribute their art on the level playing field. Make a song, post it on SoundCloud-no expensive record deal or distribution plan required. Every minute, 12 hours of new music is uploaded on the service. So, unsurprisingly it’s pretty generous with space. Up to a couple of hours of uploaded content is free, four hours is $55/year, and unlimited space for $135/year. For most of us it means SoundCloud is free to use and liberated to enjoy, another increasingly rare find.

That accessibility is the reason why SoundCloud a no-holds-barred position for artists to plop all their sounds, without frill or folly. It’s a no-brainer. Within that idea could very well be why SoundCloud has blown up previously few years, now nearing 300 million users, up from 200 million last July. That popularity’s not difficult to describe; whenever you make a platform for musicians, who are naturally inclined to enhance themselves, your product gets promoted along the way. Everyone wins!

“I’ve been carrying this out for a bit and I’ve tried a number of sites and this is actually the only person that worked,” André Allen Anjos of R.A.C. believed to Gizmodo.”The most important thing that first got me involved with it was really the volume of tracks you might build. It appears as though a given nowadays but when I had been doing this even just in 2008, and there were very few sites where you can upload your music and that i enjoyed a good amount of it. That’s what initially drew me to it, however it finished up as a fantastic community for my type of music and the type of weird electronic crossover things.”

Build a place for music to reside and breath, and music will grow in such a way you couldn’t imagine. That’s what is happening on SoundCloud.

“SoundCloud is where music culture happens on the internet. It’s where it originates,” CTO and co-founder Eric Wahlforss told Gizmodo.

He’s absolutely right. We’re within an exciting, genre-busting era of music, due to an environment through which artists of all styles can connect through some fibers and tubes. And where they’re carrying it out most is on SoundCloud. Artists you wouldn’t traditionally think about as collaborating are coming together.

In 2012, Snoop Dogg discovered Polish artist Iza Lach via SoundCloud. He was enthusiastic about what he heard, he flew in the market to Poland, recorded what Wahlforss said was “nearly one hundred” songs, and ultimately signed her to his label. If you visit Snoop’s SoundCloud page today, you’ll see him reposting tracks from a myriad of other artists you’ve probably never read about. It’s not to say that each artist on SoundCloud is nice, but established artists have found ones that are.

Go ahead and take case of Beyonce’s surprise album, which dropped back in December. Several tracks on the album were made by Boots, an artist who has been largely unknown until he revealed to the web that he ended up being working on Mrs. Carter’s album. When the internet is at a rush to identify who Boots was, where did they turn? His SoundCloud page, that was peppered with references to tracks that ultimately finished up on Beyonce. Point being, you could possibly know nothing about an artist, however, you can almost definitely check out their SoundCloud page to acquire a quick sensation of what they’re about. Fast forward to about six months later, and Boots is dropping his excellent mixtape. It’s unclear whether Beyonce found originally him on SoundCloud, although the platform was undoubtedly a part of the equation.

Boots may fall within the lines of electronic, and Beyonce, R&B or pop. Snoop Dogg is rap, sure. And Iza Lach is something else entirely. That these particular artists work together is suggestive of the brand new genre lines that happen to be being drawn and demolished, sometimes in the same track.

“There’s every one of these different genres and something totally new popping up every day. It’s sort of hard to keep up with but it’s been interesting to see that unfold on SoundCloud,” R.A.C. says. “I remember actually 2009 or 2010 when dubstep was kinda being a thing, SoundCloud was there and type of at the center of it. But not just dubstep. A good amount of other genres-the latest resurgence of deep house and that kind of thing I think that it absolutely was often fueled by that. Nowadays I view it moving not merely toward electronic music but everybody.”

There’s a tremendous music map that’s growing on SoundCloud. Says Sam Sawyer, marketing head of popular indie label Subpop:

“Washed Out is amongst the chill-wavest bands ever, which had been a subgenre that didn’t exist just before the internet, before people could share, before fans can find this stuff. You understand you can find Witch House bands and all the weird subgenres. EDM has changed in a fashion that never might have been possible before the internet. I definitely don’t assume that could have been possible without using services like SoundCloud. It’s definitely changed the landscape of how music is made and type of opened the entrance for obtaining weird or finding people worldwide who share your passion for, you already know whatever weird subgenre of 70s South American disco and totally extrapolating off that and creating some crazy new amalgamation that no one’s really heard of.”

Discovery is one of those dumb internet words that gets repeated until it loses all meaning, but on SoundCloud it really matters. Mad Decent frontman and producer Diplo offers the page DiploApproved, where he consistently posts tracks from people you’ve probably never read about. But he feels that you should, so he’s posting those to share just a little component of the pie. He’s not alone in this particular sentiment. R.A.C. says he does exactly the same.

“Obviously as my career builds I would like to bring my girlfriends along and with this repost thing I will let them have a sheet of my audience. It’s its not all on me nevertheless i use a friend’s band called Speak and I’ve known them for a long time and I just reposted a selection of their tracks as well as on their SoundCloud along with other social networking situations are 80dexnpky to move.”

Reposting, commenting on portions of tracks, etc. Great, easy features that make SoundCloud a natural tool to make use of. But there was clearly another word that consistently sprouted in conversations I had about SoundCloud: embeddability. SoundCloud embeds on Twitter, Facebook, this amazing site, any web site, and any place else really. Simply click your chosen music blog, or any blog for instance. SoundCloud is everywhere. As it must be. But that was always area of the plan, as Wahlforss said:

“The way you can interact, became important could possibly be area of the fabric of your web everywhere. Also you do have a great level of control as being a creator of the things you publish and just how you publish it and you may kind of spread it around in a way that enables virality.”

“Before SoundCloud existed we did the exact same thing when we’re promoting an album essentially, it’s just easier now,” Sawyer said. “We employed to host our own tracks and our downloads on our website maybe eight in the past, and we would direct people there but in a much more passive way. It was pre-MySpace, people needed to be far more proactive with regards to the way they discovered music, and they would need to seek it all out. And now you know, we sort of push it into people’s feeds via Soundcloud.”

The only catch? Nothing good stays free-or at least not ad-free-forever. SoundCloud told Gizmodo that finding out that dirty little word “monetization” is among its next struggles, but it’s an issue they’re not taking lightly. Along with the Twitter overture, though it seemingly didn’t pan out, was actually a stark reminder that unless get youtube comments figures out how to become profitable, it may suffer the same fate as a variety of promising services that get gobbled up by way of a bigger fish and disappear.

We’ve heard from some music industry sources that SoundCloud is utilizing major labels on licensing deals, and from others that it comes with a pre-roll ad model, similar to YouTube, from the works. Hopefully that’ll be enough. There is a lot of proper happening in music today; interesting artists sprouting up, genres being created, rules changed. And also the bigger SoundCloud gets, the greater number of possible those evolutions may become, one mixtape at a time.

Olympus E-M5 II Battery – The Top Web Store to Shop for a Discounted Leading Quality Battery Pack.

Portrait photography might look easy, After all, surely all you have to do is point your camera and shoot? It’s actually a whole lot harder than that and if you have a great deal of equipment to improve your photography, it may seem even more overwhelming and harder. But following many of these tips will certainly help. Tip primary though is charge your battery using olympus E-M1 battery or equivalent, and off you choose to go.

Real Tip 1: Composition. You have to workout what you are going to use your subject, the sort of feel you need through the image and make use of of backgrounds etc. It is a big decision, but essentially the most important one. So consider if you wish interior or exterior, form of background and so forth.

Tip 2: Lighting. Essential and arguable the most significant distinction between an excellent photograph along with a great one. If you’re photographing outside, you will need to set a certain time of day. If it’s sunny, shooting at midday will produce harsh lighting, whereas early in the morning or evening will provide softer light. If no sun and an overcast day, you’ll have better control. If you’re shooting within a studio, then the preferred lighting would probably be to offer the lights facing the subject, although naturally this will depend on what you would like through the photo. It is possible to move one light source to the side to be able to have half your face lit, other darker and the like. Tinkering with your lights will enable a larger comprehension of lighting and assist you to exercise what you would like from the shoot.

Tip 3: Your camera settings. Ideally you wish to blur the backdrop and have a sharp focus on the subject. Setting the digital camera to f5.6 or lower will make this happen result. Of course you need to check out the distance from camera to subject too to work for this effect.

Tip 4: Kind of a continuation from tip 3, and that’s to create your camera on aperture priority mode. Which means that this lets the camera do many of the hard work for you in setting the shutter speed automatically based on the aperture you set. You can find more creative and go full on manual mode, however for most shoots it’s much easier to allow the dexnpky65 try this.

Tip 5: Don’t reach caught up with everything. The easiest method to get pictures is always to take pictures. Change a setting for every new photo and know how the graphic changes for this reason change. Be creative and move your lighting around more, move yourself around more. Try different angles and heights, and you could just stumble across something special. Portrait photography is challenging, however the more you need to do it, the greater you will learn and the more creative you can expect to become. But never forget in the first place a fully charged battery having an Olympus BLN-1 charger or equivalent for your very own camera. Always wise decision to keep an extra one too.