Beta-cell dysfunction and insulin resistance contribute to the development of prediabetes. Thus, improving insulin sensitivity and beta-cell function can be the best prediabetes treatment.

Lifestyle intervention as Prediabetes Treatment

Insulin resistance of the liver, muscle, and adipose tissue and impairment of beta cell function are the common defect that causes prediabetes.

Thus, efforts to preserve or increase beta cell functions and decrease insulin resistance could be a potent way to treat prediabetes and stop progression to type 2 diabetes.

Insulin resistance is the body cells (liver, muscle, and adipose tissue) do not respond well to the insulin, so not able to properly take up glucose from the blood. As a result, the pancreas makes more insulin to help glucose enter the cells. It puts extra strain on the pancreas that leads to impairment of pancreatic beta-cell function.

Impairment of beta-cell function - The first-phase insulin secretion deteriorates gradually when the fasting plasma glucose exceeds 90 mg/dL. And is almost completely lost when it reaches over 110 mg/dL. Ref: Diabetes. 1988 Jun; 37(6):667-87., Diabetes. 2009 Apr; 58(4):773-95., Am J Physiol Endocrinol Metab. 2008 Aug; 295(2): E401-6., and Diabetologia. 2004 Jul; 47(7):1157-1166.

Individuals in the high level of impaired glucose tolerance are maximally insulin resistant, and decline in beta-cell function is about 70% to 80%. 

Prediabetes Treatment – a Lifestyle change

Losing weight improves insulin sensitivity and preserves beta-cell function and inhibits progression to type 2 diabetes.

Clinical studies have shown that losing weight using diet and exercise improves insulin sensitivity and betterment of beta-cell function. Thus this is an excellent way to stop or slow down the progression of prediabetes to type 2 diabetes.

References:

1. The New England Journal of Medicine 2001; 344:1343–1350.
2. Diabetes. 2005; 54:2404–2414.
3. Lancet. 2008; 371:1783–1789.

A weight loss of 5 to 7 % and 150 minutes of moderate exercise per week can reduce the progression of prediabetes to type 2 diabetes by 58 %.

Losing weight through lifestyle interventions, pharmacologic therapies or bariatric surgery augments insulin sensitivity, decreases beta-cell work overload, and betterment of glucose tolerance. Reference: Diabetologia. 2011 Oct; 54(10):2506-14 and the American Journal of Clinical Nutrition 2004 Jan; 79(1):22-30.

When individuals lose 5% of their body weight, total body insulin sensitivity improves by 30%. Reference: Diabetes. 2005 Aug; 54(8):2404-14. And a decrease in their progression from prediabetes to type 2 diabetes nearly by 58%. Reference: The New England Journal of Medicine 2002 Feb 7; 346(6):393-403.

Prediabetes Treatment – Pharmacotherapy

Pharmacotherapy is the next option to improve insulin sensitivity and beta-cell function if the lifestyle intervention failed to produce a result.

Clinical studies show Pharmacotherapy improve insulin sensitivity. Also, It found to diminish the progression of prediabetes to type 2 diabetes.

Metformin may be useful in the treatment of prediabetes.

Fasting plasma glucose concentration and hemoglobin A1C can be decreased by metformin in type 2 diabetes through inhibition of liver glucose production or through preserving beta-cell function. 

References: 

1. The New England Journal of Medicine 1995 Aug 31; 333(9):541-9.
2. The Journal of Clinical Endocrinology and Metabolism 1991; 73:1294–1301.
3. The Journal of Clinical Endocrinology and Metabolism 1996; 81:4059–4067.
4. The Journal of the American Medical Association. 1999; 281:2005–2012.

Thus, it is not unusual to claim that metformin would significantly lower the conversion rate from prediabetes to type 2 diabetes.

American Diabetes Association advice metformin usage in high-risk individuals (younger than 60-year, BMI over 30 kg/m2 and HbA1c over 6.0%) with prediabetes (either IGT or IFG).

Metformin is a drug that safely improves the body’s insulin sensitivity. It enables people to lose weight, help improve the underlying metabolic problem, and progression to diabetes type 2.

Pioglitazone is also useful for the treatment of prediabetes with some additional benefits. Pioglitazone decreases triglyceride concentrations and increases HDL levels while losing weight lowers blood pressure and heals lipid profile. The New England Journal of Medicine 2002 Feb 7; 346(6):393-403. However, Pioglitazone has few side effects that need to take into account before using it. 

Another option is to initiate metformin plus low-dose pioglitazone. In high-risk IGT, individuals’ long-acting GLP-1 analog use along with diet and exercise, maybe the best option.

Lifestyle intervention or Metformin, which one is best?

The lifestyle intervention was more effective than metformin.

Lifestyle changes and metformin treatment both reduced the incidence of diabetes in persons at high risk. A study confirms lifestyle intervention is the better option compared to metformin. The New England Journal of Medicine 2002; 346:393-403.  

It is recommended to follow a strict lifestyle modification for patients with prediabetes (IGT ± IFG). 

Blood sugar normalized – what to do?

Even if the blood sugar returned to normal, you still need to follow a healthy lifestyle to stay on track. Also, you should maintain a healthy weight and have your blood glucose checked at least every three years. If you discontinue a healthy lifestyle and gaining weight, then your prediabetes or diabetes will likely to return.

What should be my fasting blood sugar level? My blood sugar spikes after full night sleep! How can I achieve my fasting blood glucose target?

Why is my fasting blood glucose high?

People point fingers towards the nighttime snack or dinner for their high fasting blood glucose. It appears to be logical! Even it may be indirectly correct in few occasions; however, the real culprit is the hormones that involved in the blood glucose control.

Before going into the details about high fasting blood glucose, you should know about four hormones that influence your blood glucose level; Insulin, Amylin, Incretins, and Glucagon.

1. Insulin is a hormone secreted by the pancreatic beta cells, which enable the body to move glucose into the body cells for energy. People diagnosed with type 2 diabetes have typically lost at least 50 % of their beta cell and function, and their insulin reserves are slowly dwindling further. People diagnosed with type 1 diabetes usually have only 15 to 40 percent of the beta-cell are still alive.
2. Amylin is a hormone secreted by the pancreatic beta cells, which slow down the release of glucose into the bloodstream after eating by slowing stomach emptying. Additionally, it increases the feeling of fullness. People with type 1 & type 2 diabetes have amylin-deficient.
3. Incretins is a hormone secreted from the intestines, which include glucagon-like peptide 1 (GLP-1); it usually enhances the body's release of insulin after eating. Which, in turn, slows stomach-emptying, promotes fullness, delays the release of glucose into the bloodstream, and prevents the pancreas from releasing glucagon, putting less glucose into the blood.
4. Glucagon is a hormone secreted by the pancreatic alpha cells. It breaks down glucose stored in the liver and muscles, then releases it to provide energy when glucose from food is not available.

Next, learn how the system works in people with and without diabetes:

What happens while fasting? As blood glucose falls, the pancreas puts out less insulin hormone. At the same time, two other hormones amylin and glucagon-like peptide 1 (GLP-1) wane; these hormones help store and use glucose. A fourth hormone, glucagon, kicks into gear to offer a constant flow of glucose. Glucagon sends messages to the liver and muscles to make glucose from storage. For people without diabetes, the liver raises glucose as needed. In people with diabetes, the liver dumps the excess of glucose than required, especially at night causes high fasting blood sugar.

What happens after eating? Food raises blood glucose and sends a message to the intestines to release GLP-1, which increases the release of the insulin and amylin. These hormones help cells to use glucose from food as fuel. The release of glucagon turns off because there's little need for glucose from the liver or muscles when food is available.  For people without diabetes, the increase in blood glucose normalized by increased insulin production. For people with diabetes, this can be a problem.

What are the causes of high fasting blood sugar? There are three leading causes of high fasting blood sugar; they are Somogyi effect, Dawn phenomenon, and waning insulin.

1. What is the Somogyi Effect? The body overreacts to extreme low sugar with counter-regulatory hormones glucagon and epinephrine. This hormone secretion results in elevated blood sugar by spurring the liver to convert stored glycogen into glucose. Researcher Michael Somogyi was the first noted and described this rebound effect. Thus it got his name as a Somogyi effect. The Somogyi effect is due to untreated nighttime hypoglycemia, resulting in elevated blood sugar in the morning. People who wake up with high blood sugar may need to check their blood glucose at around 3 AM. To stop the Somogyi effect, you need to avoid hypoglycemia.
2. What is the dawn phenomenon? The dawn phenomenon is a normal physiological process during which certain hormones in your bodywork to raise your blood glucose level to prepare you to wake up. The hormones involved in the dawn phenomenon are cortisol, glucagon, epinephrine, and growth hormone. These hormones are called counter-regulatory hormone, which works against the action of insulin. It causes the liver to release glucose to a healthy individual, and the liver dump glucose in people with diabetes. Results in an increase in blood glucose levels, which normalizes in nondiabetic and it not in the case of diabetic called a dawn phenomenon. The circadian rhythm is behind the development of DP.
3. Diminished Insulin! High fasting blood sugar among patient taking insulin (type 1 or some type 2 diabetes), indicates their insulin may wear off sooner than required. If this is your case, then you should adjust your dosage or timing of insulin to normalize fasting blood sugar.

How do you correctly distinguish the cause behind your high fasting blood sugar?

If you want to correct your fasting blood sugar, then you should understand what causes your morning hyperglycemia. For this, you need to check and record your blood sugar before bed, at about 3 a.m., and immediately after wake up. Do this for a few nights in a row. 

1. If your blood sugar is reasonably healthy before bed and at 3 a.m, then your high fasting sugar may be due to the dawn phenomenon.
2. If your blood sugar is reasonably healthy before bed and is low at 3 a.m, then your high fasting sugar may be due to the Somogyi effect.
3. If your blood sugar is reasonably healthy before bed and elevated at 3 a.m., then your high fasting sugar may be due to diminished insulin.

Six natural ways to lower your fasting blood sugar

1. Reduce or eliminate coffee consumption - Study shows high coffee consumption increased fasting insulin concentrations compared with coffee abstinence. Ref: Diabetes Care 2004 Dec; 27(12): 2990-2992.
2. Biotin or Vitamin B7 supplementation - Daily administration of 16 mg biotin for one week decreased fasting blood sugar (FBS) by up to 50% of type 1 diabetic patients. Ref: Annals of the New York Academy of Sciences June 1985; 447:389-393.
3. Cinnamon - At least three clinical studies have been performed to test the blood sugar-lowering and insulin-sensitizing effects of Cinnamon (Cinnamomum cassia).
4. Fenugreek - Clinical research in people with diabetes for both a fenugreek extract and on soaked fenugreek seeds showing improvements in fasting blood sugar and insulin sensitivity.
5. Ginger - Ginger has demonstrated promising results in basic science and animal research testing for its ability to improve insulin sensitivity. In this study, it shows that oral administration of ginger powder for 12 weeks at a dose of 2 g per day caused a significant reduction in the levels of fasting blood sugar and HbA1c. Ref: Iranian Journal of Pharmaceutical Research 2015 Winter; 14(1): 131–140.
6. Garlic - Garlic significantly reduced fasting blood glucose concentrations. Ref: Asia Pacific Journal of Clinical Nutrition 2015; 24(4):575-582.

Diabetes experts advised testing your blood sugars two hours after meals. However, most diabetics experience blood sugar spikes one hour and twenty minutes after food. So it is best to test one hour after the meal.

One study found that only 10 % of after-meal blood sugar was below 180 mg (10 mmol). It does not mean; it is not possible for you to reach healthy blood sugar.

However, be slow and in steps; first set a higher target that is easily achievable. Once achieved the set target, then lower your goal until you reach healthy blood sugar range. Be confident; you can make it with the below said tips, my advance congratulations.

Hormones & blood glucose homeostasis

1. Insulin produced by the pancreatic beta cells enables glucose from the food to move into the body cells for energy.
2. Amylin produced by the pancreatic beta cells helps slow down the release of glucose into the bloodstream from food by delaying stomach-emptying and increases satiety. Both type 1 and type 2 diabetes may have amylin deficiency.
3. Incretin is gut hormone (such as GLP-1 glucagon-like peptide 1) secreted by the intestines. It enhances the body’s ability to release insulin after eating, slow down stomach-emptying, promotes satiety, delays blood glucose release, and prevents pancreatic glucagon release.
4. Glucagon produced by pancreatic alpha cells breaks down glycogen stored in the liver and muscles into glucose and released into the bloodstream. It provides energy when there is no glucose supply from the food.

After food blood glucose rises, which instructs the intestine to release GLP-1, this in-turn increases insulin and amylin secretion. These hormones facilitate the body cells to use glucose from the food as fuel. At the same time, glucagon turn off even the reverse process that is the storage of excess glucose as glycogen takes place if the insulin level rises further.

While fasting blood glucose falls, proportionally pancreas reduces the insulin release, which in-turn switch of amylin and GLP-1 secretion, these hormones comment to store and use glucose. At the same time, a drop in insulin level turn on the release of glucagon, this breakdown stored glycogen and provide a constant flow of glucose.

After-meal, postprandial blood glucose spikes are temporary that occur after eating. Even in people who do not have diabetes, the blood glucose level rises a small amount after eating. Insulin starts doing its job to move glucose out of the bloodstream and into the cells. And Amylin keeps the food from reaching the small intestine quickly. However, in people with diabetes, this blood glucose spikes will be more significant, and it is slightly challenging to bring it back to a healthy range.

How long after food blood glucose stays high? After food, naturally, your blood glucose level goes up until insulin help the body cells to consume the glucose for energy. The blood glucose rise is a normal process of digestion; the concern is how high it goes. Blood glucose starts to rise at about 20 minutes after eating; it peaks between 1 to 2 hours and stabilizes at 2 to 4 hours after eating.

The exact timing of blood glucose spikes can vary from person to person and from meal to meal. However, on average, after-meal peaks tend to occur about one hour and 15 minutes after the start of a meal. Check before and after breakfast, lunch, and dinner. Do this several times to determine how much of a spike is taking place after each of these meals.

What should be your blood sugar levels after eating?

Here are some recommendations from the significant diabetes associations:

• The American Diabetes Association recommends keeping blood glucose below 180 mg/dl (10 mmol) one to two hours after the start of a meal.
• The European Diabetes Policy Group recommends keeping it below 165 mg/dl (9.2 mmol) at the peak.
• The American Association of Clinical Endocrinologists and the International Diabetes Federation suggest keeping it below 140 mg/dl (7.7 mmol) after eating.

In the beginning, follow after-meal goals as said below. These numbers are achievable, lead to a decent HbA1c level, and do not interfere with the daily quality of life:

• Adults who take mealtime insulin: below 180 mg/dl
• Adolescents (12–18 years): below 200 mg/dl
• School-age children (6–11 years): below 225 mg/dl
• Preschool-age and toddlers (5 or younger): below 250 mg/dl
• People with Type 2 diabetes who do not take mealtime insulin: below 140 mg/dl

Once you have achieved this target, then slowly try improving it until you reach a non-diabetic normal range of blood sugar.

A common approach to lowering after-meal blood glucose spikes is to take more insulin.

But unless blood glucose levels remain high for three to six hours after eating, taking more insulin is not going to solve the problem. Increasing mealtime insulin will most likely result in low blood glucose before the next meal.

Is Sugar Bad for You? Yes, no doubt but the total amounts of carb is more critical. So you don’t necessarily give up sugar forever, and you can enjoy it occasionally in small serving sizes.

People with diabetes when eating large amounts of simple carbs or sweets, their blood sugar spikes. And temporarily feel good (energetic) to normalize your blood sugar, your pancreas dumps insulin into the bloodstream. Your blood sugar might crash, and you feel bad (fatigue), at the same time, you gain weight like crazy. You are urged to choose simple carbs or sweets for a quick energy boost. Once again, your blood glucose spikes high and low; this vicious cycle is never-ending! This way, you may put on blood glucose roller coaster.

Know, why refined grains raises your blood glucose? Whole grain contains endosperm, bran, germ, and brush. The refining process strip off the bran, germ, and brush leave only the white-colored endosperm, which during digestion turn into glucose means sharp BS spike followed by BS crash.

When you eat whole grains, then digestion and absorption of glucose are slow and steady. Thus, more gradual blood glucose rise, followed by a nominal drop and better blood glucose homeostasis. Additionally, you can get extra nutrients for your good health.

17 Lifestyle choices to reduce BS spikes

1. Reduce carb intake - Watch, what you eat? Since food is the most important things, you can do to control your blood glucose. The wrong choice of meals with too many carbs, such as white rice and pasta can cause your blood sugar to soar. To reduce your carb intake, you should avoid sugary foods/drinks, starchy foods (such as bread, pasta, rice, beans, and potatoes), and other foods made from refined carbs. Alternatively, you can eat real foods made of whole grains, vegetables, and fruits.
2. Prefer low glycemic index foods - Glycemic Index (GI) is a measure of how much blood glucose spikes the carbohydrate in the foods produced. High GI foods produce more blood glucose spikes than medium or low GI foods. Thus as a person with diabetes, you should prefer low GI foods over high to achieve your after-meal target.
3. Take a walk after a meal - A brief (as short as 15 minutes) walk at a slow pace shortly after eating is a quick way to burn some calories, aid digestion, and reduce after-meal BS spikes. References: Journal of the American Medical Directors Association 2009 Jul; 10(6):394-7 and Diabetes Care 2013 Jun; DC_130084. Walking immediately after food can reduce post-meal blood glucose spikes in various ways. Walk after eating enhances blood flow and facilitate better absorption of insulin, faster blood glucose control. Additionally, walking divert blood flow away from the intestine, thus slow down glucose absorption. 
4. Don’t Skip Breakfast - Breakfast is the most important meal of the day, especially for people with diabetes. The study showed that on the daily breakfast was skipped, all-day spikes in blood sugar levels resulted. The researchers believed skipping breakfast can negatively affect the function of pancreatic beta cells that produce insulin.
5. Prefer smaller dinner – The digestion is better during the day than night after sunset. The study shows those who consumed a big breakfast in the morning (700 calories) and a small dinner in the evening (200 calories) had better control of their blood sugar. Those who ate a small breakfast (200 calories) and consumed a big dinner (700 calories had control of their blood sugar.
6. Eating acidic foods - Studies found acidic food slows down digestion and lowers your blood sugar spike by up to 55%. Some of the acidic foods are vinegar, tomatoes, and most other sour-tasting fruits. Drinking 1 to 2 teaspoons of apple cider vinegar immediately before meals help lower your after-food blood glucose spikes. To learn more, you can visit apple cider vinegar for diabetes.
7. Avoid Chinese Food: They are high in carb, fat, and MSG; thus, it raises blood sugar. Check your blood sugar 2 hours after eating to know who your body react to Chinese food.
8. Dried Fruits raises BS: Fruit is a healthy choice, but dried fruits such as raisins, cranberries, cherries, or dates contain more carbs.
9. Eat only 2 to 3 meals per day –
10. Sugar-Free Foods raises BS: They will raise your blood sugar levels. Why? Because of carbs from starches, it contains. Check the total carbohydrates content on the Nutrition Facts label. Also, look for the presence of sugar alcohols such as sorbitol and xylitol sweetener. It has fewer carbs than sugar (sucrose); still, they can raise your blood sugar levels.
11. Caffeine raises BS: Your blood sugar can rise after a cup of coffee, even black coffee without sugar in it. Black tea, green tea, and energy drinks containing caffeine can also raise your BS. Everyone with diabetes reacts differently for food or beverages, so keep track of your response. Ironically, other compounds in coffee may help prevent type 2 diabetes in healthy people. The study shows, type 2 diabetes who took 500 milligrams of caffeine (equivalent to four 8-ounce cups of coffee) experienced a 7.5 % increase in their average blood sugar levels. Caffeinated beverages include diet cola, coffee, and tea.
12. Artificial Sweeteners - A study published in the journal Nature. It reported about the consumption of zero-calorie artificial sweeteners. It found in diet sodas and sweeteners often added to coffee and tea. This artificial sweeteners lead to glucose intolerance, increased blood sugar levels, and potentially increase the type 2 diabetes risk.
13. Increase physical activity - Exercise enhances insulin absorption for many hours after exercise. Your body will use insulin more efficiently. In one study, just 30 minutes of slow walking reduced the average spike by 30 mg (1.7 mmol). The peaks were 45% higher when participants did not walk.
14. Manage/Lower Stress - Stress increases the release of cortisol hormone by the adrenal glands, which increases your appetite. Additionally, stress disrupts hunger hormones such as ghrelin that regulate your appetite. Anxiety-induced hunger makes you choose junk food rather than a regular healthy diet. Thus, if you are under stress, don’t eat and postpone until you are free from stress. You can lower stress by taking ten deep abdominal breathing.
15. Get enough sleep – In a study, healthy adults were asked to sleep only four hours a night for six nights. After this sleep restriction, the glucose tolerance (ability to break down glucose) on average was 40 percent lower.
16. Prevent infection - To avoid infection, wash your hands before preparing food, before eating, and after using the toilet. Always drink safe drinking water. Don't share your items such as toothbrushes, towels, handkerchiefs, razors, and nail clippers. Keep yourself clean; bath daily, brush your teeth twice daily and wash your hand whenever required.
17. Yogurt - Probiotic foods such as yogurt are load with healthy bacteria. This beneficial micro organism improves digestion and supports better blood glucose control. Always prefer homemade yogurt, because some store-bought yogurt pasteurized that kills this beneficial microbe, and also they add sugar for taste.

4 Smart ways to use insulin smartly to reduce BS spikes

1. Use Analog insulin in place of Regular insulin – Using analog insulin (Humalog, Novolog or Apidra) instead of regular insulin (Humulin R, Novolin R). Regular insulin has its peak at 2 to 3 hours, and its duration of action is up to 4 to 6 hours. The newer analog insulin has a much faster peak of at around 1 hour, and its duration of action is up to 3 to 4 hours. Analog insulin matches well with the mealtime spikes.
2. Warm up the injection site – Have you ever noticed, sitting in a hot tub for too long, bring down your blood sugar. When the skin heats up, blood vessels expand, boost circulation, and magnifies the absorption of insulin. In a study, insulin action increased on average by 30% in 51 patients in the first hour. You can warm the injection site by applying a hot pack or just rubbing the area. For people using insulin pump; Insupatch & InsuPad add a heating element with the infusion set.
3. Bolus insulin timing – Rapid-acting insulin takes 15 minutes to start working. A study shows those who take bolus insulin 15 to 30 minutes before a meal had a 4% lower A1C than those who take their bolus just before a meal. So it is better to take your insulin 15 to 30 minutes before your meal.
4. Super Bolus for insulin pump users - For people with diabetes on insulin pumps can go for “Super Bolus,” the term and technic provided by John Walsh, co-author of the book “Pumping Insulin: Everything You Need for Success with an Insulin Pump.” Super bolus is a technic to substantially reduce the basal rate for about 2 to 3 hours before eating and adding this reduced basal insulin to the normal pre-meal bolus. For example, if your basal insulin rate in the morning is one unit per hour, reduce the basal rate by 10% or 0.1 units per hour (i.e., 90 % reduction) for say 2 hours before breakfast. Then, this reduced basal insulin of 0.9 units per hour multiply by 2 hours gives 1.8 units of insulin give along with your pre-meal bolus insulin.

Does earlier bolus make a difference? Absolutely! Always best to give bolus insulin before food, but how much before? Maybe it depends on what you are going to eat and what is your pre-meal blood glucose level? Higher your pre-meal blood glucose, the earlier the bolus should be. Based on the glycemic index of the food and the pre-meal blood glucose level, bolus timing should be.

• If BS is much higher than your target, then you should give the bolus 15 to 45 minutes before a meal based on the glycemic index of the food.
• If BS is close to the target, then give the bolus at the start to 20 minutes before a meal.
• If BS is below target, then take the bolus right away to 15 minutes before eating.

Research has shown giving mealtime boluses before eating instead of after eating reduced the after-meal blood glucose spike by about 50 mg/dl or 2.8 mmol/l.

The higher the glycemic index of the food you are going to eat, then earlier should be your bolus. The glycemic index of the food is the ranking of how quickly a food causes blood glucose rise.