A 63-year-old man comes to the physician for his yearly follow up. He has no known medical problems and takes no medication. He has gained 10 lbs (4.6 kg) over the last year. Both of his parents had type 2 diabetes mellitus. He is divorced and has no children. Since his divorce, he mainly eats frozen foods and has a very sedentary lifestyle. He drinks 2 glasses of wine on the weekends.
His blood pressure is 144/96 mm Hg and BMI is 29 kg/m². He has acanthosis on his neck. The remainder of the physical examination is within normal limits.
His laboratory investigations reveal a fasting blood glucose of 112 mg/dL, serum creatinine of 1.1 mg/dL, and hemoglobin A1c of 6.2% (normal 4.0-5.6%) .
Which of the following is the best option to prevent this patient from developing overt type 2 diabetes mellitus?

Question

Quizplus · Accepted Answer

This patient's impaired fasting glucose (between 110-125 mg/dL), hemoglobin A1c of 6.2%, and strong family history of diabetes mellitus places him at high risk for developing type 2 diabetes mellitus (DM) in the future. The Diabetes Prevention Program (DPP) showed that intensive lifestyle changes were more effective than metformin in preventing the development of DM, especially in patients > age 60. Metformin is a consideration in younger patients at high risk for developing DM. Lifestyle changes include switching to a healthy diet and performing 150 minutes/week of moderate intensity physical activity (e.g., brisk walking for 30 minutes 5 times/week) with a goal of losing at least 5-10% of body weight. Rigorous lifestyle changes decrease insulin resistance and reduce the risk of developing DM by up to 60% in some studies. (Choice A) Acarbose is an alpha glucosidase inhibitor that may reduce the risk of diabetes; however, it is commonly associated with gastrointestinal side effects resulting in poor long-term compliance. (Choice D) Pioglitazone may reduce the risk of developing diabetes, but it has significant side effects (e.g., weight gain, edema, and congestive heart failure) and a possible risk of bladder cancer and bone loss. As a result, it is not used for diabetes prevention. (Choice E) Ramipril is an ACE inhibitor that may reduce the risk of diabetes by decreasing insulin resistance and improving pancreatic beta cell function, but it is not as effective as lifestyle changes. However, ACE inhibitors are appropriate first-line agents for hypertension in patients at high risk for future DM. Educational objective: Lifestyle changes (e.g., diet/exercise) resulting in weight loss is the most effective and safest way to prevent the development of type 2 diabetes mellitus, especially in patients > age 60. Metformin may be considered for diabetes prevention in younger patients at high risk for future DM. __________ References: Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. (http://www.ncbi.nlm.nih.gov/pubmed/11832527) A systematic review of lifestyle modification and glucose intolerance in the prevention of type 2 diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/20879973)

A 63-Year-Old Man Comes to the Physician for His Yearly