Preventing and Reversing Prediabetes with Dr. Shirisha Avadhanula

Podcast Transcript

Speaker 1: There's so much health advice out there. Lots of different voices and opinions, but who can you trust? Trust the experts, the world's brightest medical minds, our very own Cleveland Clinic experts. We ask them tough, intimate health questions so you get the answers you need. This is the Health Essentials Podcast brought to you by Cleveland Clinic and Cleveland Clinic Children's. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

Speaker 2: Hi, and thank you for joining us for this episode of the Health Essentials Podcast. My name is Kate Kaput, and I'll be your host. Today, we're talking to endocrinologist, Dr. Shirisha Avadhanula about prediabetes. People who have prediabetes have up to a 50% chance of developing Type 2 diabetes over the next five to 10 years but there are steps that you can take to prevent that from happening. Dr. Avadhanula is here to explain what prediabetes is, what it means for your health and what you can do to reverse it. Thanks so much for being here with us today.

Dr. Avadhanula: Thanks for having me.

Speaker 2: So I'd like to start by having you tell us a little bit about your work here at the Cleveland Clinic. What kind of work do you do and what kind of patients do you typically see?

Dr. Avadhanula: I'm a clinical endocrinologist and I run my practice out of Cleveland Clinic Lutheran Hospital. I typically see patients who have prediabetes, diabetes and obesity, which is pretty reflective of the communities that we serve. I also see patients with thyroid dysfunctions, thyroid cancer, and I also see patients who are seeking out care for gender-affirming treatment, so our transgender population. I also currently serve as the medical director for inpatient virtual health for the Cleveland Clinic enterprise and our major focus is on healthcare equity and access.

Speaker 2: Wonderful. So before we start to talk about prediabetes, I'd love for you to tell us a little bit about the basics of diabetes. Talk to us a little bit about the differences between Type 1 and Type 2, some concepts like blood sugar and insulin resistance, just so that we have a baseline of what we're talking about.

Dr. Avadhanula: Sure. So diabetes is a common illness and not just because I see it all the time in my clinic. It really is very common. around 34 million people in the US, which is around 11% of the US population, have a diagnosis of diabetes. The most common form of diabetes is Type 2 diabetes, which is typically diagnosed in adulthood and centers around insulin resistance. This defers from Type 1 diabetes, which is typically diagnosed in childhood and is due to an autoimmune illness that targets the pancreatic beta cells that are responsible for producing insulin, which is the major hormone that we talk about when we talk about diabetes.

Speaker 2: So Type 2 diabetes then is the kind of diabetes that you can acquire. So when we're talking about prediabetes today, we're talking about trying not to acquire Type 2 diabetes, is that right?

Dr. Avadhanula: So Type 2 diabetes is typically diagnosed in adulthood and it is usually acquired.

Speaker 2: So talk to us a little bit about prediabetes. What is prediabetes and how do you explain it to the average person who doesn't have a lot of existing health or medical knowledge on this topic?

Dr. Avadhanula: Prediabetes is pretty much exactly what it sounds like. It's a state that occurs usually before the diagnosis of Type 2 diabetes. Patients can have blood sugars that are usually higher than normal, but they're not quite high enough for you to be diagnosed with Type 2 diabetes. So you can think of it as a state that usually occurs before the diagnosis of Type 2 diabetes.

Speaker 2: And so when we say blood sugar, what does that mean exactly? How does your blood sugar become high? What is your blood sugar?

Dr. Avadhanula: That's a great question. I don't think I've ever actually been asked that before. So your blood sugar is the sugar that's currently circulating in your bloodstream and you can check that by either a finger stick glucose or by a continuous glucose monitor. You've probably seen commercials of the continuous glucose monitors that are attached to your arm. So we usually check those and it's the blood sugar that's circulating in your intravascular fluid. So generally speaking, when somebody has a diagnosis of prediabetes, we're usually saying this because they're fasting, blood sugar is a little bit higher than normal. So typically, it's usually anywhere between a 100 and 125, and that's one of the ways that we can diagnose prediabetes.

Speaker 2: Got it. So tell us a little bit about some of the contributing factors that lead to prediabetes, and that can ultimately lead to Type 2 diabetes.

Dr. Avadhanula: Most of the contributing factors that can lead to prediabetes are those same contributing factors that can lead to Type 2 diabetes. So the way that I ask my patients to think about it is you can think about it as factors that you can change and you can think about it as factors that you cannot change. So for example, things like the way you live your life, your lifestyle. So the food choices you make, or for example, if you're very sedentary, these are things that can potentially contribute to your risk of developing prediabetes and then ultimately Type 2 diabetes.

And then there're things that you can't change. So for example, your genetics, your genetic makeup. For example, a certain ethnic group that you belong to. These are typically things that you cannot change, but I do want you to remember that not one single risk factor or one contributing factor will lead to a diagnosis of prediabetes or diabetes.

So what I'm saying is, it's usually a combination of several different factors that come together when you can be diagnosed with a disease. So for example, if somebody has, say, a strong family history of Type 2 diabetes, the conversation centering around things like lifestyle modifications and good lifestyle habits and food choices is even more relevant in this particular context.

Speaker 2: That makes a lot of sense. So you mentioned that some of it is genetic and sort of demographics. Are there certain people or populations of people who are more likely to be predisposed to prediabetes than others?

Dr. Avadhanula: There are certain vulnerable populations that are at higher risk of developing prediabetes. So, say, for example, patients who are diagnosed with PCOS, also known as polycystic ovarian syndrome — which is the most common endocrinopathy among reproductive women worldwide — they have a predisposition of developing insulin resistance that can lead to prediabetes and Type 2 diabetes.

We have our patients who are diagnosed with gestational diabetes. They're at increased risk of developing prediabetes.

Our patients who have strong family history of diabetes or prediabetes, and then certain ethnic groups. So for example, our Hispanic populations, patients who belong to Indigenous groups and our Black population. There are certain risk factors that can put people at higher risk of developing diabetes and patients who may carry these risk factors, it's all the more important for them to be a little bit more cautious in their lifestyle choices.

Speaker 2: And you mentioned that Type 2 diabetes is most often diagnosed in adulthood. Does your risk go up as you age? What is the relationship between age and prediabetes?

Dr. Avadhanula: So your risk can go up as you age, but like I mentioned, really the most important choice is how you choose to live that life. So your risk typically, yes, it can go up with age, insulin resistance generally takes time. It can increase with age and with weight, but like I mentioned, these processes can be completely, completely reversed simply by weight loss and watching your exercise.

Speaker 2: Great. So talk to us a little bit about the risks of having prediabetes. Does this increase your risk of other health conditions of other issues of concern?

Dr. Avadhanula: So your major risk when you have prediabetes is developing Type 2 diabetes. That is the major risk for you, but it also can put you at risk of cardiovascular risk factors. So for example, heart attacks and strokes, it can actually increase your risk of certain diseases.

Speaker 2: Then tell us, if someone who has Type 2 diabetes, what are the risks associated with having Type 2 diabetes? Why is it so important that we try to prevent prediabetes from becoming Type 2 diabetes?

Dr. Avadhanula: Living with Type 2 diabetes can be particularly challenging for patients. When Type 2 diabetes progresses, generally speaking, it can lead to end organ complications and damage, things like kidney failure, things like blindness, limb amputations and, ultimately, it increases your risk of developing cardiovascular death. So things like heart attacks and strokes, which can lead to death or severely debilitate your quality of life.

Speaker 2: So quite a lot of risks that we'd like to mitigate while we still have the chance, which makes it so important to know about prediabetes and kind of how to reverse it. So tell us about the symptoms of prediabetes. Does it cause symptoms? What might those symptoms look like?

Dr. Avadhanula: The symptoms of prediabetes, the most common symptom is no symptom at all and that's the same with Type 2 diabetes. Our patients with Type 2 diabetes, sometimes, they'll present with things like blurry vision. Sometimes, they'll present with things like increased thirst or urination. Generally speaking, prediabetes is usually found on routine lab tests, but sometimes, patients can have things like blurry vision, as an example. Another symptom may be darkening of the skin under the arm and sometimes, this can be missed. We've had patients that come into our office, not knowing what this is. Thinking this might be dirt and they try to wash this off. But in reality, this is a process called acanthosis and this darkening of the skin is representative of insulin resistance. So when patients have this, it should prompt your provider to test you for prediabetes or for diabetes.

Speaker 2: So you mentioned diagnosing prediabetes. Tell us a little bit more about how it's diagnosed, about when people should be tested. If there are typically no symptoms, how do you know that it's time to be tested for prediabetes?

Dr. Avadhanula: One should be tested for prediabetes if they're overweight, or if they're obese, generally speaking, a fasting blood sugar of around a 100 to 125 can indicate that you have prediabetes or, for example, a hemoglobin A1C of 5.7 to 6.4. Or patients can do an oral glucose tolerance test, where their blood sugar result is 140 to 199. These are typically the ways that we diagnose prediabetes.

Speaker 2: And so essentially then, is it something that you have to ask your doctor for most of the time, or is it something that your doctor will likely recommend if you have obesity or some otherkind of condition?

Dr. Avadhanula: So it depends. I'm always in favor of patients advocating for themselves. So if you have a family history, or, for example, if you're overweight or if you're obese, or if you're having symptoms like blurry vision or increase thirst or urination, I always encourage patients to ask their doctor for a diabetes test. Typically, that would be a hemoglobin A1C, that's generally what we do in the office. So patients should advocate for themselves, but of course our physicians know when to test patients for diabetes and prediabetes.

Speaker 2: Great. That's great advice for all things health related. So let's talk about what needs to happen within the body for prediabetes not to develop into Type 2 diabetes. What is the actual science within your body that you're trying to reverse and what needs to happen for that to be the case?

Dr. Avadhanula: So the best way to reverse this process and the best way for you not to develop to Type 2 diabetes is weight loss. If you lose somewhere around a 5-10% of your body weight, you will reduce your risk of developing Type 2 diabetes by 58%. And this is significant. So making sure that you are choosing the right foods to eat, making sure that you're not sedentary, keeping a healthy and active lifestyle is very, very important. So, weight loss can be an incredibly powerful tool to reduce your risk of developing Type 2 diabetes when you have prediabetes.

Speaker 2: Can you tell us a little bit more about exactly why does weight play such an important role in insulin resistance? What is the relationship between the two?

Dr. Avadhanula: If you have a high density of adiposity in your body, adipose cells, so fat cells, it makes it that much more difficult for insulin to act the way it's supposed to get to the receptors it needs to get to act the way it's supposed to. So you can think about insulin, like a key to your cells. It's supposed to allow the blood sugars to go into your cells. If you have a high density of adipose tissue, it makes it that much more difficult for insulin to get to its receptor and insulin to actually do its job.

Speaker 2: So let's talk about some of the steps that people can take to reverse prediabetes, what some of those actual tangible steps look like. So to start, what role do diet and nutrition play, and are there any foods or eating styles that are best or recommended for people who have prediabetes and who are trying to reverse it?

Dr. Avadhanula: You want to really aim for caloric restriction. So there's many, many different pathways to get there and what works for your lifestyle is the best pathway for you. So for example, I have patients that do really well with intermittent fasting. Intermittent fasting has benefits that go beyond just weight loss and this works for them because they're able to maintain it. Consistency is absolutely key. And then on the other hand, I have patients that absolutely cannot do intermittent fasting and they cannot stay consistent with it so it really defeats the purpose.

You really want to aim for caloric restriction in a way that is safe, in a way that's monitored by your physician and your provider team, and in a way that is really consistent with your lifestyle. So losing 500 calories in a day will roughly get you to losing around one pound a week. And that is a typical healthy weight loss. So if you lose 500 calories a day, whether it's from your diet or whether it's from the exercise that you do, that will typically get you to around one pound weight loss in a week. And that's exactly what we're looking for.

Speaker 2: Got it. So it sounds like any healthy eating style might be able to do the trick as long as it's a healthy eating style that you can stick to. Are there certain foods that should be avoided or that are particularly bad for people who have prediabetes?

Dr. Avadhanula: So what you said was exactly correct. And there are certain foods that patients with prediabetes, or even if you don't have prediabetes. If you are trying not to develop any kind of say, impaired glucose tolerance, you want to make sure that you're staying away from things like refined sugars. You want to make sure that you're staying away from things like simple carbohydrates, making sure that you're eliminating things like syrups, sugary juices. Things like soft drinks, fruit juice concentrate, for example, in candy and any product that has added sugar, for example, baked goods or even cereals. So being really cognizant is very important. I always encourage my patients to be very educated about anything that they're putting in their mouth. It's very important to read food labels and be educated on what exactly you're consuming.

Speaker 2: So talk to me a little bit about the kind of challenges that you see amongst patients who are trying to make these lifestyle changes, but that may run into some obstacles. What kind of challenges do you see among people who are trying to reverse prediabetes?

Dr. Avadhanula: I think as providers, we often tell our patients try to make good food choices and we try to guide them in the right direction of what food choices to make. And we ask that they make healthy choices and they lead a healthy life. But one of the things that we must be thoughtful about as providers is that not every patient has the option to make healthy food choices. One, there may not be a lot of nutritional education out there. So oftentimes, our patients don't know what healthy choices are, which is why we often send them to nutritionists, where they read food labels and they start learning about calories and what foods are good foods and what foods may not be the best choices for them.

Moreover, some of our patients live in food deserts. So they don't have the resources they need to make those good choices. So it's not just about making a thoughtful decision about your food choices or your lifestyle choices. We have to be very thoughtful about patients who, for example, live in places where they just don't have that access to fresh fruits and vegetables.

Speaker 2: I think that's really important to point out. Because we always hear, "Oh, if you lose weight, if you eat healthier." And that's not always easy for folks, there's a lot that stands in the way. So you mentioned sending folks to a nutritionist to learn how to read labels better. Are there any other things that people can do to learn more on their own? How do we remedy some of these things?

Dr. Avadhanula: For our patients that may not have access to these local supermarkets, some of my patients have started using Instacart® so the food delivery service. And there's also some states where there're statewide programs, where they're working on bringing these fresh food markets into food deserts.

Speaker 2: And how do you track and manage your own blood sugar at home? Is there any way to do that at home if you are in the prediabetes stage or maybe not, but you want to be sure that you're being healthy? Is there any way to track that on your own?

Dr. Avadhanula: Fingerstick blood sugar checks are usually the traditional way of doing things. However, if you have prediabetes, I would really caution you against checking your blood sugars multiple times in a day. It could be counterproductive, anxiety provoking. What you really want to be doing, if you want, is to be checking your fasting blood sugar in the morning and that's perfectly reasonable. Any more than that, unless you have Type 2 diabetes, there's really no reason for you to be consistently checking your blood sugars like that. If you're interested in seeing your blood sugar patterns, a continuous glucose monitor may be a little bit more appropriate for you. It allows you to see how your glucose progresses throughout the day, what foods cause your blood sugars to spike. And it can really give you very good insight on how food is affecting your blood sugar.

Speaker 2: Great. So you mentioned increased physical activity. How much increased physical activity is recommended to help reverse prediabetes?

Dr. Avadhanula: The American Diabetes Association typically recommends 150 minutes of exercise in a week. And this roughly translates to around 30 minutes of exercise, five times a week. This can be intimidating sometimes for people to say 30 minutes of exercise all at once, especially if you're just starting out and that's OK. And that's why sometimes I ask people to do what I like to call an exercise snack, which is 15 minutes of exercise twice a day, during the weekdays. So, say, for example, you work at home or you work in an office building or, say, you get an hour for lunch. You can take the last 15 minutes of your lunch and you can do moderate intensity exercise and then again, at the end of the day. So asking patients to do 15 minutes of exercise snacking twice a day during the work week has been pretty successful for us.

But just remember that being consistently active is really important to carry out a healthy lifestyle. So getting 10,000 steps in a day is the baseline in addition to 150 minutes of exercise in a week. So all of us that are just walking around should typically be getting 10,000 steps in a day just at baseline. So if you have a job that say, for example, isn't an office and doesn't really allow you to be active, just making sure that you're getting up every 30 or 45 minutes, just for a couple of steps is very important. Looking at your lifestyle and taking a hard look at what you're doing during the day can also be a positive contributor to your life. For example, if you take the elevator, choose the stairs. If you, for example, park right in front of the store, maybe you can park a couple parking spots away and just walk a little bit further. So these little things during the day can make a really big impact on your overall well-being.

Speaker 2: I really love the term exercise snack. I think that's a great thought because like you said, it can be so overwhelming for people to go from a completely sedentary life to exercising 30 minutes a day, five days a week. That's an interesting way to kind of ease into it. And in this age of so many people working from home, trying to work those steps into our everyday life is certainly a challenge. So talk to us a little bit about blood pressure. How does blood pressure play a role in prediabetes or does it play a role at all?

Dr. Avadhanula: Generally, we consider patients with elevated blood pressure and prediabetes to have part of a more global encompassing syndrome called the metabolic syndrome. The metabolic syndrome encompasses things like prediabetes, high triglyceride levels, high LDL levels, low HDL levels, high blood pressure. And patients can have what we call a central adiposity, which means that they carry weight in the center. And this can increase your risk of developing things like strokes and heart attacks. So prediabetes and elevated blood pressure, as well as elevated cholesterol, are related in terms of metabolic syndrome.

Speaker 2: That makes a lot of sense. I've also read that sleep disorders like sleep apnea can also be a risk factor for diabetes. What role does sleep play in prediabetes if any?

Dr. Avadhanula: Having good healthy sleep hygiene can make a positive impact on your overall health and well-being. So we typically ask patients how their sleep patterns are and we recommend that patients get around seven to nine hours of sleep. That's usually considered a healthy sleep pattern and we really want them to be sleeping anywhere between 10 and 11, all the way to five o'clock in the morning. And the reason that's relevant is because we have a hormone that secretes from your adrenal gland, it's called cortisol. And that hormone is typically supposed to be very low at three o'clock in the morning and that can negatively impact your blood sugars if it's high. So patients that don't sleep the seven to nine hours or are not sleeping between the hours of say, for example 11 to five, they can get higher levels of cortisol because they're not sleeping at three o'clock in the morning and this can negatively contribute.

And typically it can increase your risk of developing things like prediabetes and diabetes. So it actually raises your blood sugars when your cortisol is consistently elevated like that. We have patients that work in night shift, that do shift work for example, and they have an altered, what we call, “circadian rhythm of cortisol.” And they often come to me and ask me, "Why are my blood sugar so high like this?" And a lot of the times it's because of the sleeping patterns. So having good sleep hygiene and sleeping that seven to nine hours and making sure that you are asleep between the hours of 11 to five really can contribute to your blood sugars.

Speaker 2: And so if you're one of those people who works third shift, that's really interesting. A lot of people can't help working the night shift. Is there anything that those folks can do in particular, does getting the right amount of good sleep at another time of day, help lower their risk?

Dr. Avadhanula: If you have to work night shift, then getting good, consistent sleep during the day can potentially help your blood sugars and also remembering that your entire circadian rhythm has shifted. So also mimicking meals at times that you would've during the day, during the night can also potentially help you control your blood sugars.

Speaker 2: So still sticking to some of those routines and getting your body used to kind of doing the same thing. Another risk factor for diabetes is smoking. Obviously, quitting smoking plays a huge role in all kinds of things related to our health, but how can quitting smoking in particular help with reversing prediabetes?

Dr. Avadhanula: Smoking results in oxidative stress and it can increase inflammation. So these increased stressors, they can increase your cortisol levels and this can thus in turn cause increase in your risk of developing prediabetes and diabetes. If you already have prediabetes and you have Type 2 diabetes, and on top of that, you smoke, you're increasing your risk of developing cardiovascular comorbid conditions, like heart attacks and strokes.

Speaker 2: Just another reason to quit smoking. It really impacts pretty much everything in our bodies, it sounds like. So, if someone has prediabetes and they are sort of making the right lifestyle changes and working to reverse it, is there any kind of medication that can help them along, that can help them treat or reverse that prediabetes?

Dr. Avadhanula: At some point, your physician might suggest a medication for you called Metformin. Metformin is typically the first line of treatment and standard of care for patients who have Type 2 diabetes, if they have no other contraindications to take it. Some studies have suggested that Metformin can be can be equivalent to lifestyle changes with regards to preventing the advancement of prediabetes to Type 2 diabetes. But generally, in my practice, I tend to focus more on lifestyle modifications. I tend to focus more on things that patients can change without medication. So say for example, if a patient is pretty sedentary in their life or they're drinking sugary drinks every day. They may not be making the most educated choices with respect to nutrition. I always try to help them with regards to their lifestyle habits before introducing medications.

Speaker 2: So I know you just said that you don't normally like to put people on medication, but if you are on a medication like Metformin, is there ever a time when you can go off of it? If you successfully reverse prediabetes, can you stop taking the medication as long as you continue those lifestyle changes? How does that normally work?

Dr. Avadhanula: Absolutely. It is possible to go off of your diabetes medication or your prediabetes medication. If you say, for example, reverse that process, the treatment plan is always individualized between you and your provider. So think about it like this. When somebody goes on blood pressure medications and they achieve a normal blood pressure, we don't take them off those blood pressure medications. We keep them on because it's what's keeping their blood pressure normal. So you may decide with your provider that you would like to stay on, say, for example, Metformin, if that's what she or he decided to put you on, because you would like to remain on Metformin and there's no side effects for you and it's going well.

But some patient and providers will decide together that maybe you'd like a trial off medication and that's very reasonable in certain circumstances. If you're able to maintain those good lifestyle choices. I would recommend periodically checking a hemoglobin A1C and making sure that your blood sugar still stay nice and low in that case. But certainly, medications, if you have Type 2 diabetes or prediabetes, these are reversible processes and medications are not lifetime commitments.

Speaker 2: Great. So maybe yes, maybe no, all individualized based on the patient and their plan with their doctor. How do you know whether you are successfully addressing your prediabetes? We mentioned a little bit, how you can track your blood sugar at home. Is there any other way to track it? How often do you need to see your doctor? What can you tell us about as you go through that process, how you can tell how you're doing?

Dr. Avadhanula: We typically ask our patients to see us every three months if they have prediabetes. A little bit sooner, if they have Type 2 diabetes and it's maybe not very well controlled. If patients check their blood sugars at home, we typically ask that they be below a 100. That's really what you're going for. That's a good goal to have if patients are checking their blood sugar at home, but we always ask patients to monitor their weight. We always ask patients to monitor their intake and make sure that they're getting the recommended amount of physical activity and exercise. So long as they're doing that and following up with their care team, they'll be on great track.

Speaker 2: So I'm guessing that the answer to the question I'm about to ask you is also kind of dependent on each person or each patient. But how long does it take to reverse prediabetes? How long do you have before it turns into Type 2 diabetes and how long does it often take to reverse that process before you get there?

Dr. Avadhanula: There's no timeline per se of when your prediabetes would be reversed or, say, for example, there'll be a conversion between prediabetes and Type 2 diabetes. There are factors that can accelerate this process. So, say, for example, you have prediabetes and then you may gain weight. Then that process into Type 2 diabetes can be accelerated or, say, for example, you take medications like steroids for chronic lung disease or patients that take certain medications under the treatment of HIV. These can potentially accelerate the process of going from prediabetes to Type 2 diabetes.

Speaker 2: Great. So is there anything that we haven't discussed today that you think is important for people to know about prediabetes? Whether we're talking to listeners who already have been diagnosed with prediabetes or for folks who are just trying to ward it off in the future, anything else that people should know?

Dr. Avadhanula: If you were diagnosed with prediabetes, just remember this is a reversible process. This may take time to reverse, but it certainly can be done. Give yourself some grace, be patient and be kind to yourself.

Speaker 2: Perfect. I think that's a great note to end on. Dr. Avadhanula, thank you so much for being here with us today and for speaking with us on this important topic. To learn more about diabetes care at Cleveland Clinic, please visit clevelandclinic.org/endocrinology, or call 216.444.6568. Thank you so much for listening in today.

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