Pre-Diabetes Mellitus

Pre-diabetes mellitus (Pre-DM) is asymptomatic but predisposes individuals to Type 2 Diabetes Mellitus (T2DM) and cardiovascular disease. Both Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance (IGT) are considered entities of pre-DM. Around 14% of Singaporeans have impaired glucose tolerance, and without lifestyle changes, at least 35% of persons with pre-DM in Singapore will progress to T2DM within eight years.^1,2

Diagnosis is made through a combination of Fasting Plasma Glucose and two-hour Post-Challenge Plasma Glucose.

Clinical Approach

Pre-DM is usually diagnosed when screening individuals for DM. Screening of DM should be considered in adults of any age who have one or more risk factors for DM^3,4.

In those without risk factors, testing should begin at 40 years old.
Those between 18-39 years old can consider doing the Diabetes Risk Assessment Tool (DRAT) to assess their risk of having DM.
Those who have been found to be high risk using the DRAT assessment should undergo formal blood test screening .

Prevent or delay progression to T2DM.
Prevent and screen cardiovascular disease (CVD).
Aim for BMI <23 kg/m² (Asian population) or 5-10% body weight loss from diagnosis.

Management

Behaviour: Educate & empower with patient-centred care.

Empowering patients to own their treatment goals is important to achieve sustained lifestyle changes and health improvement. Through person-centred communication and engagement, GPs can raise their patients' health literacy, so that patients can co-own their care journey. The key aspects of patient empowerment framework which are common across healthcare institutions:

Adopting a biopsychosocial model in health planning.
Using Open questions, Affirmations, Reflections and Summaries (OARS).
Using teach-back technique which confirms understanding in a non-judgemental way.
Setting SMART goals (Specific Measurable Action-oriented, Realistic, Time-limited).

For more details, please refer to the playbook on Care Team Education for Person-Centred Communication.

Lifestyle interventions

Healthy plate, reduce fat intake, avoid sugary drinks & food, reduce alcohol intake, stop smoking.
Reduce fat intake, avoid sugary drinks & food, reduce alcohol intake.
Quit Smoking.

≥150 min of moderate-intensity or ≥75 min of vigorous-intensity exercise/week.

Reduce sedentary behaviour.

Care teams may use the relevant Lifestyle Prescription to help patients understand practical steps they can take to manage pre-diabetes mellitus. A copy may be printed for patient use.

Regular follow-up .

Start Metformin for those whose glycaemic status does not improve despite lifestyle intervention/unable to adopt lifestyle intervention.

Data Submission

The following data fields should be documented in GPs' case notes as part of good clinical practice for all patients enrolled to their practice.

Submission of data fields marked with asterisks* is mandatory and required for the Healthier SG Annual Service Fee payments.

Diagnosis

Diagnosis*
Year of Diagnosis

Pre-DM Control

HbA1c (%)* OR FPG (mmol/L or mg/dL)* OR OGTT (mmol/L or mg/dL)*
Date*

Lipid Profile

LDL-cholesterol (mmol/L or mg/dL)*
HDL-cholesterol (mmol/L or mg/dL)
Triglycerides (mmol/L or mg/dL)
Total cholesterol (mmol/L or mg/dL)
Date*

Blood Pressure

Systolic BP (mmHg)*
Diastolic BP (mmHg)*
Date*

Weight

BMI (kg/m²), calculated from height*, weight*
Waist circumference (in cm)
Date*

Kidney Assessment

Serum creatinine (mol/L) OR eGFR (ml/min/1.73m²) (for patients on Metformin)
Date

Financing

CHAS/PG/MG cardholders who are Healthier SG enrollees will be eligible for the Healthier SG Chronic Tier, which provides percentage-based subsidies for a whitelist of drug products sold within the MOH price caps. When making claims, GPs will need to submit the quantities and selling prices for each whitelisted drug product prescribed.

Details on the GP Annual Service Fee for enrolees with pre-DM can be found in the Healthier SG Enrolment Programme Agreement.

References