About 1 in 3 Americans has prediabetes, according to recent diabetes statistics from the Centers for Disease Control and Prevention. If you have prediabetes, you can lower your chance of developing type 2 diabetes. Lose weight if you need to, become more physically active, and follow a reduced-calorie eating plan.

For more support, you can find a lifestyle change program near you through the National Diabetes Prevention Program. Gestational diabetes is a type of diabetes that develops during pregnancy. Most of the time, gestational diabetes goes away after your baby is born.

Even if your gestational diabetes goes away, you still have a greater chance of developing type 2 diabetes within 5 to 10 years. Your child may also be more likely to become obese and develop type 2 diabetes later in life. Making healthy choices helps the whole family and may protect your child from becoming obese or developing diabetes.

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Subgroup analysis showed similar risk reductions in those with and without T2D. While the different dietary patterns that demonstrate improved glycemic control do have some unique differences, they also have significant overlap and generally recommend increased consumption of vegetables, fruits, nuts, whole grains and healthy fats while limiting intake of refined carbohydrates, processed meats and sugar-sweetened beverages.

Dietary counseling should not be a brief process and generally should be performed with the help of a diabetes educator or dietician. Establishing dietary goals with patients is of critical importance and requires close follow-up to monitor for adherence.

To further emphasize the importance of efforts at lifestyle modification for T2D, the committee also provided a target for physical activity, recommending at least minutes of moderate physical activity or 75 minutes of vigorous activity per week.

An active lifestyle is a key component to CVD prevention as noted in the recently updated physical activity guidelines. A meta-analysis included 12 aerobic training and two resistance training studies and found an absolute reduction in hemoglobin A1c HbA1c of approximately 0.

Both aerobic and resistance exercises reduced blood glucose, but the combination was more effective, lowering HbA1c by nearly one percentage point. It is challenging to conduct clinical trials with lifestyle interventions that have adequate size and follow up needed to detect a difference in hard CVD endpoints.

However, multiple well-designed observational studies have shown that lifestyle behaviors can impact rates of CVD events in individuals with T2D.

Data from the Cardiovascular Health Study portray a significantly lower incidence of diabetes in adults with healthy lifestyle factors that include physical activity, diet, smoking status, alcohol use, body mass index and waist circumference.

In its third recommendation, the writing committee stated it was reasonable to use metformin as first line therapy at the time of diagnosis of T2D along with lifestyle changes to improve glycemic control and reduce ASCVD risk. This recommendation is consistent with the American Diabetes Association ADA Clinical Practice Recommendations.

Metformin is a well-established therapy for individuals with T2D who have been unable to obtain glycemic control with lifestyle interventions.

It has similar reductions in HbA1c as other oral options, without associated weight gain or dangerous hypoglycemia. Compared to sulfonylureas, metformin use is associated with lower CV mortality.

The goal of glucose reduction is to prevent CVD events, but until recently data demonstrating benefit for additional T2D medications beyond metformin have not shown positive results.

While insulin is effective in lowering glucose levels, use in people with T2D is associated with weight gain and increased insulin resistance. The addition of insulin compared with sulfonylurea to patients already on metformin is associated with increased CVD events and all-cause mortality.

The Action to Control Cardiovascular Risk in Diabetes ACCORD trial found that strict glucose control did not improve CVD outcomes and in fact, there was an increase in all-cause mortality. More recently, medications within two classes of diabetes medications whose mechanisms of action do not lead to weight gain have demonstrated improvement in CVD outcomes in individuals with T2D.

The SGLT-2 inhibitors decrease the reabsorption of sodium and glucose in the tubules of the kidney resulting in a decrease in serum glucose, diuresis and weight loss.

Three medications empagliflozin, canagliflozin and dapagliflozin have been studied in cardiovascular outcomes trials and found to improve outcomes for CVD and heart failure endpoints Table 1.

One trial evaluating canagliflozin observed a nearly two-fold increase in lower extremity amputations in the treatment arm, 20 but this was not observed in the other trials. The FDA-approved product labeling for canagliflozin now includes a black box warning for the association of lower limb amputations and patients with T2D and established CVD or risk for CVD.

Before initiating canagliflozin, the clinician should consider factors that increase risk of amputation, including a history of peripheral artery disease. GLP-1RAs lower glucose by stimulating insulin secretion and suppressing glucagon when glucose levels are elevated. GLP-1RAs lead to a similar reduction in HbA1c compared with SGLT-2 inhibitors.

Four GLP-1RAs have been studied in clinical trials to assess safety and effectiveness for improving CVD outcomes Table 1.

Compared with placebo, treatment with lixisenatide and exenatide, did not significantly alter CVD events, but liraglutide and semaglutide both demonstrated a significant reduction in a composite endpoint of CV death, MI and stroke. In contrast with the SGLT-2 inhibitors, the mechanism of action for GLP-1RAs appears to be centered on an anti-atherosclerotic effect as there was no reduction in heart failure.

For its final recommendation, the committee recommended that, for individuals with T2D without adequate glycemic control despite efforts at lifestyle modification and metformin, consideration may be given to initiation of an SGLT-2 inhibitor or a GLP-1RA in those who have additional CVD risk factors beyond diabetes.