We pay special attention to pre-diabetes, in all its varied manifestations, in the Track Your Plaque program. This is because these factors are potent instigators of coronary plaque growth.
Early in the Track Your Plaque program we ignored these measures. After all, this is a program for heart disease risk reduction, not for mangement of diabetes. But we saw explosive rates of plaque growth when pre-diabetic factors were not controlled--even when cholesterol and related factors were under excellent control.
It became increasingly clear that factors associated with pre-diabetes needed to be managed, as well. This includes small LDL, increased blood sugar, high blood pressure, increased inflammation (as CRP).
Many people, however, have normal blood sugars (100 mg/dl or less) with a high blood insulin level (>10 microunits/ml). (This blood test is available in most laboratories.) This means that they have early resistance to insulin. The pancreas, the source of insulin, responds to the body's unresponsiveness to insulin by increasing insulin production.
Increased blood insulin with normal blood sugar will drive production of higher triglycerides, a drop in HDL, creation of small LDL, and inflammation--and coronary plaque growth, as evidenced by increasing CT heart scan score.
Blood insulin levels can be very effectively dropped by weight loss; exercise; reduction of processed carbohydrates like breads, pretzels, and breakfast cereals; and increased raw nuts and oat products; and vitamin D replacement to normal levels. Drug manufacturers are desperately trying to make this a mandate for drug treatment (Actos, Avandia), but are encountering resistance, since most people without overt diabetes don't want to take diabetic medication (rightly so!).
You and your doctor should consider insulin as a factor to track, especially if you have small LDL, low HSL, or high triglycerides, or any of the other manifestations listed above.