The Escalating — and Useless — Diagnosis of "Pre-Diabetes"
Like most chronic illnesses, diabetes is treated most successfully when diagnosed early. But too many people are being given a diagnosis of “pre-diabetes,” which not only subjects them to unnecessary treatment, but places unsustainable burdens on the health-care infrastructure.
The title of a commentary published last month in the journal BMJ pretty much summed up the problem: “Too Much Medicine,” by Dr. Victor Montori, an endocrinologist who specializes in diabetes at the Mayo Clinic, and Dr. John Yudkin, an emeritus professor of medicine at University College London, calls a diagnosis of pre-diabetes dubious. It’s an important assessment, because a dubious diagnosis is an unreliable predictor of who will actually develop the disease.
“Pre-diabetes is an artificial category with virtually zero clinical relevance,” the Minnesota Post reported in a news statement Yudkin released when the commentary appeared. “There is no proven benefit of giving diabetes treatment drugs to people in this category before they develop diabetes, particularly since many of them would not go on to develop diabetes anyway.”
As we regularly write, overtreatment, which is what the writers are dealing with here, is not just inefficient and wasteful, but leads to unnecessary worry and the possibility of complications from procedures that stem from this unacceptably aggressive use of medical care.
Rather than turning people who are at risk of developing diabetes into patients who are given inappropriate care, the writers argue that those resources should be directed toward educating this population on how to prevent the disorder. That means helping them understand the role of diet and exercise in developing diabetes. It also means expending energy on public policies that address the obesity epidemic that promotes diabetes.
The artificial problem is the result of one segment of the medical industrial complex — the American Diabetes Association — lowering the threshold for what is defined as disease, and it’s disgraceful.
Diabetes is diagnosed when levels of blood glucose, or blood sugar, are too high. It’s a hormonal disorder — the hormone insulin helps deliver necessary amounts of energy (glucose) to cells, but sometimes the body does not make enough. That’s type 1 diabetes, a condition that usually develops when you’re young.
Type 2 diabetes is more common, and develops later in life, when the body doesn’t make enough insulin or doesn’t use what it makes properly. It’s often promoted — and controlled — by lifestyle habits
A deficiency of insulin means that glucose stays in the blood, and if the condition persists too long, can cause a host of problems including:
- heart disease;
- compromised kidney function;
- blindness; and
- skin and gastrointestinal problems.
Because glucose comes from food, weight control, and exercise, are critical to managing diabetes.
“Pre-diabetes” often is diagnosed when your blood sugar is higher than normal but not high enough, or high enough for a long enough period of time, to be called diabetes. The BMJ writers claim that 1 in 3 U.S. adults have been deemed to have pre-diabetes, and that the loose use of the term makes it more confusing than helpful.
The American Diabetes Association (ADA) coined the term, and although it is used globally, the World Health Organization, among other professional groups, discourages its use.
It’s a new descriptor for what, until the late 1990s, was known as “impaired glucose tolerance.” Its evolution to a category that invites excessive treatment reflects the fact that testing for impaired glucose tolerance was a long and complicated process that didn’t always render reliable results. According to the Minnesota Post story, about 3 in 10 people diagnosed with impaired glucose tolerance had normal results when they were re-tested.
In 1999, WHO officials revised the diagnostic criterion for diabetes and called it “impaired fasting glucose.” That replaced the earlier, balky glucose challenge test. But, in 2003, the ADA lowered those blood glucose levels, raising concern among many public health officials when that threshold doubled the number of people who would be diagnosed with impaired fasting glucose.
So in 2009, a third test was developed to measure how much of a certain blood protein is coated with sugar. By WHO standards, people with certain levels of it could be diagnosed with diabetes, and could be diagnosed at an intermediate category at somewhat lower levels.
Even that wasn’t good enough for the ADA, which reduced that threshold further. In their commentary, Montori and Yudkin called it “a decision not endorsed by any other group.”
Those lower thresholds means that as many as three times more people are told they have impaired blood sugar metabolism — or pre-diabetes. That would include half of all adults in China, or half a billion people in that country alone.
In the U.S., those levels mean that 35 in 100 people older than 20, and half of everyone older than 65, have pre-diabetes. That's about 86 million people, and although this country has a problem with obesity and diabetes, that’s outrageous. Unless you’re with the ADA.
The larger point made by Montori and Yudkin is that a pre-diabetes diagnosis is of little value. They say research shows that half of people identified with “impaired glucose tolerance” and about 2 in 3 people identified with “impaired fasting glucose” will not have diabetes 10 years later. They say there’s no evidence that borderline levels of sugar-coated blood protein are a good predictor of who will and who won’t develop diabetes.
But treating people with pre-diabetes with either lifestyle interventions or drugs also has been shown to have a modest effect. It doesn’t prevent the onset of type 2 diabetes, but delays it by only a few years.
Still, lifestyle interventions are not risky or, generally, expensive; they’re healthful habits everyone should adopt. Drugs, of course, are a different matter.
As Yudkin said in the news release, “The ADA recommends treating pre-diabetes with metformin, but the majority of people would receive absolutely no benefit. There are significant financial, social and emotional costs involved with labeling and treating people in this way.”
Using new and expensive drugs as treatments for pre-diabetes, he said, would benefit primarily the drug manufacturers. And, we would add, the practitioners who write those prescriptions.
“Healthy diet and physical activity remain the best ways to prevent and to tackle diabetes,” Montori added. “…We need to keep making efforts to increase the overall health of the population, by measures involving public policy rather than by labeling large sub-sections of the population as having an illness. This is not a problem to be solved at the bedside or in the doctor’s surgery, but rather by communities committed to the health of their citizens.”
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