You’re Prediabetic? Join the Club
The numbers don’t lie, two million Australians have pre-diabetes and are at high-risk of developing type 2 diabetes.
The website invited me to take an online risk test, promising that it would require only a few minutes. I clicked on the link and gave my gender, race and age range. I responded to a couple of questions about family history and my medical history, said that I was physically active, and filled in my height and weight.
How did I do? “Based on these results, you’re likely to have pre-diabetes and are at high risk for Type 2 diabetes.” The site advised me to see my doctor for a blood test to confirm the results.
I would be more worried about this if I hadn’t just read a new analysis in JAMA Internal Medicine.
I’m in good company: The study found that more than 80 per cent of adults older than 60 would get the same warning. So would nearly 60 per cent of those older than 40, an estimated 73.3 million people.
The researchers, at Tufts Medical Center in Boston, used data from 10,175 participants in the National Health and Nutrition Examination Survey.
Because Type 2 diabetes is a major and growing public health problem, experts certainly do want to help people avoid it. But how useful or meaningful is a test that identifies nearly every older person as likely to have pre-diabetes? As an accompanying editorial pointed out, it’s “a condition never heard of 10 years ago.”
To the lead author, Dr Saeid Shahraz, a specialist in predictive analysis and comparative effectiveness, the test represents “medicalisation”- defining something previously considered normal as a disease that requires attention, monitoring and treatment.
“It’s not a scientific tool,” Shahraz said of the online test. “A predictive model should be able to single out the high-risk people”- those most likely to benefit from interventions, research has shown.
“This one tells everyone they’re high risk. It’s completely unbelievable.”
Dr Victor Montori, an endocrinologist and diabetes specialist at the Mayo Clinic, is also skeptical. “Identifying people and putting this label on them – does that help them?” he asked.
In older people, he noted, blood sugar levels normally rise as the pancreas produces less insulin and the body becomes more insulin resistant. “They’re healthy, and this campaign will make them feel sick,” he said.
He advocates improvements to our diets instead, and reductions in poverty levels and other stressors linked to diabetes.
Ann Albright, who directs the diabetes division at the CDC, is losing patience with such criticism. “This tool is intended to help start a conversation,” she said.
“The purpose is not to give people a clear-cut diagnosis. It’s to give them an idea of where they stand.”
Arguing about the tests, she said, “has distracted the conversation intended to help raise people’s awareness, put it on their radar, get them talking to their physicians.”
The Diabetes Association and the CDC define pre-diabetes as a state of elevated blood sugar, usually assessed by a fasting blood glucose test, that’s not high enough to be diagnosed as diabetes. (It can also be diagnosed with a glucose tolerance test or an HbA1c reading.)
Many older people don’t need to be sent to a doctor for the test; past blood work probably includes blood glucose results. When it measures 126 milligrams per deciliter or higher, the patient has diabetes.
If it’s over 100 mg/dL but doesn’t exceed 125, a person is said to have pre-diabetes, which doesn’t cause organ damage or symptoms on its own but increases the risk of developing diabetes.
Not everyone classified as prediabetic becomes diabetic. The CDC says 15-30 per cent of people with pre-diabetes progress to diabetes within five years, though the rate of progression runs higher in older people.
Because the likelihood of developing diabetes can potentially be reversed, or at least delayed, the CDC in 2012 launched the National Diabetes Prevention Program, offered through local YMCAs, churches and community centers. More than 90,000 people are enrolled at 1,200 sites.
It emphasises healthy eating and exercise, and who could argue with that? As a much-cited 2002 study in The New England Journal of Medicine demonstrated, the approach more effectively reduced diabetes risk over nearly three years than metformin, the most commonly used diabetes drug.
The program proved even more effective in participants older than 60 than in younger groups. But warning nearly the entire older population of a high risk of pre-diabetes still troubles some researchers and clinicians.
“It’s an attempt to improve behavior with fear,” said Dr Jeremy Sussman, a diabetes researcher at the University of Michigan and the Veterans Affairs Ann Arbor Healthcare System.
As with any definition of disease, or a precursor to one, the guidelines are arbitrary and have changed over time in ways that categorise ever more people as prediabetic.
The World Health Organisation, for example, takes a more conservative approach, defining pre-diabetes as a blood glucose reading over 110 mg/dL, not 100. That seemingly small difference would reduce the number of adults with pre-diabetes massively, Montori said.
The first line of treatment for pre-diabetes, and for diabetes, is lifestyle changes to reduce obesity and inactivity. Will people pay attention to such advice, already so omnipresent?
“If I have a patient in my office and I define her as having pre-diabetes, I don’t have anything to tell her besides, ‘Get more exercise and control your diet,'” Shahraz said.
“These interventions are so generic and commonplace that we should recommend them to anyone, including healthy people.”
Some physicians prescribe metformin for pre-diabetes, though – a concern for older people already grappling with complex medication regimens who may be at risk for drug interactions.
Even if older patients do develop diabetes, the risks shake out differently than for younger ones. “The ill effects of diabetes develop over decades,” Sussman said.
Diabetics in their 40s have ample time to suffer the disease’s sometimes awful complications, from kidney damage and vision loss to heart attacks and strokes.
People in their 70s “have fewer years to experience the harms,” Sussman said. Properly treated, they may well die of other causes first.
The question of resources also arises. Diabetics need and consume a lot of health care. Can our system also handle the tens of millions who are prediabetic? Should it?
At the CDC, the response is a resounding yes. “Our plan is to accommodate millions of people” in the National Diabetes Prevention Program, Albright said.
Her staff works to persuade private insurers to cover the cost, typically about $500 for a yearlong course in exercise and better eating, and Medicare coverage will begin in 2018.
“We will all work together to meet the demand, but we also need to be sure the demand is there,” Albright said.
Myself, I’m willing to accept the counsel, if not the label.
If I were 0.5 kilograms lighter, as I was before cookies-and-cocktails season, and every other risk factor stayed the same, the online test would have congratulated me for my low risk and urged, “Keep up the good work.”
For many reasons, I’ll keep exercising and working to fight off unwanted weight. But I don’t need to be classified as prediabetic to do that.
New York Times
Liked this? Read these!
Got something to say? Get it off your chest here
The Juice Daily is a Fairfax Media owned website