October 3, 2014

An Argument Against the Prediabetes Classification

At least this is not a study, but an analysis by “experts.” They are talking about the two parts – the medicine and the politics of prediabetes. The article is part of a series in the British Medical Journal on over diagnosis. They say that the risks and harms to patients will depend in expanding disease definitions. They began their analysis by reminding the reader that prediabetes is a heterogeneous concept or a concept composed of parts of different kinds, having widely dissimilar elements or constituents:

“Concept one” - The original category of intermediate hyperglycemia was termed "impaired glucose tolerance" and was based on the oral glucose tolerance test. Only since 1997 was an intermediate category of "impaired fasting glucose" created, “concept two” with revision in 2003 to expand the range of qualifying values. “Concept three” Because A1c was not used for diagnostic testing until 2010; it is only recently that a nameless intermediate category based on A1c was designated. Unfortunately, the overlap of these three definitions is far from perfect, so the starting point for the discussion is already confused. This is the interpretation of the experts.

They declare there is a limited value of prediabetes. They said the importance was whether a diagnosis of prediabetes guarantees a future diagnosis of diabetes. They declare that no matter how prediabetes is defined, the answer is “no” - less than one-half of all such people will develop diabetes within 10 years. The two authors say that clinical trials from around the world have demonstrated that diabetes risk among high-risk individuals can indeed be reduced, but Yudkin and Montori argue that diabetes onset was merely delayed by 2-4 years, at high cost and only among a subset of the intervention groups.

“The following quote summarizes their position: "The US Diabetes Prevention Program results imply that you can give an at-risk person with pre-diabetes a 100% chance of using metformin with the goal of reducing by 31% their risk of developing a condition that might require them to use metformin." Yudkin and Montori conclude that it is critically important to address the epidemic of obesity and diabetes. However, they assert that available resources should be used to change the root causes of the epidemic rather than to medicalize otherwise healthy patients with prediabetes.”

Then they switch to a study published in Diabetes Care about the risk of cardiovascular disease (CVD) in people with prediabetes. “The Diabetes Prevention Program Outcomes Study (DPPOS) is the follow-up to a randomized clinical trial of individuals who had prediabetes. Of the 2775 participants in DPPOS, 1509 (54%) had achieved normal glucose regulation (NGR) at least once during the DPP, whereas 496 (18%) remained with prediabetes and 770 (28%) developed diabetes. The investigators also compared individual CVD risk factors, including cholesterol, smoking status, blood pressure, and diabetes status, all assessed annually.”

What bothers me is that 54 percent of people with prediabetes do have problems with high blood pressure and need medications and 34 percent used statins and these “experts” say we should not be concerned with prediabetes. Yes, this does mean that possibly some may be medicated that should not be, but if they could focus on those with the greatest risk factors then some would be missed, but many would be helped.

Maybe the new method of determining diabetes need to be put in place as this would be a great diagnostic tool and could more accurately tell which people with prediabetes were at risk. Read my blog here about the possible new test.

It is my opinion that these “experts” should support testing people for prediabetes and using every test possible to find those at risk for developing type 2 diabetes.

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