October 12, 2016

Doctors Debating Prediabetes

I am not sure why these doctors are discounting prediabetes so vehemently, but they are. Not everyone that is diagnosed with prediabetes develops type 2 diabetes. Those that make changes once they know they have prediabetes, may not develop type 2 diabetes. Discounting prediabetes as these doctors are, can only be a move to have more develop type 2 diabetes for them to have patients to treat.

New research shows that a majority of US adults over age 40 is at risk for prediabetes, according to an online risk calculator, but the investigators question whether so many people should receive the diagnosis.

The findings were published online October 3 in a research letter in JAMA Internal Medicine by Saied Shahraz, MD, PhD, and colleagues, of Tufts Medical Center, Boston, Massachusetts, and are based on use of the online risk instrument "Do I Have Prediabetes?" endorsed by the American Diabetes Association (ADA), the American Medical Association (AMA), and the Centers for Disease Control and Prevention (CDC).

When applied to the US population, that instrument identifies three of five among those aged 40 and older, and eight of 10 over-60-year-olds who don't already have diabetes as being at risk for prediabetes. The tool encourages those individuals to talk to their doctors about laboratory glucose testing, in line with screening guidelines.

But Dr Shahraz and colleagues question the value of that process. "We showed that the online risk test endorsed by ADA, AMA, and CDC is identifying and medicalizing a very large at-risk population, which can lead to overutilization of resources," Dr Shahraz and coauthor David M Kent, MD, wrote in an email to Medscape Medical News.

"We also note that even among those confirmed to have prediabetes, a substantial proportion are still at relatively low risk of progression to diabetes and at very low risk of end-organ damage," they add.

They cite as problematic the 2010 ADA guidelines that reaffirmed the prior widening of the definition of prediabetes by lowering the fasting blood glucose cutoff to 100 mg/dl from the previous 110 mg/dl and allowing the use of HbA1c for diagnosing prediabetes (cutoff 5.7%).

"This expansion increased the at-risk population twofold. Still, evidence favoring the long-term benefits of the definition change is very poor," the two investigators say.

In their discussion, the authors point out that there is no direct evidence that type 2 diabetes prevention alters the risk for diabetes-related complications.

Moreover, they say, progression to type 2 diabetes would likely be slower among those who qualify based on either HbA1c or fasting blood glucose as opposed to those who meet criteria based on an oral glucose tolerance test.

And Dr Shahraz and Dr Kent told Medscape Medical News that prior work from their group reanalyzing the landmark Diabetes Prevention Program — which showed that intensive lifestyle modification or metformin can prevent or delay the onset of diabetes in people with prediabetes — revealed that most of the benefit of these interventions can be captured by targeting just those individuals at especially high risk of progressing (BMJ. 2015;350:h454).

"This is important, since it is estimated that 80 million people have prediabetes. The resources that it would take to identify and treat all these people are potentially overwhelming."

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