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Will diagnosing millions more Americans as prediabetic really make things better?

Will diagnosing millions more Americans as prediabetic really make things better?

[Photo: Three Lions/Getty Images]
[Photo: Three Lions/Getty Images]

We are big advocates of the diabetes prevention program, an intensive lifestyle program shown to reduce the incidence of diabetes by 58 percent among those with prediabetes. But we are also skeptical about labeling prediabetes as a medical condition, particularly since estimates suggest that approximately a third of Americans fall into this category.

Recently, the Centers for Disease Control and Prevention, the American Diabetes Association, and the American Medical Association have called for clinicians to be more vigilant in diagnosing prediabetes. They propose a screening tool, “Do You Have Prediabetes,” to identify those with risk factors who should be tested. According to a new research letter in JAMA Internal Medicine, this screening tool could prove overwhelming, categorizing “3 of 5 people 40 years or older and 8 of 10 individuals 60 years or older as being at high risk for prediabetes, requiring a medical visit and a blood glucose test for confirmation.”

While we certainly advocate that patients at risk for developing diabetes — which indeed includes most of us! —should engage in intensive lifestyle efforts to lower their risk, we worry about over-medicalizing the situation. Will labeling millions more Americans as prediabetic really make the situation any better? Will it motivate meaningful lifestyle changes among patients? Or will a diagnosis of “prediabetes” simply lead patients and providers to use medications rather than refocus on aggressive lifestyle changes?

Indeed, for many other common symptoms that a large proportion of the population experience — such as heart burn, erectile dysfunction, anxiety, menopausal symptoms, or dandruff — we suspect medicalization through pharmaceutical advertisements and special interest campaigns has led to more harm than good. While on one hand such efforts might help those who are bothered by these common ailments seek potentially helpful therapies, in our experience these efforts more commonly lead to overuse of potentially harmful therapies and distract sufferers from the lifestyle changes that, in the long run, will offer greater benefits.

That’s why we agree with the JAMA Internal Medicine editors: Rather than investing all this effort in officially labeling our patients as prediabetic, “a better approach to preventing the epidemic of obesity and its multiple health-related complications is emphasis on healthful diet, weight loss when appropriate, and increased physical activity at all levels-by schools, the medical profession, and public health and governmental agencies.” Better yet, let’s supplement this individual approach with public health reforms, such as ensuring access to healthy foods in all communities and making inexpensive and simple physical activity opportunities more widely available. 

Comments

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Medicalizing the human condition by giving it a name seems wrong, and also ineffective.

First, if nearly everyone will test positive for the diagnosis, is it really a diagnosis (a knowable difference), or simply a fact of human biology that bears an effort to ameliorate? Do we all suffer from pre death? We take many steps to live longer every day, like wearing seat belts, or avoiding poisons. A diagnosis wouldn't change that.

Second, a Bayesian model for this problem makes the pretest probability of pre-diabetes so high, regardless of symptoms, that a screening test is actually wasteful. Rather, it makes more sense to test only those who indicate that they don't want to carry out a healthy lifestyle. Or better yet, we could simply ask if it would help if they knew that they had a condition that would make them more susceptible to disabling events like heart attacks, strokes, or kidney failure. I find many people think their unhealthy lifestyle will simply lead to an early, painless exit after a life of pleasant indulgence, rather than to the suffering that real disease can bring (it helps to actually ASK people what they think is going to happen to them, rather than to assume they understand all of the risks they are taking).

It's much easier to effectively engage people in difficult behavioral change using a concrete shared vision of years of suffering rather than by using an abstract concept that names for them a condition nearly everyone has.

If we don't need to diagnose pre-death, do we really need to diagnose prediabetes?

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