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Sun Mar 17, 2019, 10:06 PM

Dubious diagnosis

A war on "prediabetes" has created millions of new patients and a tempting opportunity for pharma. But how real is the condition?


The most common chronic disease after obesity, afflicting 84 million Americans and more than 1 billion people worldwide, was born as a public relations catchphrase. In 2001, the PR chief of the American Diabetes Association (ADA) approached Richard Kahn, then the group's chief scientific and medical officer, for help with a vexing problem, Kahn recalls. ADA needed a pitch to persuade complacent doctors and the public to take seriously a slight elevation in blood glucose, which might signal a heightened risk of type 2 diabetes. Raising the alarm wasn't easy, given the condition's abstruse name, impaired glucose tolerance, and lack of symptoms.

Kahn invited half a dozen diabetes thought leaders to brainstorm at a National Institutes of Health cafeteria in Bethesda, Maryland. Surrounded by hungry federal employees, many enjoying the kinds of fatty foods and sugary drinks tied to the diabetes epidemic, they landed on a then–little-used term that seemed sure to scare patients and doctors into action: prediabetes.

“We went back to the ADA office right after lunch and started the change. Within a relatively short period of time we … eliminated ‘impaired fasting glucose’ and ‘impaired glucose tolerance’ and substituted ‘prediabetes’ in all of our literature,” Kahn says. Soon, the term was enshrined in the Arlington, Virginia, group's standards of care—widely regarded as the bible of diabetes. ADA and the Centers for Disease Control and Prevention (CDC) in Atlanta declared war against prediabetes, with CDC diabetes prevention chief Ann Albright, an ADA board member from 2005 to 2009, leading the charge. The two groups labeled prediabetes a first step on the road to diabetes, which can lead to amputations, blindness, and heart attacks.

In medicine, prevention is usually an unalloyed good. But in this case, other diabetes specialists argue, medical and epidemiological data give weak support, at most, for increasingly dire prediabetes admonitions. “Nobody really thought at the time, how ‘pre’ is prediabetes for all these people?” says Kahn, who left ADA in 2009 and is now at the University of North Carolina in Chapel Hill. The World Health Organization (WHO) in Geneva, Switzerland, and other medical authorities have rejected prediabetes as a diagnostic category because they are not convinced that it routinely leads to diabetes or that existing treatments do much good. John Yudkin, a diabetes researcher and emeritus professor of medicine at University College London, describes the ominous warnings about prediabetes from ADA and CDC as “scaremongering.”

Yet ADA, a nonprofit that funds research, issues treatment standards, and raises public awareness, has gradually broadened its definition of prediabetes to encompass more people. “The public needs to know that right now, in the United States … one out of three may have some aspect of glucose abnormality,” says William Cefalu, ADA's current chief scientific and medical officer. “A great percentage … particularly in select ethnic groups, may have an increased chance, or a higher rate of progressing (to diabetes).”

CDC has followed ADA's lead, because “they set the primary standards of care in the U.S.,” Albright wrote in a statement to Science. (Albright declined interview requests, and CDC would not permit Edward Gregg, Albright's top epidemiologist, to comment for this story.) In the past, Albright and CDC have said repeatedly that 15% to 30% of untreated prediabetes patients progress to diabetes within 5 years—a claim that hospitals, professional organizations, and local and state health departments have embraced and publicized. She backed away from that number in response to a question from Science, saying, “We no longer use that statement to characterize risk.” Indeed, CDC's own data show progression from prediabetes to diabetes at less than 2% per year, or less than 10% in 5 years. (Other studies show even slower rates.)

The push to diagnose and treat prediabetes has come at a cost. When told they have the condition, many people face psychological and financial burdens trying to address it. ADA, CDC, and other groups have spent billions of dollars on research, education, and health improvement programs—generally focused on weight loss and exercise—that have generated lackluster results, according to critics. Kahn makes the point with rhetorical bluntness: Spending vast sums of public money on such prevention programs “has nearly the same effect as burning it in a fire … overall, (it's) a terrible waste of money.”

http://science.sciencemag.org/content/363/6431/1026

Much more at the link.

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Arrow 7 replies Author Time Post
Reply Dubious diagnosis (Original post)
Troll2 Mar 2019 OP
His Daughter Mar 2019 #1
Grumpy Pickle Mar 2019 #2
Bubba Mar 2019 #3
Currentsitguy Mar 2019 #6
Jardinier Mar 2019 #7
HerasHeaddress Mar 2019 #4
nolidad Mar 2019 #5

Response to Troll2 (Original post)

Mon Mar 18, 2019, 12:18 AM

1. This is in many ways just jargon

The medical community knows what are the precursors and signs that someone in the US is head to diabetes. It is a mix of lifestyle and genes. One can fix the lifestyle and the patient is stuck with the genes. Nomenclature changes are pretty much marketing and little more.

Certain genetic groups (AKA ethnicities) have more of a problem with diabetes than others. In the US is people of African ancestry and American Indians. Not all, but clearly some sub groups. If clearly runs in families and is rampant on many reservations.

When I was in training, I heard the story of a reservation where over 90% of the population was at some level diabetic. Not sure that is actually true, but the levels in some tribes is many times higher than the national level. There is also the cost of care. Insulin is crazy expensive and Glargine, a long lasting insulin is also silly expensive with no discernible reason. Prices have headed down recently but there is no excuse for the crazy costs.

In terms of treatment, the money is in the supplies. The meters are given away, the money is in the test strips. Same brand with require different strips with different readers. Not saying its a scam, as much as optimized to make money. Same used to be true with meter cables and software, though that too has been improving. I urge people to get Continuous Glucose Monitors. They give a great deal of insight into how your body is doing. They will allow you to tailor your diet and medications. With some insurance plans they are cheaper than 5 test strips daily. As a provider, I can plug in their reader and get 90 days worth of history immediately, and 8 hours of data from the sensor itself. Critical if the patient is in some sort of diabetic crisis.

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Response to His Daughter (Reply #1)

Mon Mar 18, 2019, 12:29 AM

2. Agree.

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Response to His Daughter (Reply #1)

Mon Mar 18, 2019, 03:22 AM

3. Thank You For The Info

And clarification, His Daughter.

About four years ago, my doctor told me I had pre-diabetes. I have made two changes in my lifestyle. They seem fairly major to me, but an outside observer might consider them minor.

First, I cut out the bowl of ice cream every night after dinner. Second, I work out five or six times a week instead of two-three as I had been doing.

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Response to His Daughter (Reply #1)

Mon Mar 18, 2019, 12:51 PM

6. WalMart's ReliOn brand meter goes for about $15 and 100 strips are less than $20.

I've compared it against some of the expensive strip brands and find little difference in accuracy. It's well worth it for those on a tight budget.

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Response to His Daughter (Reply #1)

Wed Mar 20, 2019, 01:15 AM

7. I have heard of that reservation as well where most of the tribe have diabetes.

I think it was in the south western part of the U.S.

I was telling my oldest son about how Indians as a whole, are more predisposed to diabetes. At the time we were driving through Comanche country and had been seeing a lot of bio-Hazard Sharps Containers in the restrooms.

My GP told me I was pre-diabetic and he suspected it was because I've been on varying doses prednisone for 10 years. I had a blood glucose of 126 about an hour after eating a huge lunch. Anyway, I weaned myself off prednisone and once it completely wore off (about 6 weeks later) couldn't even get up out of a chair with out it. I'm in a bit of a pickle.

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Response to Troll2 (Original post)

Mon Mar 18, 2019, 06:29 AM

4. Wonder how this research

squares with the push to glamorize obesity? The 'fat is beautiful and healthy' movement is an early death sentence for the obese, especially those with predisposing genetics (as HD describes above).

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Response to Troll2 (Original post)

Mon Mar 18, 2019, 09:01 AM

5. I love how my doc. explained it!

She said that as we get older, many times our pancreas needs a little help because it does not produce enough insulin to turn foods to usable sugars for the body.

My blood sugars and A1C are in good shape, but they have me take one metformin a day to help things along!

My co-pay for a 90 day supply is $2.57 so I don't mind!

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