A third of Americans are considered prediabetic—but many may be better off without treatment
What does it mean to have a pre-disease?” If you have slightly elevated blood pressure, does that mean that you’re pre-stroke? Or maybe in a sense, we’re all pre-death? In 2001, the American Diabetes Association began to call a slightly elevated blood sugar level “prediabetes.” By 2005, the Centers for Disease Control adopted ADA standards, and 41 million people were estimated to be prediabetic, in comparison to 21 million diabetics in the U.S. In 2010, The ADA broadened its definition of the glycemic level that would constitute prediabetes. When adopted by the CDC, tens of millions more people were swept into the definition. Today, 84 million American, 1 in 3 adults, are considered prediabetic. Meanwhile, the number of diabetics in the country is significantly lower- 30 million people. The majority of people who are at the lower range of what the ADA calls pre-diabetes never progress to diabetes. This has been shown in many studies. Prediabetes causes no symptoms or complications, and some international organizations disavow the label. One of the problems that organizations like the World Health Organization have with the way in which pre-diabetes is defined and managed in the United States and elsewhere is that, the subtext of all of these prevention programs are that, people are essentially fat and lazy, and if they could only be more responsible, eat better, exercise more, they could solve their problem. All of the programs are based on individual clinical solutions to what is really a broad socially-driven, economically-driven, problem in our society. One study done several decades ago looked at people who were in low income housing, and broke them into three groups: a control, that received nothing, another group that recieved a little assistance in finding new housing, and a third that got vouchers and assistance to relocate to better housing. After 20 years, the people who got the most help had the least diabetes and obesity, despite not receiving nutrition and exercise counseling
or drugs. No one in this debate disputes that healthful lifestyles, exercise, eating well, eating the right foods, is vitally important for everyone, but it stands to reason that more money going into the socio-economic aspects of the problem, could also be important in solving the problem. Funding is readily available to research pharmacological
solutions. The incentives to build drugs that are targeted to pre-diabetes are great. And so far, the Food and Drug Administration has never approved any drug specifically to treat pre-diabetes, so the drug makers are a little bit hamstrung. But there are drugs used for diabetes or obesity that are prescribed to patients “off-label” for prediabetes. Although some side effects from these drugs are relatively benign, others can be life-threatening. These side effects are so serious that many people have asked the question, “Does it make sense to even think about using these drugs that could have life threatening consequences to treat something that is a pre-disease?” In 2014, the ADA estimated that $44 billion dollars were spent on pre-diabetic care. This is where it starts to get sticky, the profit motive, the motivations for using drugs, it enters a murky area where some of the people making the advice also have financial conflicts with the people who would profit from that trend towards the use of drugs. This so-called disease has spawned a gigantic industry of everything from glucose testing monitors, to herbal remedies that are hawked online to naive patients. Since the definition of pre-diabetes was made and adopted by the CDC, the prevention budget that they have has risen dramatically. It’s clear that this has shifted the priorities of the agency towards diabetes prevention While some profit from the designation of prediabetes, patients are left to grapple with the consequences of an ambiguous diagnosis, such as higher health care costs and lesser health insurance options. It creates a lot of anxiety in people who have been diagnosed with pre-diabetes. And especially, people who have limited abilities to respond to that diagnosis in an effective way, because of their genetics, or because of their social environment that they live in. If you have pre-diabetes designation, particularly if you’re prescribed a drug for it, then that’s a red flag for life insurers, and you may get an unfavorable insurance rate. So, these are concrete ways that people’s lives could be diminished, and this is not to say, “You should never test people’s blood sugar,” or “you should never alert people to the importance of diet and exercise.” The question is whether you should institutionalize this very broad range, including a very mild elevation of blood sugar, as this terrible problem of, “walking towards the cliff” and “runaway train” that could harm people in these disastrous ways, and that have institutional effects downstream that cost money to solve and create anxiety for patients.