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.