Retrospective #364: “Prediabetes, in other words, is Diabetes”

This title is in quotes because…I think I cribbed it from Kelley Pounds, an RN, CDE, blogger and diabetes educator whose writings I always find interesting and informative. But, alas, I can’t find that title in her Table of Contents. So, a hat tip to Kelley Pounds. Check out her home page.

The point of the title is that Kelley, and I and many other “activists,” and of late, even some researchers, are urging the public health establishment in the U. S. and world-wide to take a hard look at the current Clinical Guidelines for defining Prediabetes and consider lowering or re-defining it. The implications of doing this are momentous; but likewise, if this is not done, the outcomes will be catastrophic. Consider this December 2016 revelation from the CDC: “Life expectancy for the U. S. population in 2015 was 78.8 years, a decrease of 0.1 years from 2014.” That’s the first DECREASE IN LIFE EXPECTANCY in the U.S. since 1999. Think it’s related to our lifestyle? To our diet?

A ton of evidence associates LIFESTYLE DISEASES with METABOLIC SYNDROME, the major outcomes of which are obesity, Type 2 Diabetes and heart disease. That’s why a Better Standard of Care is needed to address this scourge.

THE LIFESTYLE DISEASES

Cardiovascular Disease (CVD), Coronary Heart Disease (CHD), Stroke, Type 2 Diabetes Mellitus (T2DM), Non-alcoholic Fatty Liver Disease (NAFLD), Alzheimer’s Disease, aka Type 3 Diabetes, and even Erectile Dysfunction, plus several types of cancer; A large population study in July 2010 in “Diabetes Care,” shows that “the relative risks of various cancers imparted by diabetes are greatest (about twofold or higher) for cancers of the liver, pancreas, and endometrium, and lesser (about 1.2–1.5 fold) for cancers of the colon and rectum, breast, and bladder.”

METABOLIC SYNDROME

A WebMD stub puts it succinctly: “Metabolic syndrome is a collection of symptoms that can lead to diabetes and heart disease. The good news is that metabolic syndrome can be controlled, largely with changes to your lifestyle.” The five related symptoms, first introduced nine years ago to my readers in Retrospective #9, and updated in Retrospectives #78, #334 and #335 are: a Body Mass Index (BMI) ≥30, or large waist circumference (men ≥40 inches, women ≥35 inches); elevated triglycerides (≥150mg/dl), reduced HDL, the “good” cholesterol (men ≤40mg/dl, women ≤50mg/dl), elevated blood pressure (≥130/85mm Hg, and/or use of medications for hypertension) and elevated fasting glucose (≥100 mg/dl, and/or the use of medications for hyperglycemia).

A BETTER STANDARD OF CARE

In the U.S. the longstanding criteria for a clinical diagnosis of Type 2 Diabetes Mellitus (T2DM) was two consecutive office visits with a fasting blood sugar ≥140mg/dl (7.8mmol/L). In 1997 that standard was lowered to ≥126mg/dl (7.0mmol/L). In 2002 a definition for Pre-Diabetes was added: an IFG ≥ 100 to 125mg/dl (5.6 to 6.9mmol/L) or an IGT of 140 to 199mg/dl (7.8 to 11.0 mmol/L) two hours after a 75-gram glucose challenge. The WHO uses a higher IFG threshold: ≥110to 125mg/dl (6.1 to 6.9mmol/L).

Later, in the U. S., the HbA1c measurement was added to supplement or in some cases now to supplant the IFG. In the U. S., an HbA1c between 5.7% and 6.4% is considered Pre-Diabetic and ≥6.5% Type 2 Diabetes. Elsewhere in the world, Pre-Diabetes is defined as an “A1c” ratio between 49 and 56mmol/mol and Type 2 Diabetes as ≥58mmol/mol.

For years leading research scientists like Ralph A. DeFronzo and pioneering clinicians like Richard K. Bernstein have called for a lower standard for the diagnosis of incipient Type 2 Diabetes. These men are leading diabetes specialists who have devoted their lives to combating this disease. They are both superstars.

Now, as I reported in #362, the BMJ (British Medical Journal) has published IN 2016 a Chinese meta-analysis done on 1,611,339 people. The lead researcher’s takeaway: “Effective intervention in prediabetes is not just for prevention of diabetes, but also cardiovascular diseases.” The majordomos are starting to connect the dots.

WHAT HAS TO BE DONE?

Type 2 Diabetes has to be redefined, as Kelly Pounds and I and DeFronzo and Bernstein would say – indeed have said: “PREDIABETES, IN OTHER WORDS, IS TYPE 2 DIABETES.”

And at the clinical level today, physicians have to revise their Standard of Care and not treat Prediabetes with temporizing measures, e.g., “We’ll have to monitor your blood sugar” (read: to watch your Insulin Resistance worsen as you continue to eat the Standard American Diet. Clinicians need to tell you: “If you are Prediabetic, you are in fact Diabetic. You have Insulin Resistance. You need to change your diet. You are Carbohydrate Intolerant.”