Some doctors say the government’s effort to
screen millions of people risks overdiagnosis of the condition and could cause
needless fears
Alma
Schneider, who is generally in good health, was taken aback when her doctor
told her she has prediabetes.
The
47-year-old in Montclair, N.J., was stymied. “Honestly, I wish I didn’t know. I
mean for me, because I’m healthy, there’s not much I can do besides have the
stress in my head. Every time I eat something now I’m worried.”
Some
experts also say prediabetes, or blood-sugar levels that are higher than normal
but not high enough to qualify as diabetes, is often best left undiagnosed.
They are pushing back against a recent initiative by the U.S. Centers for
Disease Control and Prevention to encourage people to get screened for the
condition. Critics of the agency’s campaign say it threatens to turn millions
of people, many of whom don’t have a medical problem, into patients.
More than
1 in 3 adults in the U.S. have prediabetes, most of whom aren’t aware of it,
the CDC warns. Without intervention, between 15% and 30% of those people will
develop Type 2 diabetes within five years, the public-health agency says. Often
considered an epidemic, Type 2 diabetes has been diagnosed in about 22 million
people in the U.S., up from 5.5 million in 1980. The American Diabetes
Association and American Medical Association are partners in the CDC’s
public-awareness campaign for prediabetes.
“What is
the impact of telling somebody you have prediabetes and an increased risk of
diabetes?” says Robert Ratner, chief scientific and medical officer for the
American Diabetes Association. “Number one, you get their attention and get
them to pay attention to their lifestyle. What’s the downside of a better
lifestyle?”
But some
experts say the agency has set the bar too low on what level of blood sugar
should define prediabetes. And the number of people with the condition who will
develop Type 2 diabetes is far lower than the CDC estimates, they say.
“Only a
small portion of those people are going to progress” to Type 2 diabetes, says
Victor Montori, an endocrinologist who specializes in diabetes at the Mayo
Clinic, in Rochester, Minn. By raising alarms about prediabetes, “the only
thing you’re guaranteed to get is more tests, more appointments, more
patients.” Another concern: Some people could end up taking medications that
aren’t needed.
“Our
major message is to use this as a warning, not to frighten people,” says Ann
Albright, director of the CDC’s Division of Diabetes Translation. “It’s just
not an option to stand by and watch millions of people march to diabetes,” she
says.
The ad
campaign includes amusing public-service announcements that urge viewers to
take an online quiz to find out if they likely have prediabetes. If the quiz
says yes, they are advised to get a blood test. And if they are diagnosed, to
enroll in one of about 900 CDC-recognized, weight-loss-and-exercise programs
around the country to modify their lifestyle, including healthier eating and
reducing stress. Being overweight is a primary risk factor for diabetes.
Since the
ad campaign launched in January, more than 186,000 people have completed the
online quiz, she says. The CDC doesn’t track how many of those people went on
to do a blood test or enroll in a healthy-lifestyle program.
The Mayo Clinic’s Dr.
Victor Montori worries that prediabetes is being overdiagnosed.
Photo: Patricia
Barrionuevo
Type 2
diabetes, the most common form of the disease, develops when the body cannot
use insulin properly, or make enough of it. Without insulin, glucose, a form of
sugar, can’t get into the body’s cells and accumulates in the bloodstream. The
disease can cause severe complications such as heart attacks, strokes,
blindness and kidney disease.
A doctor
will diagnose diabetes when a person has a blood-sugar level of 6.5% or higher
as measured on a test known as hemoglobin A1C. People with blood glucose of
5.7% to 6.4% are considered at elevated risk for diabetes.
Most
people with prediabetes have blood-sugar levels at the low end of the
range—between 5.7% and 6.0%, says the Mayo Clinic’s Dr. Montori. Studies show
only about 5% of people with A1C levels of 5.7% or 5.8% will progress to Type 2
diabetes within five years, and very few progress after that, he says.
The CDC’s
estimate that up to 30% of people with prediabetes will develop Type 2 diabetes
is based on studies of especially high-risk patients and doesn’t apply to the
general population, says Richard Kahn, a professor of medicine at the
University of North Carolina.
“Stop
worrying. Don’t worry below 6” on the A1C scale, Dr. Kahn says he tells people
diagnosed with prediabetes. He says he suggests people who are overweight or
obese to lose weight, not just those with prediabetes.
Dr.
Albright, of the CDC, agrees the definition of prediabetes covers a wide range
of people. “Those in the high-risk categories do fall in the 15-to-20% range,
as high as 30%” for risk of developing diabetes. “As you move lower, there
certainly is lower risk.”
Internationally,
the World Health Organization says it discourages use of the term prediabetes
“to avoid any stigma associated with the word diabetes and the fact that many
people do not progress to diabetes as the term implies.”
“There is
no value to implementing a widespread prevention program that does very little
if anything to reduce the development of diabetes,” wrote Dr. Kahn, a former
chief scientific and medical officer for the American Diabetes Association, and
Mayer Davidson in a paper published in the journal Diabetes Care in 2014. Dr.
Davidson, a past president of the ADA, is a professor of medicine at Charles R.
Drew University and the David Geffen School of Medicine at UCLA.
People
with prediabetes need to lose and keep off at least 5% of their body weight to
delay the onset of diabetes by a few years, and that is an amount few people
ever achieve, says David McCulloch, a diabetes specialist and medical director
for clinical improvement at Group Health Cooperative, a Seattle-based health
system.
Critics
of widespread prediabetes screening say changes in food, education and
urban-design policies, aimed at encouraging consumption of healthy foods and
exercise, would be more effective to counter the rise in diabetes.
Ms.
Schneider, who was diagnosed with prediabetes, says her first warning about the
condition came when she went for an annual checkup last fall. Her family doctor
called afterward to say her blood-sugar level was 5.5%, close to the
prediabetes level. “I was completely shocked,” says Ms. Schneider, a licensed
clinical social worker whose business, Take Back the Kitchen, coaches people on
getting comfortable with cooking.
She cut
out the last thing she thought could possibly be bad in her diet—dried
fruit—and kept exercising three times a week. When she saw an endocrinologist
three months later for another reason, she asked him to test her again. The
result came back 5.7%, the threshold of prediabetes. (The higher score could be
a normal test variation and didn’t necessarily mean her condition worsened.)
“Neither
doctor made too big a deal out of this. But for many people just hearing this,
your mind runs off,” says Ms. Schneider. “I started imagining my leg being
amputated,” which can happen to people with Type 2 diabetes. “The stress is
worse than anything else.”
Dana
Wechsler Linden
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