Friday, July 15, 2016

Prediabetes Awareness Campaign Sparks Pushback

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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