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Prediabetes Unknowingly Affects Millions Of Americans
More Than 57 Million Could Be At Risk For Heart Attack, Stroke
By Herb Denenberg, The Bulletin
About 57 million Americans (one in four adults) have prediabetes and, until recently, there was no agreement on how to treat it and what to do about it. That was true, even though those with prediabetes are at increased risk for type 2 diabetes and all the complications that come with it, including heart disease and stroke.
This condition sounds like it is just a warning shot, but it should be treated as a disease, as some of the long-term damage to the body, especially the heart and circulatory system, start occurring during pre-diabetes. So prediabetes is probably a bad name, as it seems to understate its seriousness. Perhaps a better name would be type 3 diabetes.
Those 57 million people should know there are now clear standards that will enable them to possibly avoid prediabetes progressing to type 2 diabetes and to avoid any complications.
To understand prediabetes, you have to understand type 2 diabetes (once, also called adult onset diabetes — so-called until an epidemic of children started getting it). It occurs when the pancreas doesn’t produce enough insulin or when the fat cells are insensitive to insulin. Insulin is necessary for cells to metabolize glucose and that metabolic process is necessary to produce energy.
When diabetes causes poor metabolism of glucose, the cells starve and sugar accumulates in the blood, causing high blood sugar (hyperglycemia). Chronic high blood sugar leads to all kinds of complications including kidney, eye, and nerve damage; foot and skin infections that often lead to amputations; cardiovascular disease; and premature death.
Two tests are used to diagnose diabetes:
1. Fasting Plasma Glucose (FPG)
This measures blood glucose after an overnight fast. The American Diabetes Association defines prediabetes as glucose levels of 100-125 mg/dl. Levels higher than that are diabetes.
2. Oral Glucose Tolerance Test(OGTT)
This measures blood glucose after eating a standard amount of glucose. Prediabetes is 140-200 mg/dl on this test. Higher than that is diabetes.
The American Diabetes Association says either test is appropriate for determining prediabetes. So the choice might depend on cost and convenience. The FPG test requires an overnight fast followed by a blood test. The OGTT also requires an overnight fast, but then it requires one blood test followed by another two hours later.
Those levels for prediabetes were increased in 2004. The old FPG level was 110-126. The old OGTT level was 160-200. The new levels enable doctors to catch prediabetes earlier when there is a greater chance of preventing its progression to diabetes and complications. That’s important as most people with prediabetes often progress to diabetes. More than half have diabetes in 10 years, and 11 percent have diabetes within three years.
This is all explained in a recent edition of the Johns Hopkins Medical Letter, Health After 50 (May 2009). It reports that only last year was a consensus reached on guidelines for treatment of prediabetes. Now both the American Diabetes Association and the American College of Endocrinology agree that the treatment goals should be the same for prediabetes as they have been for diabetes:
• LDL cholesterol (bad cholesterol) below 100 mg/dL.
• HDL cholesterol (good cholesterol) for women greater than 50 mg/dL and for men 40 mg/dL.
• Triglycerides levels below 150 mg/dL.
• Blood pressure below 130/80 mm Hg.
• Daily low-dose aspirin.
There is also a wealth of material on the Web site of the American Diabetes Association (www.diabetes.org).
The methods of preventing prediabetes from progressing to diabetes are the rules for good health in general.
Exercise
Exercise is a master key to good health for all. An American Diabetes Association study found that people with prediabetes who lost 10 percent of their body weight and exercised 30 to 60 minutes five days a week were 71 percent more likely to prevent or at least delay progression to diabetes.
Diet
The Hopkins newsletter specifies a healthy diet (fruits and nonstarchy vegetables, lean meats and nonfat dairy products, for instance). The famous study by Campbell and Campbell, The China Study, found a plant-based diet with some limited amounts of fish is a way to prevent or minimize the chances of diabetes, cancer, heart disease and many other chronic diseases.
Those with prediabetes should not smoke (and no one else should) or use alcohol in excess (again, no one else should). Excess is one drink a day for women and two for men.
The Hopkins newsletter doesn’t mention other master keys to good health but they make sense for everyone. They would include stress control and getting enough sleep. Stress and sleep deprivation can have devastating long-run effects on health and well-being.
Some of the goals for prediabetics may be hard to achieve without medication. It may take a statin (or some other drug) to get cholesterol levels down to recommended levels. It may also take a diuretic, an ACE inhibitor, or other drug to get blood pressure down to where it should be.
Needless to say, lifestyle changes such as diet and exercise should be the first resort. However, if exercise and weight loss don’t keep your glucose in check, as a last resort, a doctor may recommend a diabetes drug. Diabetes drugs such as metformin (Glucophage) and acarbose (Procose) can delay the onset of diabetes. However, the Hopkins newsletter says they don’t do so as effectively as lifestyle changes.
What’s more, the drugs are approved by the FDA for diabetes but not for prediabetes, and also have some serious side effects. Doctors can prescribe drugs even if not approved by the FDA for the purpose in question.
Screening For Prediabetes
Most people with prediabetes don’t know they have it.
• That’s one of the reasons the American Diabetes Association recommends that everyone who is overweight and age 45 and older should get screened for prediabetes. If tests show normal levels, then every three years thereafter the tests should be repeated. If 45 or older but not overweight, ask your doctor whether screening makes sense for you.
• For adults younger than 45 who are overweight and have any other risk factors for diabetes, your doctor may recommend screening. The other risk factors include high blood pressure, low HDL, high triglycerides and a family history of diabetes.
• Women who delivered a baby weighing more than nine pounds or who were diagnosed with gestational diabetes should be tested.
• Screening may be recommended for members of groups at increased risk of diabetes and prediabetes: African Americans, Latinos, Native Americans, Pacific Islanders and the aged population.
This isn’t mentioned by the Hopkins letter, but you may want to get a blood glucose meter and start testing yourself as a diabetic does. This would give you continuous monitoring of your blood glucose levels and also let you know how different foods influence those blood glucose levels. One prominent diabetologist told me that might be a good idea. However, he said insurance companies won’t pay for it in the absence of a diabetes diagnosis.
It should be noted that one company (Freestyle) was actually giving away meters to everyone who called in. What’s more, you can buy a meter (which comes with some lancets and test strips) for around $20.
The prediabetes scenario does have one important lesson. It shows how much preventive medicine could do if fully and properly applied. But it also shows that contrary to some universal health insurance proponents, prevention will save in the long run but not the short-run. If 57 million people suddenly start getting treated for prediabetes and if millions of other adults are screened, you have short-term increases in costs and they may be dramatic.
If many millions get counseling on diet and other matters from diabetes educators, you have another huge cost. Many will require medicines such as statins, another huge cost. But there is no doubt we will never get health care costs down to manageable levels unless we figure out a way to do serious preventive medical care.
President Barack Obama’s reliance on prevention and electronic medical records to reduce costs is a delusion. As initially, both could dramatically increase costs, and their reduction of costs would kick in only in the long, long run. So at this time, with record spending, debt, and deficits, such additional costs are indeed problematic.
The Obama cost analysis and proposals for universal health care are just further evidence that President Obama doesn’t know what he’s doing when he proposes grand solutions for health care and everything else, relying on saving money from prevention and electronic medical records. He’s in over his head on a whole series of frightfully ambitious programs.
As I’ve said, the grandiosity of health care proposals is usually inversely related to the understanding of the proponents. The uninformed on health care understand few of the problems or solutions, but construct castles in the sky in a fantasyland to deliver the benefits. I’ve noticed that people who have experienced universal health care in its many variations agree it is a disaster in practice however elegant in theory.
See, for example, the views of a Brit, James Delingpole, in his book Welcome to Obamaland: I Have Seen Your Future and It Doesn’t Work, or the comments of the member of the European Parliament, Daniel Hannan, who burst on the scene awhile back as a shrewd observer of our fiscal mess.
There is some good news on the prevention front. The National Diabetes Education Program has been launched to tell Americans how they can prevent diabetes. It is called “The Small Steps, Big Rewards, Prevent Diabetes Type 2 Campaign.” It is so named because with a few small steps, you can get big awards by preventing diabetes. The campaign is focusing on patients as well as providers. But here again, this barely scratches the surface in getting information to the public and appropriate action. Yes, prevention is no free lunch, and calls for huge resources to get the needed payoff.
Herb Denenberg is a former Pennsylvania Insurance Commissioner, Pennsylvania Public Utility Commissioner, and professor at the Wharton School. He is a longtime Philadelphia journalist and consumer advocate. He is also a member of the Institute of Medicine of the National Academy of the Sciences. His column appears daily in The Bulletin. You can reach him at advocate@thebulletin.us.
This condition sounds like it is just a warning shot, but it should be treated as a disease, as some of the long-term damage to the body, especially the heart and circulatory system, start occurring during pre-diabetes. So prediabetes is probably a bad name, as it seems to understate its seriousness. Perhaps a better name would be type 3 diabetes.
Those 57 million people should know there are now clear standards that will enable them to possibly avoid prediabetes progressing to type 2 diabetes and to avoid any complications.
To understand prediabetes, you have to understand type 2 diabetes (once, also called adult onset diabetes — so-called until an epidemic of children started getting it). It occurs when the pancreas doesn’t produce enough insulin or when the fat cells are insensitive to insulin. Insulin is necessary for cells to metabolize glucose and that metabolic process is necessary to produce energy.
When diabetes causes poor metabolism of glucose, the cells starve and sugar accumulates in the blood, causing high blood sugar (hyperglycemia). Chronic high blood sugar leads to all kinds of complications including kidney, eye, and nerve damage; foot and skin infections that often lead to amputations; cardiovascular disease; and premature death.
Two tests are used to diagnose diabetes:
1. Fasting Plasma Glucose (FPG)
This measures blood glucose after an overnight fast. The American Diabetes Association defines prediabetes as glucose levels of 100-125 mg/dl. Levels higher than that are diabetes.
2. Oral Glucose Tolerance Test(OGTT)
This measures blood glucose after eating a standard amount of glucose. Prediabetes is 140-200 mg/dl on this test. Higher than that is diabetes.
The American Diabetes Association says either test is appropriate for determining prediabetes. So the choice might depend on cost and convenience. The FPG test requires an overnight fast followed by a blood test. The OGTT also requires an overnight fast, but then it requires one blood test followed by another two hours later.
Those levels for prediabetes were increased in 2004. The old FPG level was 110-126. The old OGTT level was 160-200. The new levels enable doctors to catch prediabetes earlier when there is a greater chance of preventing its progression to diabetes and complications. That’s important as most people with prediabetes often progress to diabetes. More than half have diabetes in 10 years, and 11 percent have diabetes within three years.
This is all explained in a recent edition of the Johns Hopkins Medical Letter, Health After 50 (May 2009). It reports that only last year was a consensus reached on guidelines for treatment of prediabetes. Now both the American Diabetes Association and the American College of Endocrinology agree that the treatment goals should be the same for prediabetes as they have been for diabetes:
• LDL cholesterol (bad cholesterol) below 100 mg/dL.
• HDL cholesterol (good cholesterol) for women greater than 50 mg/dL and for men 40 mg/dL.
• Triglycerides levels below 150 mg/dL.
• Blood pressure below 130/80 mm Hg.
• Daily low-dose aspirin.
There is also a wealth of material on the Web site of the American Diabetes Association (www.diabetes.org).
The methods of preventing prediabetes from progressing to diabetes are the rules for good health in general.
Exercise
Exercise is a master key to good health for all. An American Diabetes Association study found that people with prediabetes who lost 10 percent of their body weight and exercised 30 to 60 minutes five days a week were 71 percent more likely to prevent or at least delay progression to diabetes.
Diet
The Hopkins newsletter specifies a healthy diet (fruits and nonstarchy vegetables, lean meats and nonfat dairy products, for instance). The famous study by Campbell and Campbell, The China Study, found a plant-based diet with some limited amounts of fish is a way to prevent or minimize the chances of diabetes, cancer, heart disease and many other chronic diseases.
Those with prediabetes should not smoke (and no one else should) or use alcohol in excess (again, no one else should). Excess is one drink a day for women and two for men.
The Hopkins newsletter doesn’t mention other master keys to good health but they make sense for everyone. They would include stress control and getting enough sleep. Stress and sleep deprivation can have devastating long-run effects on health and well-being.
Some of the goals for prediabetics may be hard to achieve without medication. It may take a statin (or some other drug) to get cholesterol levels down to recommended levels. It may also take a diuretic, an ACE inhibitor, or other drug to get blood pressure down to where it should be.
Needless to say, lifestyle changes such as diet and exercise should be the first resort. However, if exercise and weight loss don’t keep your glucose in check, as a last resort, a doctor may recommend a diabetes drug. Diabetes drugs such as metformin (Glucophage) and acarbose (Procose) can delay the onset of diabetes. However, the Hopkins newsletter says they don’t do so as effectively as lifestyle changes.
What’s more, the drugs are approved by the FDA for diabetes but not for prediabetes, and also have some serious side effects. Doctors can prescribe drugs even if not approved by the FDA for the purpose in question.
Screening For Prediabetes
Most people with prediabetes don’t know they have it.
• That’s one of the reasons the American Diabetes Association recommends that everyone who is overweight and age 45 and older should get screened for prediabetes. If tests show normal levels, then every three years thereafter the tests should be repeated. If 45 or older but not overweight, ask your doctor whether screening makes sense for you.
• For adults younger than 45 who are overweight and have any other risk factors for diabetes, your doctor may recommend screening. The other risk factors include high blood pressure, low HDL, high triglycerides and a family history of diabetes.
• Women who delivered a baby weighing more than nine pounds or who were diagnosed with gestational diabetes should be tested.
• Screening may be recommended for members of groups at increased risk of diabetes and prediabetes: African Americans, Latinos, Native Americans, Pacific Islanders and the aged population.
This isn’t mentioned by the Hopkins letter, but you may want to get a blood glucose meter and start testing yourself as a diabetic does. This would give you continuous monitoring of your blood glucose levels and also let you know how different foods influence those blood glucose levels. One prominent diabetologist told me that might be a good idea. However, he said insurance companies won’t pay for it in the absence of a diabetes diagnosis.
It should be noted that one company (Freestyle) was actually giving away meters to everyone who called in. What’s more, you can buy a meter (which comes with some lancets and test strips) for around $20.
The prediabetes scenario does have one important lesson. It shows how much preventive medicine could do if fully and properly applied. But it also shows that contrary to some universal health insurance proponents, prevention will save in the long run but not the short-run. If 57 million people suddenly start getting treated for prediabetes and if millions of other adults are screened, you have short-term increases in costs and they may be dramatic.
If many millions get counseling on diet and other matters from diabetes educators, you have another huge cost. Many will require medicines such as statins, another huge cost. But there is no doubt we will never get health care costs down to manageable levels unless we figure out a way to do serious preventive medical care.
President Barack Obama’s reliance on prevention and electronic medical records to reduce costs is a delusion. As initially, both could dramatically increase costs, and their reduction of costs would kick in only in the long, long run. So at this time, with record spending, debt, and deficits, such additional costs are indeed problematic.
The Obama cost analysis and proposals for universal health care are just further evidence that President Obama doesn’t know what he’s doing when he proposes grand solutions for health care and everything else, relying on saving money from prevention and electronic medical records. He’s in over his head on a whole series of frightfully ambitious programs.
As I’ve said, the grandiosity of health care proposals is usually inversely related to the understanding of the proponents. The uninformed on health care understand few of the problems or solutions, but construct castles in the sky in a fantasyland to deliver the benefits. I’ve noticed that people who have experienced universal health care in its many variations agree it is a disaster in practice however elegant in theory.
See, for example, the views of a Brit, James Delingpole, in his book Welcome to Obamaland: I Have Seen Your Future and It Doesn’t Work, or the comments of the member of the European Parliament, Daniel Hannan, who burst on the scene awhile back as a shrewd observer of our fiscal mess.
There is some good news on the prevention front. The National Diabetes Education Program has been launched to tell Americans how they can prevent diabetes. It is called “The Small Steps, Big Rewards, Prevent Diabetes Type 2 Campaign.” It is so named because with a few small steps, you can get big awards by preventing diabetes. The campaign is focusing on patients as well as providers. But here again, this barely scratches the surface in getting information to the public and appropriate action. Yes, prevention is no free lunch, and calls for huge resources to get the needed payoff.
Herb Denenberg is a former Pennsylvania Insurance Commissioner, Pennsylvania Public Utility Commissioner, and professor at the Wharton School. He is a longtime Philadelphia journalist and consumer advocate. He is also a member of the Institute of Medicine of the National Academy of the Sciences. His column appears daily in The Bulletin. You can reach him at advocate@thebulletin.us.
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