Lown Right Care

Reducing Overuse and Underuse

Prediabetes Diagnosis: Helpful or Harmful?

 

Am Fam Physician. 2021 Dec ;104(6):649-651.

Author disclosure: No relevant financial affiliations.

Case Scenario

A 74-year-old man with hypertension, hyperlipidemia, and a body mass index of 35 kg per m2 presented for a physical examination. His primary care physician ordered a basic metabolic profile. The laboratory report showed that his blood glucose level was 105 mg per dL (5.83 mmol per L), which is high.

After researching online, the patient's daughter told him that he might have a condition called prediabetes. She arranged an appointment with an endocrinologist, who told the patient to check his glucose level twice per week with a home glucose monitor and ordered an A1C measurement, which was 5.9%. The endocrinologist confirmed the diagnosis of prediabetes and told the patient that he was at high risk of developing diabetes mellitus and its complications unless he gets his glucose levels down.

For the next few months, the patient checked his glucose level three times per day, sometimes graphing the results; ate fewer donuts; and tried to walk more. When his glucose numbers did not improve, his endocrinologist prescribed metformin, which caused diarrhea. Frustrated and stressed, the patient returned to his primary care physician for advice.

Clinical Commentary

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TAKE-HOME MESSAGES FOR RIGHT CARE

Older adults with prediabetes are less likely to progress to diabetes mellitus than younger adults.

In a U.S. study of adults 71 to 90 years of age, 73% met at least one diagnostic criterion for prediabetes. After six years, 9% of the group had progressed to diabetes, and 13% were normoglycemic.

Although the use of metformin in patients with prediabetes delays conversion to diabetes, no studies show that metformin or any other drugs prevents complications.

A diagnosis of questionable clinical significance could cause psychological distress and lead to additional testing, overtreatment, increased physician visits, and financial hardship.

TAKE-HOME MESSAGES FOR RIGHT CARE

Older adults with prediabetes are less likely to progress to diabetes mellitus than younger adults.

In a U.S. study of adults 71 to 90 years of age, 73% met at least one diagnostic criterion for prediabetes. After six years, 9% of the group had progressed to diabetes, and 13% were normoglycemic.

Although the use of metformin in patients with prediabetes delays conversion to diabetes, no studies show that metformin or any other drugs prevents complications.

A diagnosis of questionable clinical significance could cause psychological distress and lead to additional testing, overtreatment, increased physician visits, and financial hardship.

ORIGINS AND INCIDENCE

Hyperglycemia below the diabetes threshold was not considered a significant illness until 2004, when the American Diabetes Association (ADA) labeled it as prediabetes to increase awareness and prompt physicians to act. Prediabetes was initially defined as a fasting blood glucose level between 110 and 125 mg per dL (6.11 and 6.94 mmol per L) or an A1C of 6% to 6.4%. In 2010, the ADA lowered these thresholds to between 100 and 125 mg per dL (5.55 to 6.94 mmol per L) or 5.7% to 6.4%. The diagnosis of pre-diabetes has led to increased testing, physician visits, and treatments. In 2012, the cost of treating prediabetes was $44 billion, or 1.6% of all health care costs.1 In 2017, an estimated 352 million adults had prediabetes, which constitutes 7.3% of the world's adult population.2 The prevalence is even higher among older people in the United States.3

PROGRESSION TO DIABETES

The ADA and other organizations have estimated prediabetes to diabetes conversion rates of 5% to 10% within one year, 25% within five years, and 70% any time after a prediabetes diagnosis.4 But the reality is more nuanced. Depending on the definition of prediabetes, the conversion rate can be much lower, especially when only people with a fasting blood glucose

Address correspondence to Andy Lazris, MD, CMD, at alazris50@gmail.com. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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1. Piller C. The war on ‘prediabetes’ could be a boon to pharma—but is it good medicine? Science. March 7, 2019. Accessed March 10, 2021. https://www.sciencemag.org/news/2019/03/war-prediabetes-could-be-boon-pharma-it-good-medicine...

2. Shang Y, Marseglia A, Fratiglioni L, et al. Natural history of prediabetes in older adults from a population-based longitudinal study. J Intern Med. 2019;286(3):326–340.

3. Dinerstein C. Prediabetes does not predict diabetes. American Council on Science and Health. June 10, 2019. Accessed March 10, 2021. https://www.acsh.org/news/2019/06/10/prediabetes-does-not-predict-diabetes-14080

4. Hostalek U. Global epidemiology of prediabetes – present and future perspectives. Clin Diabetes Endocrinol. 2019;5(5). Accessed March 10, 2021. https://clindiabetesendo.biomedcentral.com/articles/10.1186/s40842-019-0080-0

5. Bansal N. Prediabetes diagnosis and treatment: a review. World J Diabetes. 2015;6(2):296–303.

6. Rooney MR, Rawlings AM, Pankow JS, et al. Risk of progression to diabetes among older adults with prediabetes [published correction appears in JAMA Intern Med. 2021;181(4):570]. JAMA Intern Med. 2021;181(4):511–519.

7. Davidson MB, Kahn RA. A reappraisal of prediabetes. J Clin Endocrinol Metab. 2016;101(7):2628–2635.

8. Woolf SH, Rothemich SF. New diabetes guidelines: a closer look at the evidence. Am Fam Physician. 1998;58(6):1287–1288, 1290. Accessed October 8, 2021. https://www.aafp.org/afp/1998/1015/p1287.html

9. Tuso P. Prediabetes and lifestyle modification: time to prevent a preventable disease. Perm J. 2014;18(3):88–93.

10. Lam K, Lee SJ. Prediabetes—a risk factor twice removed. JAMA Intern Med. 2021;181(4):520–521.

11. Centers for Disease Control and Prevention. About the national DPP. Accessed October 10, 2021. https://www.cdc.gov/diabetes/prevention/about.htm

12. Moin T. Should adults with prediabetes be prescribed metformin to prevent diabetes mellitus? Yes: high-quality evidence supports metformin use in persons at high risk. Am Fam Physician. 2019;100(3):134–135. Accessed October 8, 2021. https://www.aafp.org/afp/2019/0801/p134.html

13. Brown SR. Should adults with prediabetes be prescribed metformin to prevent diabetes mellitus? No: evidence does not show improvements in patient-oriented outcomes. Am Fam Physician. 2019;100(3):136–138. Accessed October 8, 2021. https://www.aafp.org/afp/2019/0801/p136.html

14. Richter B, Hemmingsen B, Metzendorf M, et al. Development of type 2 diabetes mellitus in people with intermediate hyperglycaemia. Cochrane Database Syst Rev. 2018;(10):CD012661.

15. Doust JA, Treadwell J, Bell KJL. Widening disease definitions: what can physicians do? Am Fam Physician. 2021;103(3):138–140. Accessed September 7, 2021. https://www.aafp.org/afp/2021/0201/p138.html

Lown Institute Right Care Alliance is a grassroots coalition of clinicians, patients, and community members organizing to make health care institutions accountable to communities and to put patients, not profits, at the heart of health care.

This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

A collection of Lown Right Care published in AFP is available at https://www.aafp.org/afp/rightcare.

 

 

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