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Pre-diabetes label ‘unhelpful and unnecessary’

Treating ‘pre-diabetes’ only delays onset of diabetes by a few years, and some patients don’t develop it anyway

Ingrid Torjesen

Thursday, 17 July 2014

Labelling people with moderately high blood sugar as pre-diabetic is of no medical value and associated with huge financial and social costs, says an analysis* published in The BMJ.

The authors from University College London and the Mayo Clinic in Minnesota considered whether a diagnosis of pre-diabetes carried any health benefits such as improved diabetes prevention. They found that treatments to reduce blood sugar in these patients only delayed the onset of type 2 diabetes in those who developed it by a few years, and found no evidence of long-term health benefits.

People with a haemoglobin A1c over 6.5% can be diagnosed with diabetes but the latest guidelines from the American Diabetes Association (ADA) define anyone with an A1c between 5.7% and 6.4% as having pre-diabetes. If the ADA guidelines were adopted in the UK, a third of the adult population would be diagnosed with pre-diabetes.

However, the World Health Organisation (WHO) discourages the “use of ‘pre-diabetes’ to avoid any stigma associated with the word diabetes and the fact that many people do not progress to diabetes as the term implies.” Guidance from the UK National Institute for Health and Care Excellence (NICE) broadly aligns with the WHO statement, looking to “move away from describing 'pre-diabetes' as a separate condition”.

Lead author John S Yudkin, emeritus professor of medicine at UCL, said: “Sensibly, the WHO and NICE and the International Diabetes Federation do not recognise pre-diabetes at present but I am concerned about the rising influence of the term. It has been used in many scientific papers across the world, and has been applied to a third of adults in the UK and half of those in China. We need to stop looking at this as a clinical problem with pharmaceutical solutions and focus on improving public health. The whole population would benefit from a more healthy diet and more physical activity, so it makes no sense to single out so many people and tell them that they have a disease.”

Previous research has shown that type 2 diabetes treatments can do more harm than good for people with A1c levels around 6.5%, let alone people below this level.

3.2 million people in the UK are currently diagnosed with type 2 diabetes, but approximately 16 million would fall into the ADA’s pre-diabetes category. There is a condition known as impaired glucose tolerance (IGT) that affects around 3.7 million adults in the UK (8%), who are at high risk of diabetes, but the test is more time-consuming than a simple A1c blood test. There is evidence to suggest that interventions can delay the progression of IGT into diabetes, but the ADA category of pre-diabetes also includes another 12 million people who are at a much lower risk of progressing to diabetes.

“Pre-diabetes is an artificial category with virtually zero clinical relevance,” professor Yudkin. “There is no proven benefit of giving diabetes treatment drugs to people in this category before they develop diabetes, particularly since many of them would not go on to develop diabetes anyway.

“The ADA recommends treating pre-diabetes with metformin, but the majority of people would receive absolutely no benefit. There are significant financial, social and emotional costs involved with labelling and treating people in this way. And a range of newer and more expensive drugs are being explored as treatments for ‘pre-diabetes.’ The main beneficiaries of such recommendations would be the drug manufacturers, whose available market suddenly leaps to include significant swathes of the population.”


* John S Yudkin J S and Montori V M. The epidemic of pre-diabetes: the medicine and the politics. BMJ2014; 349 doi:10.1136/bmj.g4485

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