Pre-Diabetes: Medicalization or Vigilance?

Is pre-diabetes a pre-diagnosis that crosses the fine line between pursuing good health and medicalizing all of life? In their new analysis published this week by BMJ, John Yudkin and Victor Montori suggest that it is.

In challenging the need to screen and intervene to prevent progression to diabetes in people with pre-diabetes or impaired glucose tolerance, Yudkin and Montori take the greatest issue with drug treatment for these patients. But they also take issue with intensive behavioral intervention, like the interventions proven effective in landmark Diabetes Prevention Program. They question the value of providing individual attention and advice, going on to say:

Rolling out intensive lifestyle interventions like these to populations with pre-diabetes (comprising an estimated 86 million people in the US or 493 million in China) would be challenging.

They conclude their analysis by saying:

We need a shift in perspective. It is critically important to slow the epidemic of obesity and diabetes. Rather than turning healthy people into patients with pre-diabetes, we should use available resources to change the food, education, health, and economic policies that have driven this epidemic.

We note that they are proposing systematic changes to the food supply and social systems, but they offer no evidence-based recommendations for specific changes. Yet they seem to be rejecting the evidence for intensive behavioral therapy as too “challenging” to undertake.

We can’t help but think these advocates are neglecting to apply any standard of evidence for social changes they desire.

“Be careful about reading health books. You may die of a misprint.” — Mark Twain

Click here to read the analysis in BMJ and here to read more from the BBC.

Vigil, photograph © Andreas Kambanis / flickr

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4 Responses to “Pre-Diabetes: Medicalization or Vigilance?”

  1. July 17, 2014 at 2:37 pm, Rose A. said:

    so good!!!!
    everyone who denies the ability for lifestyle change is part of the epidemic!
    I made a great shift recently and it feels sooo good!
    Life style changes are a great thing indeed!
    Go for it!

    • July 17, 2014 at 5:47 pm, Ted said:

      I agree, Rose. The argumentation in this paper left me scratching my head.

  2. July 19, 2014 at 2:14 pm, Rose A. said:

    I have looked at these papers now somewhat more closely.
    The argumentations seems to be based on three studies, one of which is from 1997 and not indexed in Bub Med any more.
    In the second one lifestyle intervention was individual counseling by nutritionist and guidance how to increase the level of physical activity. The intervention goals were “a reduction in weight of 5 percent or more, in total intake of fat to less than 30 percent of energy consumed, and in intake of saturated fat to less than 10 percent of energy consumed; an increase in fiber intake to at least 15 g per 1000 kcal; and moderate exercise for at least 30 minutes per day. Frequent ingestion of whole-grain products, vegetables, fruits, low-fat milk and meat products, soft margarines, and vegetable oils rich in monounsaturated fatty acids was recommended. ”

    The third one, the U.S. Diabetes Prevention Program, aimed “a weight reduction of at least 7 percent of initial body weight through a healthy low-calorie, low-fat diet and to engage in physical activity of moderate intensity, such as brisk walking, for at least 150 minutes per week. A 16-lesson curriculum covering diet, exercise, and behavior modification was designed to help the participants achieve these goals. The curriculum, taught by case managers on a one-to-one basis during the first 24 weeks after enrollment, was flexible, culturally sensitive, and individualized.”

    Given this extensive efforts, the results – which are positive! – may seem somewhat moderate, which could have lead to the really unjustified “hopeless” conclusion.

    However, what we do not know:
    1) All interventions have been rather traditional, with counseling in the major fields – nutrition and exercise and some psychological support. What we do not know, is, how programs work which do not tell the participant, what to do, but rather works on autonomy and help for self-help. These are the major effects of self-managed online programs. They are more composed as self-management-tools and empowering self-esteem. A few studies are promising that they work at least as effectively, and they are just emerging!

    2) We have no clue what the effective lifestyle changes really are. If people used to go round half an hour a day, than for an hour? Maybe it it is not such a dramatic change? We don´t have any nutritional information. What was eaten before, what was eaten during study time.In some aspects, we even do not have any information, how much “advice” was actually followed, part of the moderate results is just: non compliance?

    3) Were the “goals” too moderate? Often a more marked Goal is more promising and more motivating and brings about more effects? Of course, You should not be over obsessive. It is wise, to start step by step. But – I far can a we go? I suspect – we are “under-challenging” our patients!

    • July 19, 2014 at 2:35 pm, Ted said:

      Good analysis. I think you’re right.