New research published in The Lancet Diabetes & Endocrinology promises to shake up laissez faire attitudes about prediabetes. Elsa Vazquez Arreola and colleagues show, in post-hoc analyses of two landmark diabetes prevention trials, that reversing prediabetes can cut the risk of cardiovascular death or hospitalization by half in diverse populations.

This finding, though it comes from post-hoc analyses, is not one to dismiss.

Three Perspectives

Opinions about intervening in prediabetes cover quite a range. For a hint of this, you might note that Lancet published not one, but three separate commentaries along with this study.

Andreas Birkenfeld, the senior author of this new paper, wrote one of them along with nine other colleagues from all over the world. They make a forceful argument for doing more than just slowing the progression of prediabetes to a diabetes diagnosis. Instead, they argue the goal should be remission of prediabetes because it “redirects the disease trajectory towards health, rather than merely slowing the decline to β-cell dysfunction and type 2 diabetes.” In other words, we should aim for health, not just a slower progression of disease.

Linda Mellbin and Lars Rydén acknowledge the timeliness and importance of this new paper. But they make a valid point that this is hardly the final word. They propose what could become a landmark clinical trial:

“Randomised controlled trials investigating both a lifestyle intervention and a cardioprotective glucose lowering agent or placebo, in individuals with prediabetes at high-risk (such as those with hypertension or dysglycaemia) but without previous cardiovascular events, would help determine if it is possible to protect such individuals not only from progression to type 2 diabetes but also from premature cardiovascular death or future MACE.”

Finally, the journal itself offers an editorial to argue even more strongly that the knowledge of prediabetes risks is simply too incomplete to make sweeping recommendations:

“Limited population-level data impedes a complete understanding of the impact of diabetes-related complications in these settings. Epidemiological efforts must therefore evolve to capture complications and risk factors across diverse populations to inform effective, context-specific diabetes care and policy.”

Imperfect vs. Good Knowledge

The spectrum of these arguments is both enlightening and frustrating. It does seem, though, that all of this equivocation carries some risk. It is the risk of making a desire for perfect knowledge into an enemy of good insight, and thus an impediment to making good decisions.

There can be little doubt that prediabetes puts a person at risk for heart problems and premature death. Doing nothing is a bad option, because we have surgeries, medicines and patterns for healthy living that can serve to reduce that risk. Not just a little, but a lot.

More research is a fine idea. But action to help people move toward better health is equally important.

Click here for the study, here, here, and here for the commentaries. For further perspective, click here and here.

The Heart, painting by Henri Matisse / WikiArt