Analysis Too Much Medicine

The epidemic of pre-diabetes: the medicine and the politics

BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g4485 (Published 15 July 2014) Cite this as: BMJ 2014;349:g4485

This article has a correction. Please see:

  1. John S Yudkin, emeritus professor of medicine1,
  2. Victor M Montori, professor of medicine2
  1. 1Division of Medicine, University College London, London, UK
  2. 2Knowledge and Evaluation Research Unit, Division of Endocrinology and Diabetes, Departments of Medicine and Health Sciences Research, Mayo Clinic, Rochester, MN, USA
  1. Correspondence to: J S Yudkin j.yudkin{at}ucl.ac.uk

Summary box

  • Clinical context—Attempts to tackle the increasing prevalence of diabetes have focused on identifying and treating people at risk of developing the disease

  • Diagnostic change—The definition of people at risk has expanded from impaired glucose tolerance to include people with raised fasting glucose or glycated haemoglobin (HbA1c) concentrations and cut-off points have been lowered

  • Rationale for change—People in all the above categories have a raised diabetes risk, although prediction is poorer for fasting glucose and HbA1c than for impaired glucose tolerance

  • Leap of faith—Treatment of people in newly defined categories will improve mortality and morbidity

  • Impact on prevalence—The expanded categories increase the prevalence of pre-diabetes by twofold to threefold

  • Evidence of overdiagnosis—New definitions result in over 50% of Chinese adults having pre-diabetes

  • Harms from overdiagnosis—A label of pre-diabetes bring problems with self image, insurance, and employment as well as the burdens and costs of healthcare and drug side effects

  • Limitations of evidence—No studies have examined the effect of lifestyle or drug interventions in newly added subcategories

  • Conclusion—Diabetes prevention requires changes to societies and therefore a concerted global public health approach. Diagnoses and thresholds for clinical application may unrealistically burden societies in exchange for limited value

Aldous Huxley wrote that “Medical science has made such tremendous progress that there is hardly a healthy human left.” Changes to the American Diabetes Association (ADA) guidance on the diagnosis of pre-diabetes in 2010 make this statement even more true.1 If implemented globally the guidance could create a potential epidemic, with over half of Chinese adults,2 for example, having pre-diabetes, a national burden of around 493 million people.

Pre-diabetes is an umbrella term and the most widely used phrase to describe a blood concentration of glucose or glycated haemoglobin (HbA1c) that lies …

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