Intended for healthcare professionals

Analysis Too Much Medicine

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

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

Pre-diabetes: an alternative perspective

We read with interest the point-of-view of Yudkin and Montori who, questioning the value of pre-diabetes as a clinical entity, suggest putting the term in “cold storage” [1].

We suggest that many of the concerns raised around disease-labelling are widely held and indeed this position reflects the WHO/IDF consensus guideline for the HbA1c range 6.0–6.4% termed “intermediate hyperglycaemia” [2].

Whilst advocating that the definition “pre-diabetes” should be restricted and used appropriately, to abolish it would firstly neglect the accepted wealth of data around IFG and IGT elegantly described in the article, and secondly would eliminate a readily comprehensible public health message and marker of a condition carrying a recognised increased risk of cardiovascular disease.

Moreover, as reported in the article, available observational evidence would indicate a graded continuum of the risk of vascular events for FPG values ≥5.6 mmol/L (≥100 mg/dl) in subjects not on anti-hyperglycaemic treatment [3, 4]; therefore, using such rationale not only the definition of “pre-diabetes”, but also of “diabetes”, should be questioned.

Lastly, the existing evidence over the psychological harm of being defined as “pre-diabetic” is very limited [5, 6].

In conclusion, we believe that the term “pre-diabetes” should not be abandoned, but used objectively within existing terms of reference for plasma glucose.

References

1. Yudkin JS, Montori VM. The epidemic of pre-diabetes: the medicine and the politics. BMJ 2014;349:g4485.
2. http://www.idf.org/webdata/docs/WHO_IDF_definition_diagnosis_of_diabetes... accessed 24/07/2014
3. Emerging Risk Factors Collaboration. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med 2011;364:829-41.
4. Emerging Risk Factors Collaboration. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet 2010;375:2215-22.
5. Andersson S, Ekman I, Lindblad U, Friberg F. It's up to me! Experiences of living with pre-diabetes and the increased risk of developing type 2 diabetes mellitus. Prim Care Diabetes 2008;2:187-93.
6. Troughton J, Jarvis J, Skinner C, Robertson N, Khunti K, Davies M. Waiting for diabetes: perceptions of people with pre-diabetes: a qualitative study. Patient Educ Couns 2008;72:88-93.

Competing interests: No competing interests

12 August 2014
Francesco Zaccardi
Clinical Research Fellow
David Webb; University of Leicester, Diabetes Research Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, England
University of Leicester
Diabetes Research Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, England