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CDC’s new ‘pre-diabetes’ campaign is misguided, Mayo physician says

“Take the Prediabetes Risk Test” video from the Ad Council

In January, the Centers for Disease Control and Prevention (CDC), the American Diabetes Association (ADA) and the American Medical Association, in partnership with the Ad Council, launched a new campaign to increase the public’s awareness of pre-diabetes.

According to the CDC, some 86 million American adults may have pre-diabetes, which the agency says is characterized by “blood glucose (sugar) levels [that] are higher than normal — but not high enough to be diagnosed as diabetes.”

“Pre-diabetes increases the risk for type 2 diabetes, heart disease, and stroke,” says Ann Albright, director of the CDC’s Division of Diabetes Translation, in a video released on MedScape with the campaign. Indeed, Albright says that without treatment — “a structured lifestyle program that provides real-life support for healthful eating, increasing physical activity, and enhancing problem-solving skills” — some 15 to 30 percent of people with pre-diabetes will go on to develop full-fledged diabetes within five years.

The campaign is encouraging people to talk with their physicians about getting tested for pre-diabetes.

Diabetes is certainly a serious disease. It can lead to disabling and sometimes life-threatening health complications, including heart disease, kidney failure, blindness and amputations. More than 29 million Americans, or 9.3 percent of the U.S. population, have the disease — a number that has increased four-fold over the past three decades.

But many experts are not convinced that pre-diabetes, a term coined by the ADA a few years ago and used almost exclusively in the United States, deserves the attention it’s receiving in the new public awareness campaign.

In fact, they don’t think pre-diabetes is a medical condition at all, but rather “an artificial category with virtually zero clinical relevance” — and one that may lead to more harm than good. As two diabetes experts argued in a 2014 commentary published in the journal BMJ, the pre-diabetes diagnosis is needlessly putting millions of people at risk of receiving unnecessary medical treatment and is creating “unsustainable burdens” for health care systems.

One of the authors of that commentary is Dr. Victor Montori, an endocrinologist who specializes in diabetes at the Mayo Clinic in Rochester, Minnesota. MinnPost recently spoke with Montori regarding his concerns about the pre-diabetes diagnosis and the new public awareness campaign that is encouraging people to seek out that diagnosis. A condensed and edited version of that conversation follows.

MinnPost: What is pre-diabetes?

Victor Montori: The CDC is now defining it based on the ADA’s definition, which is essentially any measure of elevated blood sugars, whether [resulting from] a fasting blood glucose [test] or after a two-hour glucose tolerance test or a hemoglobin A1C [test]. If it’s elevated and it doesn’t qualify you as having diabetes, it qualifies you as having pre-diabetes.

Dr. Victor Montori
Dr. Victor Montori

The problem with that definition is that it includes too many people, and the problem with including too many people is that the proportion of those people who will then go on to develop diabetes is actually very small — in the order, perhaps, of 2 to 3 percent over the course of three to five years. This is different from the number that the CDC normally gives of around 20 to 30 percent moving on to diabetes in that period of time. [Those larger percentages] come from studies in which only one of the criteria was used to define pre-diabetes, which was the blood sugar being abnormal two hours after a glucose tolerance test.

But nobody does a glucose tolerance test in practice. So the majority of people that will be diagnosed with pre-diabetes will be diagnosed that way because of elevated [fasting] blood sugars or because of a hemoglobin A1C. And the proportion of those people who go on to develop diabetes is infinitely smaller than the proportion that goes on to develop it if they have an abnormal glucose tolerance test.

MP: The CDC is estimating that 86 million people in the U.S. have pre-diabetes, and that nine out of 10 of them are unaware of it.

VM: That number is a reflection of the loose definition that the CDC and the ADA have chosen to identify the nature of the problem. Obviously, they want the problem to appear very large. This is not acceptable — to create a public health problem by virtue of changing the definition. By that definition, the number of people with abnormal sugars, either diabetes or pre-diabetes, is too large.

And yes, the majority of people don’t know they have a problem. But, I might add, most don’t have a problem.

MP: What are your concerns about the impact of the new public service campaign?

An example of the pre-diabetes awareness print campaign.
Ad Council
An example of the pre-diabetes awareness
print campaign.

VM: The CDC and Congress and some insurers and some other groups — departments of health in several states — are committed to asking the health care system to check blood sugars in people who come in contact with the health care system in order to identify those people with pre-diabetes. If they identify someone as having pre-diabetes, they are then [to be] referred to programs, for instance, like those offered by the YMCA, where they can [receive] physical activity and diet recommendations.

In general, I don’t have a problem with any of that. But I do have two fundamental concerns. First, if the problem affects one in three Americans, is it possible that diabetes is not the result of poor individual decision-making or poor individual habit choices, but rather the society that we are building? That society — the environment that we create — is a combination of advertisement, food policies, worksite policies, transportation policies, education policies. If these things are what is causing diabetes, why would we want to intervene one person at a time while keeping them in the environment that is pushing them in the direction of diabetes? How likely is it that we are going to have a sustained benefit from identifying individuals and treating them individually? So that’s one problem I have.

MP: And the second one?

VM: Patients already complain about their doctors not having time to meet with them and about hurried consultations. So we’re now going to be sending 86 million or more Americans to that overtaxed and overwhelmed health care system to seek individual care and counseling for pre-diabetes. It seems to me that people with diabetes are going to have to compete for access to care — the kind of care that is really important, like preventing complications. And if they don’t have such access, we’re going to have a net negative impact in that now we’re going to have more people living with the complications of diabetes.

MP: What should people do with the messages they’re hearing from the CDC’s pre-diabetes campaign?

VM: It’s hard to know. We’ve reviewed those messages here in our research group, and we’ve found some of them to be really problematic. There seems to be some language in those ads that is very paternalistic, condescending and guilt forming, particularly some of the ones directed at young mothers.  So, to some extent, I think that if diabetes is not making them sick yet — because, of course, they don’t have the disease — then the messaging itself, by producing guilt and blaming individuals for the shortcomings of our policies, may produce discomfort, distress and disease.

I find the campaign misguided. Maybe I’m a dreamer, maybe I’m a romantic, maybe I’m unreasonable, but I think we should be taking the numbers that the CDC has produced from their very generous definition of pre-diabetes and use them as a wake-up call for policymakers. How might we develop our towns, workplaces, cities, families, schools [so that] diabetes is not the outcome?

For example, we build wider roads so more cars can move around, and we create more suburbs so that people have to get in their cars to go shopping. But what if we changed the zoning so that people can walk to shops? What if we create more public transportation so that people can get to their workplace and spend the last mile, perhaps, walking from the transportation to their workplace? If you go to large urban centers in cities with lots of opportunities of that nature, you see a lot fewer people with obesity.

The other part of the policymaking we need to not forget is that where there is a lot of wealth and income inequality, where there is a lot of chronic stress related to poverty and violence, there is also more diabetes. In the United States, there is a group that is actually having less diabetes: people who are affluent and white. Poor, brown, young people are having more diabetes now. That should tell you that [the diabetes epidemic] is probably not a crisis in will power among the poor, but rather something fundamental about how we are distributing social justice in our society.

I would love to see the presidential candidates tackle the issue of how our society is creating diabetes. It’s much easier to talk about the lack of personal responsibility and tell everybody to eat more broccoli. I think it’s much more interesting to say, gosh, we’ve created a society in which the poor and the brown are developing diabetes. What can we do to change that?  Let’s look at our policies, both in terms of chronic stress and poverty and violence and also in terms of activity and lifestyle. What would lead to better health? I think that investment would be better than tackling this problem as if it were the fault of individuals.

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Comments (7)

  1. Submitted by Presley Martin on 02/08/2016 - 10:15 am.

    Thank you!

    Thank you Dr. Victor Montori, I think you’re right. I wish more doctors were speaking up about issues like this.

  2. Submitted by Ron Gotzman on 02/08/2016 - 10:26 am.

    thank you!

    To me – these articles are interesting. I enjoy hearing the point- counterpoint regarding science and medicine. It is also interesting how politics and business and the health industries compete for the shaping of public opinion.

  3. Submitted by Ray Schoch on 02/08/2016 - 01:36 pm.

    I’ll add

    …a third “Thank you!” to the chorus. Having been diagnosed with Type 2 diabetes less than a year ago – at age 70 – I began the article in skeptic mode, but Dr. Montori raises relevant and important questions. While I don’t want personal choices to be taken off the medical and rhetorical table entirely, it’s undeniable that the *range* of personal choices available to people varies between and among different geographic, economic and ethnic/racial segments of the population, and that range of choices is often – not always, but often – the result of political and policy decisions made far outside the range and scope of individual decision-making.

    For just one tiny example: I’ve lived here 6-1/2 years, and it’s only within the past few months that Metro Transit has begin to affix at bus stops in my neighborhood small signs to indicate which bus routes stop at that particular place. Those signs still don’t tell me where the bus is going, or coming from, or when it should arrive, but they do, at least, provide a phone number I could call. If you have to rely on public transit to get somewhere else, this is the sort of very small, but crucial, item that can make all the difference if you can’t afford a car and just got a job that requires you to leave the neighborhood.

  4. Submitted by Greg Kapphahn on 02/08/2016 - 03:21 pm.

    Until We Replace the Dysfunctional Idea

    that the reason other people have problems is that they’re not sufficiently like US,…

    with the realization that,…

    “there but for the grace of God go I,” as the old saying puts it,…

    we will continue to try to blame people for the problems their environment creates in their lives,…

    expect changes in attitude and behavior from people who are VERY unlikely ever to be able to accomplish them,..

    and NEVER begin to see that people need to healed in order to escape from the effects of the routine, daily traumas they’ve suffered,…

    and that society which has had a role in creating the circumstances which cause such a high level of daily insult and trauma,…

    has a major role in changing those causes.

    The angry conservative baby boomers are major victims of what I’m describing,…

    but they’ve been hoodwinked into thinking that their circumstances will be changed,…

    only by allowing those who have caused those circumstances complete carte blanche to do even more of the same.

  5. Submitted by Greg Kapphahn on 02/08/2016 - 03:26 pm.

    Call Me Cynical

    But I now fully expect major figures working at the CDC,

    to soon be employed by a pharmaceutical company,

    offering a new drug about which we are all supposed to “ask your doctor,”

    a drug which claims to prevent “pre-diabetes” from turning into,…

    that horrible, life-threatening, deadly real thing: type II diabetes, itself,…

    with the implication that if you don’t get this new drug you’re going to die a horrible death.

  6. Submitted by Britter Ritter on 02/08/2016 - 10:14 pm.

    A1C-

    I can speak from personal experience that the lowering of the defining number of Diabetes or Pre-Diabetes from 8 to 7, or whatever it was done recently, resulting in experiencing outright bullying from medical professionals, from doctors to nurses, to dieticians. Moreover, the dieticians and medical specialists in diabetic treatment were ill-informed, woefully inadequately educated, with little or no knowledge of the chemistry of food absorption. They didn’t even know things published in the 1970s by Adelle Davis.
    It is another manifestation of the fat-shaming initiated by the AMA to draw attention away from the role of doctor’s salaries in the high cost of Medicine. It is a regular habit of theirs, whenever Congress threatens to scrutinize their pay, that they launch a national campaign against an easy target.
    While taking metformin has been helpful, without too many side-effects, and I do have a problem with how I react to foods, I have been “borderline” for years, and sufficient physical activity nearly eliminates the need to change diet.
    Sad to say, this is just another example of the lean, mean bullying machine of fit people against those they deem “unfit.” Isn’t it interesting how people who spend most of their time exercising lack sympathy, empathy and compassion toward others? And the same for those who exert unnatural amounts of self-control? Why is it such people expect everyone else to be like them? Could it have something to do with narcissism? Egomania?
    It is long past time to get rid of the fictional Body Mass Index, the culprit underlying all these many cruelties. It is time to put away the technology that is actually driving our society into utter sedentariness. It is time for them to pay for their crimes against society. It is time to go dancing.

  7. Submitted by Daniel` Burchett on 03/07/2016 - 03:05 pm.

    Pre-Diabetes

    As a Type 2 diabetic for the past 18 years I don’t believe anyone has a clue about the disease. Ask any long term diabetic about the disease and they will tell you that you either have diabetes or you don’t. The criteria used to support the idea of pre-diabetes is so flawed that everyone could be in danger of contracting diabetes. There are so many misconceptions, fraudulent claims and myths about the disease that it is impossible for anyone that truly has the disease to make informed decisions on how they are supposed to evaluate their treatment or who they can trust their care to. Most of the information on how to treat the disease comes from pharmaceutical companies touting their latest and greatest pill, injectable, gadget or diet that naturally produces revenue in the tens of billions of dollars. There is no more personal disease than diabetes and no set course of treatment because it is different for everyone. No two diabetics are the same consequently any form of treatment must be tailored to the individual diabetic. It isn’t and never has been a one-size-fits-all disease.

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