It’s a message I’ve posted many a time…..waiting until a disease state has taken hold before deciding there’s a problem is faulty reasoning. Change is happening with dyslipidemia and ASCVD. Now T2D….about time.
I remember in the days of the Diabetic Fools board, Fuskie hammered this home when newbies to the board would complain that “their doctor wants….(insert a sensible intervention)” but they were “only prediabetic”. He’d explain quite patiently the reasons why prediabetes as a term was an artificial construct and the potential for pathology to get a hold while waiting for that AIc to get a point or two higher before intervening.
That’s my SIL. She thinks she doesn’t have to do anything because she’s only prediabetic. We keep trying to tell her that doesn’t mean what she think it means.
Well, in a way, if her medical providers aren’t articulating the idea that prediabetes in and of itself is a pathological condition (even without the official diabetes moniker), then she really can’t be blamed, right?. Not saying that’s necessarily the case….patients do put their own interpretation on what they hear….but, as I found myself, being proactive doesn’t seem to be a common trait at primary care level.
At the visit when I asked my new-to-the-practice physician about more “advanced” lipid testing (Apo-b and Lp(a)) plus a CAC scan, I also asked about a fasting insulin test, even though fasting glucose and AIc were both in the healthy range…..looking more to eliminate any possibility that there was a fixable problem causing my elevated LDL-C. Turned out my HOMA-IR was barely above 1 so nicely insulin sensitive.
I don’t know why more primary care docs don’t do this simple add-on if the index of suspicion is high.
Well, telling her what to do is a start…..but what about the why she should. Prediabetes is not innocuous. The reasons for the interventions aren’t just to prevent the slide downhill to the real deal, but to stop the damage that’s already being done (heaps of resources online to highlight this……hey, even Google AI overview might be useful, given the right question)
Where do folk get these odd ideas? You might ask her if she’d leave, say, a pre cancerous lesion to become the real thing before doing anything meaningful.
Well, I guess there’s nothing wrong with that if someone is making that decision in full possession of the facts (although simply making that decision suggests they’re not, I’d think) Might as well wait until the spit hits the fan, I guess.
An inlaw married to a cousin is a great guy. He drinks heavily with her, he smokes, he has a stomach but not as bad as mine. He does not exercise, I do and at times very heavily. He is Euro numbers 100 for his sugar, metric I should say. He has two stents. And “everything is going well”, he tells my cousin. She’s a nurse. She gives out to him.
As a nurse she wanted my number in metric, I said about a 55. She said nothing to worry about. The idea is over time the number creeps, but my weight has come down. His number twenty years from now, nothing changes for the better, is a leg amputated. My number is not a threat. 55 was my highest number. The current number would be in the 43 area, 40 or less is good according to mi cousin.
I think someone is confused over those blood glucose numbers….I know I am.The alternative to the mg/dl that we use in the US is the mmol/l…..SI units…..that are used most everywhere else that I’maware of……certainly Europe. Something like 80 mg/dl converts to 4.4 mmol/l, and would be considered a “good” fasting glucose.
However, HbA1c is usually included in bloodwork (I can’t remember a time when I didn’t see that on my results). This gives a better overview of average blood glucose over a 3 month period than an isolated test. The A1c number is generally used to determine when someone is in the healthy range, the prediabetic range and the arbitrary number marking the tipping point into diabetes…..6.5% being the magic number.
So, it’s relatively easy to see when the spit is starting to hit the fan as blood tests show that A1c creeping up over 5.7% (which I think marks prediabetes) and one can choose to take notice…..or not.
Here’s the conundrum, though, as I see it. What’s going on under the hood when numbers are in the healthy range….say, 80-85 mg/dl fasting glucose and HbA1c 5.5 as mine are routinely. There’s no way from just those tests to see if that’s the result of everything actually being as healthy as it looks and with normal insulin sensitivity…..or if insulin resistance is causing the pancreas to pump out increasing amounts of insulin to compensate. This is what I’d call the early departure from healthy homeostasis and it comes with recognised pathology even with those healthy A1c levels.
With so many choices out there low sugar diet is not difficult. But they often read you the riot act and ask for a low carb diet. That is much more difficult.
Settle for a low sugar diet. Diet beverages and sugar substitutes like aspartame and sucralose are readily available. Of course you have to be careful to read labels and watch for products loaded with sugar like ketchup or ice cream. (Sugar free ice cream, brownies, and Jello are available.)
There is a problem with sugar substitutes though. A few studies have shown that the “fake sugar” fools the brain into thinking there is a bunch of calories coming its way. When the calories don’t show, the brain sends a signal to increase cravings/food intake.
Not for everyone, but many people need to keep their LDL under 70 to avoid plaque. The part that might not be for everyone, saturated fat, is the problem for LDL.
What we really want to do is to make stage 1 and stage 2 [T2D] a disease (from your link)
This is pure farce
A diabetes diagnosis requires an A1C of >6.5% measured twice in a year. A lifetime reading of an A1C of 6.0% will not lead to any negative medical outcomes as related to diabetes. Defining an A1C >5.7% as a disease is pure fiction and is probably only related to reimbursement for treatment. In fact, a person with an A1C of 5.6% has almost the exact same chance of becoming a diabetic with an A1C of over 7% as someone with an A1C of 5.7%. Even your Lancet article points this out:
The assumptions that people with prediabetes will develop type 2 diabetes and people without meeting prediabetes criteria are unlikely to develop diabetes are incorrect.
An A1C of 6.4% is considered a optimally controlled diabetic on either metformin or insulin. Creating a disease from an A1C blood test less than 6.0% is ridiculous. Risks leading to diabetes are multiple, including weight, obesity, activity, family history, diet, etc … if you’re overweight and do not exercise regularly you have a higher risk of diabetes than a consecutive A1C of 5.7%. Does that mean that a BMI of 125 should be considered a disease?
If you have a family history of diabetes, heart failure, or prostate cancer, does that mean you have a disease? A risk factor is not a disease. Your article is medicine at its worst.
Change is happening with dyslipidemia and ASCVD
Furthermore, aggressively treating a patient with a disease condition is not new. Putting a cast on a person with a broken leg doesn’t confer to putting a cast on all people who are involved in sports with high risk of broken bones. A person with ASCVD already has an aggressive disease process. There IS an underlying disease being treated, unlike a healthy person with an A1C of 5.7%.
In Ireland, prediabetes is generally diagnosed with an HbA1c level of 42–47 mmol/mol (or 6.0%–6.4% in older units), according to Health Service Executive (HSE) guidance. This range indicates higher-than-normal blood sugar that is not yet high enough for a type 2 diabetes diagnosis.
HSE website
HSE website
+3
Key diagnostic markers used in Irish healthcare include:
HbA1c: 42–47 mmol/mol.
Fasting blood glucose: 6.1–6.9 mmol/L.
HSE website
HSE website
+1
Note VeeEnn, I thought my cousin was talking sugar not A1C. I did not quiz her. In this my A1C would be 40.
Quite possibly…..but that doesn’t mean that an HbA1c of 6% is sufficiently innocuous to deserve the “only prediabetes” label either. It’s a pretty strong indicator that there’s underlying insulin resistance together with the ugly sisters of hyperglyceamia and hyperinsulinema. The impaired glucose tolerance of metabolic dysfunction…..with consequences associated with that condition in and of itself as I mentioned upstream (and mentioned in the article and per the references cited in the Lancet abstract, also: cardiovascular disease, kidney disease, early onset dementia, “certain cancers”….. not to mention MASH as my husband added….and gawd knows what else) and whether or not that slide away from healthy homeostasis becomes severe enough to be called T2D and suddenly become worthy of attention.
The analogy of a broken leg is itself a bit nonsensical really as (pathology aside….say, the frailty associated with osteopenia and sarcopenia) as it’s a result of a single traumatic event, no? In the seconds before that event, a patient could certainly be considered healthy. What genre of dunderhead would make that claim of the conditions existing in the run up to an official diagnosis of diabetes.
Edit: here’s one link from the Lancet anstract. A long read with multiple suggestions of “risk factors”…..but also the statement of strong links with the development of those diseases mentioned, together with hyperlinks to decent enough evidence to support the authors’ contention
Association between prediabetes and risk of all cause mortality and cardiovascular disease: updated meta-analysis | The BMJ https://share.google/Yr4eAcc0IMsJsxpm2
…and as a PS, I had a quick check on Google regarding my husband’s assertion about MASH. Not because I doubt his opinion (doing enough proof reading of this very topic to be confident it’s not his error)….but I do know that there are folk who love the fact checking capabilities of AI overview.
. The prompt was “Is there a causal relationship between prediabetes and MASH”.
Quite a few sources used that also give an overview of the pathophysiology too, for anyone interested. Manifestly, the answer wasn’t “No”.
Most everyone is tested for their Liver enzymes. It is not lost on the medical profession who has MASH.
Metabolic Dysfunction-Associated Steatohepatitis (MASH) is usually a “silent” disease with no symptoms until advanced, often found through routine blood tests (high liver enzymes) or imaging for other conditions.
Err…that’s what it was. As in …. not “No”. Which is what it it would’ve been if, in fact, pre diabetes happened to be consequence free, as many folk believe, apparently.
Yep, the medical profession sure does know a thing or 17 about MASH. For but one example…..
Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): New Perspectives on an Evolving Epidemic - PMC Checking your browser - reCAPTCHA
Edit: …as an FYI, the easy reading of this Bad Boy is due to moi (You’re welcome) Give my husband free rein, it’d be twice as long and (even?) more pedantic. It was, believe it or not, part of a 6 parter that he put together last year for the Journal of Clinical Medicine. Easy to see why AI overview gifted opinions tend to leave me cold on given topics.
That is exactly how it’s defined by the CDC, NIH (specifically NIDDK), and American Diabetes Association (ADA).
not to mention MASH
There are a collection of assumptions here. Fatty Liver disease leading to MASH in a patient w/o metabolic syndrome or ETOH abuse and nothing other than an A1C of 6.0% would be almost impossible and very rare. At least you would have to suspect hypertriglyceridemia and rule it out. The first rule is always; treat the patient, not the number.
Even the Lancet article pointed out concentrations of 5.6-6.05 mmol/L were associated with only a mildly increased risk of coronary heart disease And…the risk of all cause mortality associated with impaired fasting glucose was mainly attributed to fasting plasma glucose concentrations in the range 6.1-6.9 mmol/L. The comprehensive meta-analysis with 129 studies doesn’t allow for the number of patients in the 5.6-6.9 mmol/L cohort who went on to DM Type 2 or untreated DM Type 2.
My primary contention is that a risk factor is not a disease, but that never meant to imply that a risk factor should be ignored and not followed. If you’re ten pounds over-weight, don’t assume that is your weight for the rest of your life. If your A1C is 6%, then you will add that to your lab panel every year; and further consider coexisting conditions. Remember, treat the patient, not the number. Even depression has a higher risk of DM Type2 in patient without a pre-diagnosed A1C >5.7% <6.4%.
