July 16, 2014

expert reaction to whether labelling people with moderate blood glucose levels as having ‘pre-diabetes’ is helpful

Authors of an analysis article in the BMJ argued that diagnosing patients with moderately high blood sugar as having pre-diabetes is unhelpful and unnecessary, reporting that blood sugar reduction treatments resulting from a diagnosis of pre-diabetes delayed the onset of type 2 diabetes only by few years and there was no evidence of long-term health benefits.

Prof Tom Sanders, Head of Diabetes and Nutritional Sciences Division, King’s College London, said:

“Type 2 diabetes is the result of a much longer process which is preceded by resistance to the action of insulin, raised blood pressure and an abnormal lipid profile.  The increase in blood sugar occurs much later on when the pancreas is no longer able to produce sufficient amounts of insulin to maintain normal blood glucose levels.  The terms pre-diabetes and metabolic syndrome are used almost synonymously but the definition of metabolic syndrome used by the International Diabetes Federation is broader and also includes raised blood pressure and abnormal blood fats (low HDL cholesterol and raised triglycerides) and central obesity defined as a waist measurement greater than 80 cm in women and 94 cm in men.  Both are strongly affected by being overweight and can to some extent be ameliorated by weight loss and exercise.

“John Yudkin (not to be confused with his late uncle of Pure White and Deadly fame) argues that focusing on moderate elevations of blood glucose may not be worthwhile and that blood glucose lowering drugs may not be helpful.  Indeed, this is supported by most trials of blood sugar lowering drugs in people with type 2 diabetes that show no effect on risk of cardiovascular disease.  This is in contrast to the results from trials of drugs that lower blood pressure or blood lipids, which consistently show benefit in terms reduced cardiovascular disease incidence.  The article importantly challenges the ‘glucocentric’ view of type 2 diabetes promoted by the major pharmaceutical companies.  However, some caution is required as high blood glucose levels do contribute to risk of cataract, retinopathy, kidney failure and possibly dementia.  The proportion of adults over 40 years old with pre diabetes has shot up from about 12% in 2003 to 35% in 2011 (http://bmjopen.bmj.com/content/4/6/e005002.full) in line with the growth in obesity. This heralds a tsunami of type 2 diabetes in years to come. Rather than sitting round waiting for a new drug to low blood sugar, we need to encourage middle-age adults to get off their butts and take daily exercise (30 minutes brisk walking a day will do) and lose a bit of weight by eating less because this is the most effective way of preventing type 2 diabetes.”

‘The epidemic of pre-diabetes: the medicine and the politics’ by John S Yudkin and Victor M Montori published in the BMJ on Wednesday 16 July 2014.

Declared interests

None declared