Prediabetes

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Prediabetes. Lately it seems like many of my patients have been diagnosed with this condition. After receiving this diagnosis from their health provider, usually accompanied by some scary warnings about eventually developing diabetes and often with a side of weight shaming, these patients end up in my office feeling freaked out and worrying about the (seemingly) rapid decline in their health. A number of these patients have been advised by their doctor to start medications such as Metformin or GLP-1s to help manage their blood sugar. And more than I care to count have been advised to cut out carbohydrates and lose weight. While I do think that having information about one’s blood sugar and looking out for changes are important, I also believe that some members of the medical community are creating panic around this condition while simultaneously pushing medications and diets that are unwarranted.

What is prediabetes? Well, it’s a relatively new diagnosis that was first introduced in the late 1970s to describe patients whose blood sugar levels are higher than “normal” but not yet high enough to be in the range for type 2 diabetes. There are currently four different blood tests that can be used to diagnose someone with prediabetes (and diabetes): random blood sugar test, fasting plasma glucose (FPG) test, oral glucose tolerance test (OGTT), and hemoglobin A1C (A1C) test, but the majority of patients receive their prediabetes diagnosis following the A1C test. The A1C test measures average blood sugar levels over the previous two to three months. A level under 5.7% is considered “normal,” a level between 5.7% and 6.4% is considered “prediabetes” range, and over 6.5% results in a diagnosis of type 2 diabetes. Originally, the range for prediabetes was an A1C between 6.0% and 6.4%, but after extensive lobbying by the pharmaceutical establishment, the range was lowered to 5.7%-6.4% in 2010 by the American Diabetes Association (ADA), resulting in 72 million new cases in the USA. As a result of lowering the threshold for prediabetes, about one in three people in the USA is prediabetic.

So what does the research say about prediabetes and risk of developing diabetes? According to a 2018 comprehensive review of 103 studies, most people in the prediabetes range do not progress to diabetes over any period studied, with 59% of the prediabetes patients studied returning to normal blood sugar within one to eleven years without any treatment. In a 2019 article for Science.org, Charles Piller reports that the Center for Disease Control’s data show that less than 2% of prediabetics go on to develop diabetes per year. But despite this, the medical community continues to put forth the message that a diagnosis of prediabetes is basically a guarantee that diabetes will ensue. And what do these medical professionals recommend to their patients to “reverse” their prediabetes? Weight loss, primarily by way of cutting carbohydrates.

As we know, dietary and exercise interventions for weight loss are unsuccessful for the majority of people, with 90-95% of dieting individuals regaining the weight within five years. In addition to this, weight cycling, or losing and gaining weight over and over again, can result in a number of negative health outcomes such as cardiovascular disease and (you guessed it) diabetes. Telling a patient to try to lose weight to reverse their prediabetes is honestly just lazy doctoring. There are plenty of things people can try to improve their blood sugar levels that have nothing to do with weight loss. Some of these include: making sure to pair carbohydrates with protein, fat, and/or fiber at meals and snacks to help slow down the digestion of carbohydrates, resulting in steadier blood sugar; consistently getting seven to nine hours per night of sleep (as poor sleep quality has been associated with an increase in insulin resistance); engaging in moderate cardiovascular movement (such as walking) which immediately lowers blood glucose, an effect that can last up to 24 hours. But most importantly, if you are diagnosed with prediabetes, please do not panic. While it makes sense to get your A1C tested regularly to look for changes, having A1Cs in the prediabetes range does not mean that you are destined for diabetes.

How should one measure health?

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“I really like your blog posts.  They’re really well thought out and are a step above what I imagine normal nutrition blogs are like.  It’s like the philosophy of nutrition or something.  Question, though, when you say this: ‘Joanne and I advocate focusing on health rather than weight.  In that sense, weight outcomes are only somewhat interesting to us.’  I think you’re right, but it also seems challenging to measure one’s health without focusing on weight.  There are very few things a person can do other than stepping on a scale (without regular blood draws and periodic EKGs [electrocardiograms]) to measure their health.  In other words, how do you recommend someone measure their health to see if their health is improving?”

The above email arrived in response to a blog I posted earlier this month in which I compared the slim hopes of winning the lottery to the poor success rate of weight-loss endeavors.  Indeed, Joanne and I do advocate adapting lifestyle changes in pursuit of better health as opposed to taking a weight-centered approach because the latter rarely turns out well.

Furthermore, weight in and of itself is generally not a good indicator of health (although there are some exceptions to this generality, such as for a patient who is recovering from anorexia nervosa).  About a decade ago, I had a weekly doubles game with three other guys.  One player was very lean and clearly had the lowest body mass index (BMI) of any of us.  Was he the healthiest in the group just because he was the lightest for his frame?  After we had been playing together for a few months, I got a call one afternoon saying he had had a heart attack.  I came to find out he was also diabetic.

So if not by weight then, by what should we measure our health?

First, we need to understand that just because a measuring tool is convenient and easy to use does not mean it is valid.  In other words, just because gaining access to a scale and stepping on it are actions that most people can perform does not mean that the resulting data are automatically useful.

You know from my biography that I have an undergraduate degree in mathematics.  For a statistics class project, I analyzed the November 6, 1997 trade between the Red Sox and Rangers that sent Aaron Sele, Mark Brandenburg, and Bill Haselman to Texas in exchange for Damon Buford and Jim Leyritz.  In an effort to determine which team got the better end of the deal, I analyzed the past performances of the trade’s cornerstones, Sele and Leyritz, and determined which metrics were the best predictors of the outcome that ultimately mattered most: team wins.  Some statistics, like strikeouts for a pitcher or home runs for a hitter, are easy to compute and understand, but it turned out that other metrics that were more complex to calculate and comprehend were better predictors of team wins.

While I was in the process of switching careers, I did a similar project in my nutrition assessment course in which I tried to determine which anthropometric measurement is the best predictor of cardiovascular disease.  The results were complex, but the conclusion that I reached is not the point of this blog entry.  The point is that just as I found with the baseball project, the ease of obtaining a particular measurement has nothing to do with the utility of said measurement.  In other words, just because it is easy to count the number of home runs a player accumulates or to step on a scale and find out our weight does not mean that these numbers are great indicators of team wins or our health, respectively.

With that in mind, let us now turn our attention to just some of the ways we can measure health.  This list is far from complete, but it gives a sense of all of the measurement tools healthcare practitioners have at their disposal.

We have anthropometric data, such as waist circumference, waist-to-hip ratio, body fat percentage, and BMI.  We have the numerous biochemical markers that doctors can examine through blood and urine tests, including blood glucose, insulin, total cholesterol , LDL (“bad cholesterol”), HDL (“good cholesterol”), triglycerides, red blood cells (RBC), white blood cells (WBC), and markers of liver health, protein stores, electrolytes, and inflammation.  Clinical indicators include hair and skin quality, finger nail appearance, and tests for hydration status.  Electrocardiograms and blood pressure readings comprise part of a cardiovascular system assessment.  Men and women can screen themselves for signs of testicular and breast cancer, respectively, through regular exams.

When I was a personal trainer, I used tests like the eight-repetition maximum bench press, Rockport walk, and sit-and-reach to assess my clients’ fitness and track their changes over time.  In my realm of nutrition, dietitians will sometimes use tools, such as a 24-hour recall or food frequency questionnaire, to assess the health of one’s food intake.  Aside from one’s intake of fruits and vegetables, for example, one can track other health-related behaviors themselves, such as physical activity duration and frequency as well as usage of tobacco, alcohol, and recreational drugs.

Health is not just about the physical; emotional and psychological health is also important.  This is not my area of expertise, but I am sure psychologists and psychiatrists have ways of screening for and assessing the magnitude of conditions ranging from depression to schizophrenia.

With all of these different tools we have for assessing and tracking health, the criteria that one uses has to be individualized, which is why it is important to talk with your healthcare team about how you should track your own health.  For example, diabetics may measure their health in part by monitoring their blood sugar at home and keeping their A1C under a benchmark value set by their doctors.  A patient with a family history of cardiovascular disease may monitor his health in part through periodic blood lipid level checks and self-monitoring of blood pressure at home.  A patient with celiac disease may monitor her health in part through bone density screenings and tTG blood tests.  A patient with a history of skin cancer may measure his health in part through routine screenings with the dermatologist.

The permutations of how to measure health are endless and must be customized with the help of your doctor and any other healthcare practitioners who are on your treatment team.  Just because weight is easy to measure does not mean one should put much stock in the number or even track it at all.