Prediabetes diagnosis may not curb Type 2 diabetes, experts say

NEW YORK, Oct. 10 (UPI) — An epidemic of Type 2 diabetes continues to plague the United States, leading to calls for reassessing how the disease is diagnosed and treated, experts told UPI.

As many as 1 in 10 people nationally meet the criteria for Type 2 diabetes, with levels of hemoglobin A1C in the blood above 6.5%, according to the American Diabetes Association.

In addition, nearly 100 million adults in the country have what’s called prediabetes, or hemoglobin A1C blood levels between 5.7% and 6.4%, meaning they’re at high risk for Type 2 diabetes, the Centers for Disease Control and Prevention estimates.

Historically, a diagnosis of prediabetes was intended to serve as a warning from physicians to patients that they were at risk for Type 2 diabetes and related health problems, such as heart disease.

“For some patients that diagnosis is a wake-up call to make changes,” Dr. Eva Tseng, an associate professor of general internal medicine at Johns Hopkins School of Medicine, told UPI in an email.

“On the other hand, I have patients who are aware they have the condition, but they are not motivated to make changes — making lifestyle change is difficult and often hard to sustain,” said Tseng, who has researched how primary care physicians manage patients with prediabetes.

Preventing progression from prediabetes to Type 2 diabetes typically requires treatment with prescription medication, as well as “lifestyle changes,” such as eating a healthy diet and exercising, according to Tseng.

However, patients need to know they have prediabetes to begin making these changes — and as many as 80% of those who meet the criteria for the condition haven’t been diagnosed.

Using insurance claims data for 4,000 adults who met the criteria for prediabetes between 2016 and 2021, Tseng and her colleagues found that only 10% had coded diagnoses of prediabetes.

“The research we conducted was from eight years ago so it should not be interpreted as what physicians know and do these days,” Tseng said.

“There has been increasing public health messaging about prediabetes and changes in guidelines have made prediabetes an important condition to manage,” she said.

Cost challenges

In Tseng’s study, only 1% of the patients with prediabetes were referred for nutrition services and 5% were prescribed a drug to lower their hemoglobin A1C.

Part of the problem here is cost: through its National Diabetes Prevention Program initiative, the CDC is setting up a network a national network of healthcare providers urging patients to make the needed lifestyle changes to avoid Type 2 diabetes.

However, many health insurers currently do not “pay for this program as a benefit to their covered members,” though it is covered by Medicare and Medicaid in certain states, Tseng said.

Even among insurance plans that do cover Type 2 diabetes prevention programs, “reimbursement rates are insufficient to cover the cost of delivering a high-quality program, despite good evidence that the program saves money from preventing people from developing diabetes,” she said.

Preempting prediabetes

Another issue is that too many physicians “don’t emphasize [prediabetes] and the health risks enough” when talking to patients who meet the criteria, Dr. Ralph DeFronzo told UPI in a phone interview.

“In general, physicians don’t understand prediabetes is a major risk factor, and they pass it on to patients,” said DFronzo, a professor of medicine and chief of the Diabetes Division at the University of Texas at San Antonio Health Science Center.

Although they don’t meet the criteria for full-blown Type 2 diabetes, many people with prediabetes arguably should be treated as if they have the disease, according to DeFronzo, who also is deputy director of University Health’s Texas Diabetes Institute.

This is because even with hemoglobin A1C levels of 6.4% and fasting glucose — or blood sugar — between 100 and 125, they are still at high risk for health complications associated with Type 2 diabetes, such as heart attack or stroke, as well as kidney disease and vision problems, he said.

High levels of blood sugar, or glucose, suggest that the body has poor glucose tolerance, or an inability to properly process sugar, according to the American Diabetes Association.

“A big part of the problem is that the Food and Drug Administration has not approved any medications for the treatment of prediabetes,” DeFronzo said.

“If a medication were approved for prediabetes, then it would be ‘a serious disease’ and people would be more aware of it,” he said.

In recent years, a new class of drugs called glucagon-like peptide-1, or GLP1, agonists — such as dulaglutide and semaglutide, or Ozempic — have revolutionized how Type 2 diabetes is treated.

These drugs have been shown to reduce blood sugar levels by up to 15% and reduce a person’s risk for heart attack and stroke, research suggests.

Many people with prediabetes could benefit from these drugs, as well, but they cost “cost about $12,000 a year,” DeFronzo said.

In fact, a CDC analysis reveals that only about 1 in 3 people with Type 2 diabetes are taking GLP1s, likely due to the high cost.

A lower-cost option for those with Type 2 diabetes, and even some with prediabetes, would be metformin, a drug DeFronzo helped bring to the U.S. market.

Another drug that may be effective is the insulin sensitizer pioglitazone, he said.

Studies have shown pioglitazone can reduce the progression from prediabetes to diabetes by 75%.

When to treat

To identify people with prediabetes who might benefit from earlier treatment, he and his colleagues at the University of Texas at San Antonio Health Science Center propose a new risk category called “pre-prediabetes.”

In a study published in the Journal of Clinical and Applied Research and Education: Diabetes Care in September, they found that many people with normal glucose tolerance already have severe insulin resistance, meaning their body doesn’t respond properly to the hormone — a deficiency that can lead to high blood sugar.

They also may have early indications that their pancreas is unable to produce sufficient beta cells to process insulin and have “measurable” heart disease.

“Insulin resistance can lead to diabetes, beta cell failure, heart disease and kidney disease — we can see it and measure it years before people meet the criteria for diabetes,” DeFronzo said.

“People need to understand diabetes is a continuum — you don’t just develop Type 2 diabetes one day,” he said.