April 16, 2019
Staging the severity of type 2 diabetes could save millions of lives
The authors propose avoiding the confusing term "prediabetes" in exchange for the more accurate "stage-1 diabetes".
By Riva Greenberg, Trent Brookshier
Diabetes is the predominant worldwide cause of non-traumatic amputations, blindness and end-stage renal disease, but these microvascular complications begin before the actual clinical diagnosis. At the prediabetes stage, multiple other pathways are affected including possible macrovasculature damage like stroke and myocardial ischemia. For most people, the disease and its complications, will progress if not treated properly with diet, exercise, and pharmacological intervention. Taking prediabetes more seriously and earlier intervention can lead to better outcomes. This is precisely why we believe staging the severity of type 2 diabetes could save millions of lives.
Prediabetes, or Impaired Glucose Tolerance (IGT), is a fasting blood glucose between 100 (5.6 mmol/l) and 125 mg/dl (6.9 mmol/l), according to the American Diabetes Association Guidelines (International Diabetes Federation (IDF) guidelines are slightly different using 6.1 to 6.9 m/moL). One point higher, 126 mg/dl (7 mmol/l), and you have type 2 diabetes.
According to the IDF Diabetes Atlas, 350 million adults worldwide have IGT. By 2045, the Atlas predicts 587 million people will have IGT. Further, most people with IGT don’t know they have it.
Many physicians today don’t inform their patients they have prediabetes. Thus those who have it have little to no knowledge, education, or incentive to do anything about it.
It is our argument that part of the lack of urgency concerning prediabetes comes from the name of the condition itself.
Prediabetes says you currently have nothing; you don’t yet have diabetes. The name informs you to wait and watch. Yet this is exactly when taking action may reverse the condition and possibly prevent type 2 diabetes.
We propose avoiding the confusing term “prediabetes” in exchange for the more accurate “stage-1 diabetes”. We also believe that creating a staging system for type 2 diabetes will help with management of the disease. These two steps can change the perception of severity of the condition and prompt earlier intervention.
I first wrote about this for an article in 2013. At the time, improving awareness of prediabetes was the dominant conversation. However, I believe the first critical step to prompt healthier behaviors is a name change. As I wrote, “…recognizing prediabetes as “stage-1″ diabetes will get millions more people to take action to stop their diabetes from progressing.”
Last year, a medical student, now doctor, Trent Brookshier, read my article and he had the exact same idea. While doing his graduate work he conducted a survey to test whether a name change and staging platform would change perceptions, attitudes, and actions about diabetes. He discovered it would.
Many physicians today don't inform their patients they have prediabetes. Thus those who have it have little to no knowledge, education, or incentive to do anything about it.
Dr. Brookshier surveyed 44 adults, 39% male, 61% female, of various races at the Western Diabetes Institute and Patient Care Center in Pomona, California. 27% had previously been diagnosed with diabetes, 9% with prediabetes, and 63% had never been diagnosed with any kind of diabetes.
86% of all those surveyed stated they would be willing to take medication for “stage-1 diabetes.” 66% of those with prediabetes, not on medication, said they would take medication if diagnosed with stage-1. Comparatively, 61% saw medication unnecessary for “prediabetes”. The perceived severity of “prediabetes” was 6.36 out of 10, whereas for “stage-1 diabetes” it was 7.43 out of 10, a 17% increase. Anecdotally, many physicians said they would recommend treatment and provide education sooner.
Here is the suggested staging model for type 2 diabetes:
Stage 1 — Regulation of blood glucose is impaired and blood glucose is higher than normal. Diabetes complications may be present. Hemoglobin A1c (HbA1c) 5.7-6.5%
Stage 2 — Ability to produce and use insulin is further impaired than Stage 1. Complications are often present, particularly in the circulatory and nervous systems. Metabolic syndrome is common. HbA1c 6.5-9.0%
Stage 3 — Severe diabetic complications including neuropathy, vision loss, foot ulcers, amputation, blindness, kidney disease and heart disease. Hospitalizations may be frequent. HbA1c above 9.0%
Stage 4 — Dangerously high glucose levels putting patients in danger of organ failure, highest chance of mortality. HbA1c of 12% and/or diabetic emergencies
Clinically, the progression of diabetes makes a staging classification appropriate. Psychologically, staging diabetes appears to motivate earlier action by both health professionals and patients. Finally, it may reduce the number of people who proceed to Stages 2, 3, and 4 diabetes, preserve individuals’ health, and decrease the burden to families, communities and global economies.
Riva Greenberg is a leading global expert in flourishing with diabetes and has had type 1 diabetes for 47 years.
Trent Brookshier is a physician and surgeon, currently training in San Diego, California, who specializes in limb salvage and diabetes care.