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.
You may also find these interesting
Tanya HimathongkamApril 26, 2019 at 11:00 am
Totally agree with the article and would like to share what we are doing here at Theptarin Hospital in Thailand.
At Theptarin, we have what we call “Theptarin Diabetes Staging (TDS)”. There are 5 stages ranging from pre-diabetes all the way through diabetes with disabilities. All diabetes patients are classified according to TDS.
The idea of TDS originated about 10 years ago from our attempt to monitor how well we are doing in helping patients control their diabetes which is the combination of so many services such medical, education, lifestyle modification, etc. The goal is to stay at the stage where they are as long as possible, or even regress for those who are at early TDS.
Currently, apart from monitoring quality of care, TDS is used for 3 main purposes:
1. For each multidiscipline (MD, diabetes educator, dietitian, foot specialist, physical therapist, exercise specialist, pharmacist, nurse, etc.) to write up their practice standards.
2. For designing our service flow specifically for each TDS.
3. For communication among multidiscipline and between multidiscipline and patients.
What we really want to do is to diagnose pre-diabetes (TDS 1). Starting 3 years ago we launched hospital-wide diabetes screening program where we offer 3 step screening. First screen with risk score, then risk group will be invited to go through random BG check, and those 110 mg/dl or above are approached to come back for OGTT. Although it is a free service, it is a real challenge to convince. Given limited staff capacity, we focus the screening effort on thyroid patients (we are a diabetes and thyroid center) and relatives of our diabetes patients. And for other patients, we try to draw physician’s attention to the importance of recommending those at risk for OGTT.
Trent BrookshierMay 18, 2019 at 11:47 pm
Wow thank you so much for sharing! This sounds like an amazing system you all have set up and I’m sure the world would benefit to approaching type 2 diabetes in this manner. You shared what you are doing, how are the results?
Shaukat SadikotApril 25, 2019 at 2:23 pm
The survey was undertaken on 44 people and we are publishing and accepting their conclusions to change the classification on this small number of people!!!
Many health insurance companies will not cover the person if we classify this as a disorder calling it a pre-existing condition. As an international federation we have to consider the the socioeconomic realities all over the world!
Diabetes VoiceApril 26, 2019 at 4:09 pm
Thank you for your comment. In publishing articles on Diabetes Voice, the opinions expressed are those of the authors, not necessarily the views of IDF.
The editorial team
Trent BrookshierMay 18, 2019 at 11:50 pm
This was the first study of its kind which is why there was only 44 subjects. Obviously future studies should be done but the problem is that we all know those at the “pre-diabetes” stage have major health issues that if not treated will damage the body AND progress. Many of these people need medical treatment and sometimes pharmacological intervention and yet are denied because according to the insurance eyes it is “pre” diabetes and therefore not covered. So what good does it do if you have insurance if it won’t pay for the treatment you need. If you have insurance to start out you won’t have to worry about the “pre-existing” condition that you fear. They can’t drop you. So therefore, once insurance is established we should start calling it what it really is, which is the first stage of diabetes.
Gauranga DharApril 18, 2019 at 8:04 pm
Very good idea about the staging of type 2 diabetes (T2DM). Specifically I fully agree that it is necessary to rename pre-diabetes to “Stage-1 diabetes”. Most of the physicians gives not much importance when HbA1C is between 5.7% to 6.4% (patients without any hemoglobin disorders) and do not alert the patients about his or her bad prognosis. Practice shows that both macro and microvascular complications may develop at the pre-diabetes stage. Apart from cardiovascular complications, many patients visit their physicians with symptoms of neuropathy or retinopathy. Routine screening shows low eGFR or albuminuria in many patients without any renal symptoms. Screening of HbA1C of these patients found >5.7% but <6.5%. If we can name such condition as “Stage-1 diabetes”, both physician and patient will be more serious and start specific management strategies. Both specific lifestyle change and possible drug therapy may be started to prevent progression to overt T2DM and complication management as well.
Of course physicians are always serious and make patients serious about stage-2 to stage-4 but we need to give special and more importance to patients with pre-diabetic stage or stage-1 T2DM to save really millions of lives. This is possible if we can rename pre-diabetes to "Type 2 diabetes stage-1"
Trent BrookshierMay 18, 2019 at 11:53 pm
Thank you for your comment. I could not agree more with all the statements you made. YES, something needs to be done. And if we do not do something soon, diabetes will continue to kill millions more people.