Imperfect prediabetes diagnosis provides opportunity to identify, prevent diabetes
Click Here to Manage Email Alerts
Key takeaways:
- Consensus is needed to better define prediabetes.
- A prediabetes diagnosis offers a patient time to reduce their risk for developing overt type 2 diabetes.
PHILADELPHIA — Prediabetes is a high-risk state associated with substantial morbidity and mortality, yet consensus is needed regarding an “optimal” definition to better identify who could benefit from interventions, according to a speaker.
Hyperglycemia and its associated risks exist along a continuum; the term “prediabetes” applies to people falling below the threshold for a diagnosis of diabetes but at high risk for diabetes, Elizabeth Selvin, PhD, MPH, professor of cardiovascular and clinical epidemiology at the Johns Hopkins Bloomberg School of Public Health, said during a presentation at the Heart in Diabetes CME Conference. The prevalence of prediabetes has increased substantially during the past 2 decades; however, prevalence depends on the definition used. Some experts said they believe that the condition is a “dubious diagnosis” without clinical relevance at all, according to Selvin.
“Prediabetes is a problem; other people think it does not even exist,” Selvin said. “I have colleagues who are experts in the field who say prediabetes is not real, that it is not a medical condition. One issue where we are not doing ourselves any favors is there are five definitions of prediabetes that are in clinical use across the globe. The fact that no one can agree on how to actually define it is a major problem for the field.”
Conflicting definitions
Varying definitions of prediabetes in current clinical use continue to cause confusion in the field, Selvin said.
The American Diabetes Association (ADA) defines prediabetes as a fasting glucose between 100 mg/dL and 125 mg/dL or an HbA1c between 5.7% and 6.5%. WHO defines prediabetes as a fasting glucose between 110 mg/dL and 125 mg/dL and provides no HbA1c threshold. WHO and the ADA agree that a 2-hour fasting glucose between 140 mg/dL and 199 mg/dL meets the threshold of prediabetes, whereas an international expert committee defined prediabetes as an HbA1c between 6% and 6.4%.
“One of the issues with these five different definitions is they categorize different people, with overlap, but depending on which definition you use, you are capturing very different populations with very different prevalence estimates,” Selvin said. “If you use the ADA definition, almost 44% of people have prediabetes. In the same population, if you use the WHO definition, only 15% of people have prediabetes.”
Selvin said all five definitions of prediabetes are associated with poor clinical outcomes such as CVD, kidney disease and death, refuting the notion that prediabetes does not have clinical relevance. Prediabetes “represents a high-risk state” and is associated with substantial morbidity and mortality. Important actions in patients with prediabetes are to address lifestyle factors and CV risk, weight loss and prevention of weight gain.
How to assess diabetes risk
As debate over the term continues, an “easy way” to accurately assess a person’s risk for developing type 2 diabetes is using fasting glucose and HbA1c in combination when possible, Selvin said. A person with a fasting glucose above 100 mg/dL along with an HbA1c above 5.7% is at very high risk for developing type 2 diabetes, she said.
“Prediabetes provides an opportunity and that is why it is a very important category,” Selvin said. “It allows us to identify it and intervene to prevent diabetes. It allows us to address lifestyle factors and CV risk. We know from randomized controlled trials that even modest weight loss can reduce risk for diabetes. And something often neglected is that preventing weight gain in the first place is also important; maintaining stable weight over the life span.”
Risk-based definitions of prediabetes are needed, Selvin said. Professional societies should develop and validate new definitions that incorporate demographics and clinical factors such as age and BMI and explore adding other biomarkers such as C-reactive protein and lipids. Research in genetics and proteomics may also yield a better understanding of diabetes risk, Selvin said.
“There is tremendous heterogeneity in terms of prognosis with prediabetes in middle age and older age,” Selvin said. “We do ourselves no favors with definitions that are age- and BMI-agnostic. We need to also take a lesson from the field of cardiology and tie those definitions to clinical guidelines, the same way CV risk prevention is tied to clinical decision-making. There are a million diabetes risk scores out there. None of them are used clinically. It must be tied to clinical decision-making for us to make real headway.”
Collapse
Selvin E, et al. Session 6 – Enigmatic Cardiometabolic Conditions. Presented at: Heart in Diabetes CME Conference; June 9-11, 2023; Philadelphia.
Read more about
Click Here to Manage Email Alerts