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Independents' Day

What is pre-diabetes?

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When I was young it was quite hard to be diagnosed diabetic. You had to present in a coma and wake up on the Expensive Care Unit, mainlining insulin, or in the A&E rumpus room after slugging the medical SHO in an apparently drunken rage.

No one had ever heard of the term ‘pre-diabetes’. If you had a little trouble controlling your blood sugar and ballooned beyond 18 stone or so, you were asked to cut down on the carbs and you’d get labelled ‘mildly diabetic’.

Now if you so much as eat a Mars bar and have a blood test on the same day, you get a new diagnosis, a prescription for metformin and spend the rest of your life batting away questions about the firmness of your erections.

But what exactly is ‘pre-diabetes’? Apart from this year’s diagnostic fad, that is. (Vitamin D deficiency? Honey, that’s so 2013). 

The now-laughably-outdated terms ‘impaired glucose tolerance’ and ‘impaired fasting glycaemia’ at least made sense in that I could explain them to patients: ‘IGT means that you can’t handle large glucose loads, so lay off the fizzy drinks’; ‘IFG means that your blood sugar is high even when you haven’t eaten, so lay off the fizzy drinks’. Life seemed somehow simpler then

Putting pre- in front of a diagnosis just renders it meaningless. Pre-diabetes? Well, it’s a bit like pre-dead. Except you really will get dead one day.

If you have pre-diabetes, it sounds like you are definitely going to go on to develop the real thing. Except that you probably aren’t. (At least not anytime soon).

Anyone who’s read anything about blood and sugar in the last few decades will be familiar with the name Professor John Yudkin, whose book Pure, White and Deadly became a bestseller. His probably entirely unbiased take on the pre-diabetes thing? ‘An artificial category with virtually zero clinical relevance.’ 

Suppose for a moment that medicalising and monitoring 16 million adults in the UK was actually achievable, bearing in mind that GPs as a whole aren’t terribly busy. What purpose would it serve? Millions of patients on metformin would mean a hike in the share prices of the pharmaceutical companies that make it.

It would also pep up the biological washing powder manufacturers, who were just resigning themselves to the news that the bottom was falling out of the orlistat market and that skidmarks would soon be a thing of the past.

Explain it to patients this way: ‘If you take these tablets after every meal the extra days at the end of your life, the ones you’ll spend enjoying the view out of your nursing home window over the graveyard next door, will just about pay back the extra time you’ll spend on the crapper or shopping for bulk buy deals on toilet paper at LIDL. I’m guessing it’s time that that you’d rather have spent doing something more interesting.’

‘Like shopping for Belgian chocolate, Doc?’

Well, you can’t win ‘em all.  

Dr Tony Copperfield is a GP in Essex. You can follow him on Twitter @DocCopperfield

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Readers' comments (6)

  • I like the term pre-dead, I will use that more that reflection for my appraisal?

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  • "If you take these tablets after every meal the extra days at the end of your life, the ones you'll spend enjoying the view out of your nursing home window over the graveyard next door......."

    Absolutely hit the nail on the head with this statement!

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  • There wouldn't be such a diabetic and "pre-diabetic" situation if more of the medical profession and government health agencies had listened to Professor John Yudkin instead of Ancel Keys, if people had not been advised to eat high carb, low fat, but had been advised to eat low carb. Hey, NHS dieticians still recommend high carbs at every meal for diabetics ! They preface the word carb with "complex" but it makes little difference once it's ingested if you have some sugar or a bit of wholemeal bread !

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  • Moderation in all things - er, that's it.

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  • yes moderation in all things... who is suggesting we screen the entire population? semantics not important... IFG/IGT / prediabetes.. early conversations with patients are!
    no label = not important . we can have a balanced debate about this!

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  • Brilliant, and if you remove the entertaining superlatives this is all totally true. You become diabetic when you might benefit from treatment including non drug treatment. If you have an IGTT you have a small increased annual risk of becoming diabetic. If a clever doctor says you are pre diabetic you are not diabetic, there is no immediate risk from diabetes, it is only about prevention. There is clearly a large mixed camp, often with a self interest, who don't mind the confusion, turn a blind eye and seem happy to over diagnose diabetes. However an accurate diagnose is far better all round, especially for the individual and the resource implications. The current guidelines are confusing so you can probably do what you like and not be criticised but I would be very careful about diagnosing diabetes on single and borderline HBA1c alone. Always repeat with a FBS, and if both are still borderline always make sure to do a GTT. Then monitor the HBA1c and FBS those with IGT annually.

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From: Copperfield

Dr Tony Copperfield is a jobbing GP in Essex with more than a few chips on his shoulder