I've seen several discussions recently in the Diabetes Online Community recently about the notion of "pre diabetes", a situation where a patient has blood glucose levels that are abnormally elevated without meeting the diagnostic criteria for Type 2 diabetes. Mike Hoskins wrote a thoughtful post about it not long ago, and it was discussed in the second Diabetes Social Media Activism session. It's come up one or two other times, as well.
By and large, the people I've seen weigh in don't care for it, either as a term or as a concept. And I have to say that I disagree, at least in regards to the concept. This post relates pretty heavily to yesterday's post about "reversing" Type 2.
I've seen a number of folks who argue against the notion of pre-diabetes by drawing an analogy to pregnancy. You can't be pre-diabetic, and you can't be a little bit pregnant. Once you're pregnant, you stay pregnant until the pregnancy is interrupted in some way or the baby is born. According to the analogy, either you're diabetic or you're not, and once you're diabetic you're always diabetic until death or such time as there's a cure.
In pregnancy, there is a pretty well-defined beginning, to the best of my layman's understanding: an ovum is fertilized by a sperm cell. It may be that the onset of Type 1 diabetes is comparable, if onset is considered to occur when the immune system starts trying to kill off the pancreatic beta cells. So, it may be that the pregnancy analogy would work for Type 1. (It's also a distasteful analogy, in my mind. Comparing the prospective birth of a child to a disease state? Really?)
But what's the analogous is/isn't point in Type 2 diabetes? Is it when insulin resistance rises above a certain point, and how wold this be measured? Is it when the observable measure of fasting blood sugar rises above a certain level, or a certain A1c, or a certain result from a glucose tolerance test? Is it when the ability of the pancreas to supply insulin begins to be impaired, through a mechanism that I don't believe is yet understood?
And, do we really know that no one who meets whatever criteria you choose ever stops meeting that criteria?
Ironically enough, I think the case against the pregnancy analogy ultimately falls when we consider gestational diabetes. Some significant percentage of women develop insulin resistance during pregnancy and need to be treated with oral medications or insulin. When the pregnancy ends, so does the diabetes. A woman who's had gestational diabetes is at significant risk of later developing Type 2, but for many the diabetes goes away and stays away.
The pregnancy analogy just doesn't work for Type 2.
The next point I want to consider is whether the concept of pre-diabetes is meaningful or not, temporarily laying aside the choice of term. It may be that further research will allow us to dump it entirely, if the diagnostic criteria for T2 can be refined such that a patient is considered diabetic at one level (of whatever we're measuring), and those folks below that don't need to worry. But, given what we think we know now, this seems counter-intuitive.
As I discussed at length yesterday, there does seem to be a stage early in the development of T2 when lifestyle interventions may arrest the progression of the disease and development of symptoms. It makes sense to me that there would be a stage where there's sufficient insulin resistance to cause blood glucose levels to climb but precede (it is to be hoped) much in the way of damage to the pancreas' ability to produce sufficient insulin.
(Mike, in his post linked above, describes an experience his wife had being "diagnosed" with pre-diabetes in a health fair. It would be my hope that, if such a fair showed elevated blood glucose levels, the patient would not be "diagnosed" but rather encouraged to visit their physician for possible further testing and perhaps intervention.)
If there IS such a state, if significant lifestyle change can stop disease development (possibly for a lifetime), it seems to me that physicians have a strong obligation to watch for it. And there's another thing: we're used to Type 2 progressing pretty slowly, but that's not the case for everybody. A patient who doesn't quite meet diagnostic criteria at one checkup may, I'm guessing, come to the next checkup complaining of foot pain and blurred vision.
So I'm a fan of the concept of pre-diabetes, at least until it's shown not to be useful in helping people be as healthy as possible. However, I don't much care about the term itself. I don't doubt that there would be good candidates, and I'd be happy with any of them if the support for it is broad enough to minimize confusion.
So, if you hate the term, I'm not going to argue with you. If you hate the concept, though, I'd ask that you give the idea another look.