As always, an extremely important and timely topic. When my A1c was elevated by one or two points I was frantic and I thought that I was going to become diabetic at any minute. Thank goodness my doctor explained to me that the range from one point to the other is very very different and no need to worry particularly since I had no intervening issues. Too bad I hadn’t read this sub stack a year ago. I would’ve saved myself a lot of aggravation. Thank you for posting this so important and timely.
As an internist and having a public health background, I think the author has missed a point while using her own example, as she is actually likely to be an outlier in the population who actually have optimal metabolic health. What I see in my daily practice, is a completely different reality, where I would say 70-80 % of my patients have overall poor metabolic health, which is the underlying root cause etiology for all their conditions.
As doctors, and in current "in and out" model of medicine, metrics and numbers are unfortunately what are used to assess performance which has so many downstream second order effects. Rather than focusing on labs like A1c, as the only measure and lipid panel, we forget the big picture of what is causing them to have these numbers in the first place. On one side, there is over treatment of elderly patients in terms of A1c, which can lead to risk of having risks of hypoglycemia, but on the other spectrum, there are too many patients who have completely normal A1c < 5.6, on whom I cannot put them on medications that can help improve their metabolic health, (eg, GLP-1 analogues), that have had a profound effect of helping patients lose weight, and have subsequently helped with their overall mental and physical wellbeing.
A recent NHANES study, found only 6.3 % of adults in optimal cardiometabolic health, which is just appalling. Considering that we are reaching 20 % of GDP, as health expenditure, and most states, the biggest employers are either retail giants like Walmart, and Amazon, and hospital systems, the market incentives are complete opposite to what we perceive as a good health.
"Less is more" model of healthcare doesnt work, as hospitals rely on sick patients being seen consistently, without poor biopsychosocial care provided outside. No wonder, we spend the highest $$ in the last year of patient's life, trying to fix something that was broken a long time ago. What I strive for in my patients, is how to convince them to change their daily behaviors, which I thing arguably is the most difficult thing to do, and unfortunately as part of training, we spend the least amount of time on it. We just assume that patients arent going to change, and its all their bad decisions that have led them to be like this, which is a very naive way to look at the systemic issues present. I occcasionally joke, the primary care DR stands for "Downstream Revenue", as it is just a referral based system to incentivize specialist interventions, so that they have to justify their existence. Obviously, this is an overgeneralization, but we spend less on primary care, and its in a dire state because of how it is perceived as low status in the healthcare world. In one year of my practice, my assumptions of thinking that primary care is boring are completely proven wrong, and I have never felt so grateful and proud of my patients, that have actually gotten better, and improved their behaviors if provided with the correct tools, and actually "LISTENING" to them.
We are all pre-death. How do we screen? We have moved from treating to disease to defining pre-diseases that maybe aren't diseases, maybe don't progress and which treating may actually harm. It is not even clear sometimes when we find pathology that treating it is any benefit to the patient at all.
I agree that "communication between physician and patients requires serious improvement." People are told they have Type 2 diabetes, but they are not told that with lifestyle, diet and exercise changes they can reverse it. They are often just given a pill and told that will help. The television is inundated with advertisements for Trulicity and other blood sugar lowering drugs, so people think these are easy ways to solve the Type 2 diabetes problem. But these drugs are very expensive, when lifestyle changes can work just are well. We also have a severe communication problem between nutritionists and patients. People are given the Myplate.gov lecture but that method never made sense to me. Why put that much food on your plate? Now everyone is doing the Keto and other fad diets when they need to do lifestyle changes to make a lasting difference. Learn to eat in moderation and don't fill up your plate; even minor changes to your exercise routine can get rid of "prediabetes."
The author asks us to imagine what would happen if a precancerous diagnosis existed and what effect this would have. It’s called ductal carcinoma in situ or DCIS, and it’s been plaguing women for decades now with anxiety. This article can be used to create a treatise on DCIS almost word for word with “prediabetes” replaced by “DCIS”. The diagnosis today of DCIS, a nonobligate precursor to breast cancer, or the pre-DCIS diagnosis of Atypical Ductal Hyperplasia, is scaring many women into lumpectomy/radiation or even double mastectomies. I myself had a mastectomy this year after sitting on a DCIS diagnosis that did later develop into invasive ductal carcinoma (IDC), despite my change in diet that year to (mostly) vegetarian and a 20-lb weight loss and increased daily exercise. But most women don’t want to wait it out. Medicine needs to do better to identify those women that are at highest risk for IDC instead of clumping all DCIS together. There are stages of DCIS that have been identified but the communication of the risk levels of each stage to patients is lacking based on anecdotal evidence. Gratefully, there is an important randomized controlled trial ongoing known as COMET that is trying to address these issues. In particular, it is addressing the real question of whether women diagnosed with stage I or stage II DCIS can wait and researchers at UCSF and Duke are trying to identify what factors can we investigate in women with these diagnoses to try to avoid overtreatment. I would appreciate if Sensible Medicine could offer a treatise on DCIS/ADH diagnoses like this article, but I suppose it might be too soon.
Every study shows the importance of keeping blood glucose low - that even those with high-normal levels have increased risk of dementia, heart issues, eye issues, and the thousand metabolic problems that high blood sugar can cause. Of course, the purpose of all the screening is to sell drugs but instead of running an article by someone trying to justify doing nothing about her high-ish blood sugar, Dr. Prasad would have done well to highlight how desirable and easy it is to lower blood sugar with time-restricted eating (intermittent fasting), lowering carbs, and a little more exercise.
More scary info about aggressive and money driven American medicine.
A question. Does anyone remember the diagnosis of benign systolic hypertension?
It suggested that a high systolic and a relatively normal diastolic without end organ effects could be normal in older people and didn’t necessarily need to be treated.
As always, an extremely important and timely topic. When my A1c was elevated by one or two points I was frantic and I thought that I was going to become diabetic at any minute. Thank goodness my doctor explained to me that the range from one point to the other is very very different and no need to worry particularly since I had no intervening issues. Too bad I hadn’t read this sub stack a year ago. I would’ve saved myself a lot of aggravation. Thank you for posting this so important and timely.
As an internist and having a public health background, I think the author has missed a point while using her own example, as she is actually likely to be an outlier in the population who actually have optimal metabolic health. What I see in my daily practice, is a completely different reality, where I would say 70-80 % of my patients have overall poor metabolic health, which is the underlying root cause etiology for all their conditions.
As doctors, and in current "in and out" model of medicine, metrics and numbers are unfortunately what are used to assess performance which has so many downstream second order effects. Rather than focusing on labs like A1c, as the only measure and lipid panel, we forget the big picture of what is causing them to have these numbers in the first place. On one side, there is over treatment of elderly patients in terms of A1c, which can lead to risk of having risks of hypoglycemia, but on the other spectrum, there are too many patients who have completely normal A1c < 5.6, on whom I cannot put them on medications that can help improve their metabolic health, (eg, GLP-1 analogues), that have had a profound effect of helping patients lose weight, and have subsequently helped with their overall mental and physical wellbeing.
A recent NHANES study, found only 6.3 % of adults in optimal cardiometabolic health, which is just appalling. Considering that we are reaching 20 % of GDP, as health expenditure, and most states, the biggest employers are either retail giants like Walmart, and Amazon, and hospital systems, the market incentives are complete opposite to what we perceive as a good health.
"Less is more" model of healthcare doesnt work, as hospitals rely on sick patients being seen consistently, without poor biopsychosocial care provided outside. No wonder, we spend the highest $$ in the last year of patient's life, trying to fix something that was broken a long time ago. What I strive for in my patients, is how to convince them to change their daily behaviors, which I thing arguably is the most difficult thing to do, and unfortunately as part of training, we spend the least amount of time on it. We just assume that patients arent going to change, and its all their bad decisions that have led them to be like this, which is a very naive way to look at the systemic issues present. I occcasionally joke, the primary care DR stands for "Downstream Revenue", as it is just a referral based system to incentivize specialist interventions, so that they have to justify their existence. Obviously, this is an overgeneralization, but we spend less on primary care, and its in a dire state because of how it is perceived as low status in the healthcare world. In one year of my practice, my assumptions of thinking that primary care is boring are completely proven wrong, and I have never felt so grateful and proud of my patients, that have actually gotten better, and improved their behaviors if provided with the correct tools, and actually "LISTENING" to them.
Vandan Panchal, MD MPH
We are all pre-death. How do we screen? We have moved from treating to disease to defining pre-diseases that maybe aren't diseases, maybe don't progress and which treating may actually harm. It is not even clear sometimes when we find pathology that treating it is any benefit to the patient at all.
I agree that "communication between physician and patients requires serious improvement." People are told they have Type 2 diabetes, but they are not told that with lifestyle, diet and exercise changes they can reverse it. They are often just given a pill and told that will help. The television is inundated with advertisements for Trulicity and other blood sugar lowering drugs, so people think these are easy ways to solve the Type 2 diabetes problem. But these drugs are very expensive, when lifestyle changes can work just are well. We also have a severe communication problem between nutritionists and patients. People are given the Myplate.gov lecture but that method never made sense to me. Why put that much food on your plate? Now everyone is doing the Keto and other fad diets when they need to do lifestyle changes to make a lasting difference. Learn to eat in moderation and don't fill up your plate; even minor changes to your exercise routine can get rid of "prediabetes."
The author asks us to imagine what would happen if a precancerous diagnosis existed and what effect this would have. It’s called ductal carcinoma in situ or DCIS, and it’s been plaguing women for decades now with anxiety. This article can be used to create a treatise on DCIS almost word for word with “prediabetes” replaced by “DCIS”. The diagnosis today of DCIS, a nonobligate precursor to breast cancer, or the pre-DCIS diagnosis of Atypical Ductal Hyperplasia, is scaring many women into lumpectomy/radiation or even double mastectomies. I myself had a mastectomy this year after sitting on a DCIS diagnosis that did later develop into invasive ductal carcinoma (IDC), despite my change in diet that year to (mostly) vegetarian and a 20-lb weight loss and increased daily exercise. But most women don’t want to wait it out. Medicine needs to do better to identify those women that are at highest risk for IDC instead of clumping all DCIS together. There are stages of DCIS that have been identified but the communication of the risk levels of each stage to patients is lacking based on anecdotal evidence. Gratefully, there is an important randomized controlled trial ongoing known as COMET that is trying to address these issues. In particular, it is addressing the real question of whether women diagnosed with stage I or stage II DCIS can wait and researchers at UCSF and Duke are trying to identify what factors can we investigate in women with these diagnoses to try to avoid overtreatment. I would appreciate if Sensible Medicine could offer a treatise on DCIS/ADH diagnoses like this article, but I suppose it might be too soon.
Every study shows the importance of keeping blood glucose low - that even those with high-normal levels have increased risk of dementia, heart issues, eye issues, and the thousand metabolic problems that high blood sugar can cause. Of course, the purpose of all the screening is to sell drugs but instead of running an article by someone trying to justify doing nothing about her high-ish blood sugar, Dr. Prasad would have done well to highlight how desirable and easy it is to lower blood sugar with time-restricted eating (intermittent fasting), lowering carbs, and a little more exercise.
More scary info about aggressive and money driven American medicine.
A question. Does anyone remember the diagnosis of benign systolic hypertension?
It suggested that a high systolic and a relatively normal diastolic without end organ effects could be normal in older people and didn’t necessarily need to be treated.