The prediabetes paradox: Balancing early intervention and overdiagnosis

American Academy of Family PhysiciansMay 28 2024

Background: Prediabetes, a diagnosis intended to identify high-risk persons and prevent progression to diabetes, has been a topic of ongoing debate, and experts continue to disagree about its screening criteria, interpretation, and implications.

Author stance: An epidemiologist and health services researcher argues that prediabetes is overdiagnosed. A prediabetes diagnosis for patients like herself who are at low risk of developing type 2 diabetes can cause more harm than good. They may experience undue distress, undergo unnecessary consultations and tests, and pay additional health care costs. It may be implied-;incorrectly-;that prediabetes will inevitably develop into diabetes. Ultimately, the author feels, clinicians should focus on identifying and treating patients at high risk or with diabetes: "Let's put out fires, not fan flames."

Conversely, a family physician argues that a prediabetes diagnosis "represents a crucial stage for intervention in primary care." Prediabetes can signal an individual has metabolic syndrome, which increases the risk of all-cause mortality, cardiovascular disease, risks of common cancers, and neurocognitive disorders. To provide a comprehensive health assessment-;and to avoid causing patients anxiety-;physicians shouldn't over-rely on a single biomarker. He presents three hypothetical case studies to illustrate the complexities of diagnosing and managing prediabetes. He concludes, "By recognizing the early signs and adopting a holistic view of patient health, family physicians play a pivotal role in preventing the long-term risks associated with prediabetes and metabolic syndrome, and ultimately improving patient outcomes and quality of life."

Why it matters: We now know that type 2 diabetes is a preventable disease. There is disagreement about who is at higher risk and who would be a good candidate for preventive interventions. Balancing potential harms of overdiagnosing prediabetes with opportunities for early intervention to prevent progression is complex. Patient-centered counseling and patient preferences matter in these discussions.