Final Paper for Politics of Disease Control

1. Running Head: PREDIABETES OR HEALTHCARE MARKETING 1
Is Prediabetes a Valid Diagnosis or a Healthcare Marketing Tool
Marisa McCarty
The University of Georgia

2. Running Head: PREDIABETES OR HEALTHCARE MARKETING 2
In 2009, the American Diabetes Association (ADA) adopted a new lower threshold to
measure the occurrence of Type II diabetes and coined the new aliment prediabetes (Piller,
2019). Hemoglobin A1C testing is widely endorsed as a preferred method of testing for diabetes
as well as prediabetes even though there is mounting evidence that higher ranges can be
influenced by other variables besides blood glucose levels (Sacks, 2011). The ADA defines
prediabetes as an A1C level range between 5.7% and 6.4% with greater than 6.5% diagnosed as
diabetes (Bergman et al., 2012). Globally, however, the World Health Organization affirms there
is not substantial evidence to support a diagnosis of a blood glucose disorder with an A1C level
below 6.5%, and a recommends using a combination of available tests to determine an accurate
diagnosis for diabetes (Bergman et al., 2012). In a press release from adcouncil.org, the Centers
for Disease Control and Prevention and the American Diabetes Association report that more than
86 million Americans are pre-diabetic which suggests 15 to 30 percent of these individuals will
develop diabetes in five years if not treated. Many doctors and researchers are skeptical of the
ADA's unique guidelines and feel there is no need to diagnose otherwise healthy people with a
"disease" that is widely treatable by exercise and healthy eating (Bansal, 2015). While the
validity of a prediabetes diagnosis is widely debated by public health organizations and medical
professionals worldwide, the assignment of a name to the midrange to borderline levels might
encourage more individuals to take action in preventative care to reduce their chances of a final
diagnosis of diabetes. It begs the question if prediabetes is a viable condition or if it is a
healthcare marketing tool utilized by the ADA and CDC to promote preventative care in
Americans through lifestyle interventions.
Before examining the implications of prediabetes as a diagnosis, it is pertinent to compare the
various methods to test glucose levels in the blood to determine a diabetes diagnosis. Sacks

3. Running Head: PREDIABETES OR HEALTHCARE MARKETING 3
(2011) reports the three main tests used to diagnose diabetes as fasting plasma glucose level, oral
glucose tolerance test (OGTT), and A1C measurement. The first is the fasting plasma glucose
measurement which requires the patient to fast for at least eight hours before testing (Sacks,
2011). This test is widely used and accepted because it is inexpensive, accessible, and uses a
single sample; however, there are several disadvantages including the extended fasting time,
instability of the sample, and variation in glucose concentration due to sample source (Sacks,
2011). Furthermore, the factors above contribute to the inability to reproduce conclusive results
from this glucose test as it has been observed that there is a variance of approximately thirty
percent (Sacks, 2011). The next test, OGTT, is accepted by the ADA, WHO and International
Diabetes Federation (IDF) as an acceptable standard to diagnose diabetes (Sacks, 2011). This test
produces a sensitive measurement and can be an early predictor of glucose anomalies, but it is
time-consuming, inconvenient, expensive, and requires extensive preparation for the patient
(Sacks, 2011). The final form of testing is the Hemoglobin A1C test which has resounding
popularity due to the sample stability, accuracy of the test, reflection of long-term
concentrations, and low variability (Sacks, 2011). However, there are still disadvantages. There
is evidence that race may be a contributing factor to altered levels of A1C where Black and
Mexican Americans had higher values than White Americans (Sacks, 2011). There could be
other constraining factors that influence these results especially if differences in cultural
traditions regarding diet patterns are considered. These tests produce the baseline to determine
diabetes or prediabetes diagnosis. Bergman et al. (2012) report the standards established by the
ADA for a prediabetes diagnosis as an FPG result of 5.6-6.9 mmol/l or A1C level between 5.7%
and 6.4% with any number higher than those values resulting in a diabetes diagnosis. The WHO
does not recognize prediabetes as a valid diagnosis and asserts the diabetes threshold for the FPG

4. Running Head: PREDIABETES OR HEALTHCARE MARKETING 4
is 6.1 mmol/l and an A1C level of greater than 6.5% (Bergman et al., 2012). The discrepancies in
global agreement of adopting specific diagnostic criteria are not unheard of; however, the
concern for the ADA's adoption of the prediabetes diagnosis comes from a distrust of the
organization by the public due to the potential benefits for the pharmaceutical industry and lack
of support by endocrinologists of the criteria (Piller, 2019).
Charles Piller (2019) reports in Science Magazine that in 2007, the ADA began to recommend
the drug metformin as a treatment for prediabetes. However, Tuso (2014) says metformin and
drugs alike aid more in managing adverse side effects from prediabetes or diabetes than
reversing the diagnosis, which is the leading intuitive of the ADA and CDC's preventative
efforts. Specific lifestyle changes such as weight loss and moderate physical activity can reduce
the risk of the development of diabetes by 58%, and studies also show lifestyle modifications can
either delay or prevent the development of diabetes in patients who are classified as having
prediabetes for up to ten years (Tuso, 2014). Moreover, Healthy People 2020 suggests
"preventative care practices are essential to better health outcomes for people with diabetes."
Narayan (2016) also asserts that an emphasis on preventative care will help win the war on
diabetes. To promote preventative care, the CDC and ADA have endorsed tools to help the
general public determine their risk factors. DoIHavePrediabetes.org is a marketing campaign to
screen for risk factors for prediabetes. The American Council on Science and Health reports the
website boasts a short, simple quiz to assess an individual's risk factor for developing prediabetes
but lacks validity due to "a digital device's lack of finger-pricking capabilities."
Diabetes is one of the top ten leading causes of deaths in the United States and a significant
contributor to cardiovascular disease, the number one leading cause of death (CDC).
Preventative care is cited as a substantial risk reduction factor in the development of diabetes

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with weight loss lifestyle modifications for every 1 kg in weight decrease resulting in a 16% risk
reduction for developing diabetes (Bansal, 2015). The CDC and ADA's push to create a new
diagnosis for prediabetes might have the opposite impact than anticipated and create an apathetic
attitude toward prediabetes (ACSH Staff, 2016). Ann Albright, the director of the CDC's division
for diabetes, assures the development of risk assessment tests and other tools for prediabetes
diagnosis is to raise awareness and create a conversation between physicians and patients (Span,
2016). Dr. Victor Montori of the Mayo Clinic notes that diabetes is preventable but making
every healthy person a patient is not an effective method of prevention (Piller, 2019).
The prevalence of diabetes continues to increase, and the incidence level remains high even
with the introduction of the prediabetes diagnosis (Narayan, 2016). The ADA continues to
suggest drug interventions for prediabetes, most recently recommending weight loss drugs for
treatment (Piller, 2019). Evidence supports lifestyle modifications as the most effective form of
treatment for preventing diabetes which should be a general recommendation from doctors
anyways. Studies showed significant improvements in risk reduction when patients labeled pre-
diabetic reduce their weight by 7% and strive for 150 minutes of physical activity per week
(Tuso, 2014). The reliance on drug recommendations for weight loss by the ADA instead of
promotion of a balanced diet and moderate exercise for pre-diabetic patients is in the very least
concerning and continues to perpetuate a public distrust in public health agencies prioritizing big
pharma.
Healthy People 2020 estimates the cost of diabetes in the United States to be $245 billion.
Physicians and global health agencies alike reject the prediabetes diagnosis for the lack of
scientific evidence that the condition will progress to diabetes as the name suggests and the rest
of the population is not at risk of developing diabetes (Piller, 2019). Anyone who does not abide

6. Running Head: PREDIABETES OR HEALTHCARE MARKETING 6
by a balanced diet or does not get enough physical activity is at risk of becoming diabetic. The
American Diabetes Association has created dubious blood glucose or A1C diagnosis range for
prediabetes which only supports confusion in public surrounding the disease and induces higher
levels of anxiety that an individual will one day have diabetes. The CDC and ADA in
conjunction have successfully created diabetes prevention programs across the US which have
more than 90,000 enrollees (Span, 2016). However, the emphasis of these programs is to eat
healthily and exercise which is something Dr. Saeid Shahraz argues should be something doctors
recommend to everyone, even healthy people (Span, 2016). The adoption of the prediabetes
definition has done more harm than good because the public widely distrusts the ADA and
CDC's intentions to create a healthier population due to their reliance on fear to change public
behaviors and the recent promotion of certain drugs to help reduce the risk of prediabetes and
diabetes. Based on the implementation of campaigns advertising websites and programs
sponsored by the CDC and ADA to prevent prediabetes it seems the creation of the pre-diabetic
diagnosis has created more benefit for these agencies than promoting public confidence and
empowerment in their health.

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References
Ad Council. (n.d.). First of its kind PSA campaign targets the 86 million American adults with
prediabetes [press release]. Retrieved from https://www.adcouncil.org/News-
Events/Press-Releases/First-of-its-Kind-PSA-Campaign-Targets-the-86-Million-
American-Adults-with-Prediabetes
American Council on Science and Health Staff. (2016, February 3). CDC turning “prediabetes”
into a bogus diagnosis. Retrieved from https://www.acsh.org/news/2016/02/03/cdc-
turningprediabetes-bogus-diagnosis-9105
Bansal, N. (2015, March 15). Prediabetes diagnosis and treatment: a review. World Journal of
Diabetes, 6(2), 296-303.
Bergman, M., Buysschaert, M., Schwarz, P. E., Albright, A., Narayan, K. V., & Yach, D.
(2012). Diabetes prevention: global health policy and perspectives from the
ground. Diabetes management, 2(4), 309–321.
Centers for Disease Control and Prevention. (n.d.). Diabetes a major health problem. [PDF file].
Retrieved from https://www.cdc.gov/diabetes/ndep/pdfs/ppod-guide-diabetes-major-
health-problem.pdf
Healthy People 2020. (n.d.). Diabetes. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/diabetes
Narayan, V.K.M. (2016 May). Type 2 diabetes: why we are winning the battle but losing the
war?. Diabetes Care, 39, 653-663.
Piller, C. (2019, March 8). Dubious diagnosis. Science Magazine, 363(6431), 1026-1031.
Sacks D. B. (2011). A1C versus glucose testing: a comparison. Diabetes care, 34(2), 518–523.

8. Running Head: PREDIABETES OR HEALTHCARE MARKETING 8
Span, P. (2016, December 16). You’re “prediabetic”? join the club. The New York Times,
Retrieved from https://www.nytimes.com/2016/12/16/health/youre-prediabetic-join-the-
club.html
Tuso P. (2014). Prediabetes and lifestyle modification: time to prevent a preventable
disease. The Permanente journal, 18(3), 88–93.