Within the first 5 minutes of comedian Kevin James' comedy special Irregardless, he recounts a conversation he had with his doctor during a routine appointment. It went something like this:
Doctor: Everything looks really good. I do want to let you know though, you are prediabetic.
James: [Chuckles] Who isn't?
James: Do I have diabetes?
Doctor: No.
James: But I could get diabetes?
Doctor: Yes.
[There's a brief pause as James thinks about this.]
James: Do you have diabetes?
Doctor: No.
James: But could you get diabetes?
Doctor: I guess so.
James: Let me tell you something, you're prediabetic.
In this bit, James suggests that medicalization has gone too far, and I tend to agree with him. However, medicalization isn't inherently bad; it's simply the process by which human conditions that weren't previously considered to be pathological come to be defined as medical conditions and treated as such. Examples include halitosis, obesity, infertility, impotence, menopause, alcoholism, and grief.
As it turns out, the boundaries between health and disease are a little blurry. Therefore, sociologists developed the concept of medicalization in the 1970s. They wanted to study how something people once considered to be a normal part of life came to be viewed as a medical condition warranting medical intervention. Researchers Wieteke van Dijk, PhD, et al. explain, "Society's norms and values develop at a continual pace, influencing all of us in our perception of health, [and] what constitutes a medical problem." However, where to draw the line between what's considered normal and what's a medical problem is often rife with controversy.
For instance, when is a fasting glucose level considered "elevated"? If a patient has a fasting glucose level of 105 mg/dL, do they have prediabetes? According to the World Health Organization (WHO), the answer is "no," but clinicians following the American Diabetes Association (ADA) criteria would likely say "yes." That's because diagnostic criteria differ. The ADA "defines prediabetes as a fasting glucose of 100–125 mg/dL and/or an A1C of 5.7% to 6.4%." The WHO, on the other hand, "defines prediabetes using a narrower fasting glucose range of 110–125 mg/dL" and does not use A1C.
The difference between these two organizations' diagnostic criteria matters because it drastically affects how many people are told they have prediabetes. According to a research paper published in 2020, the prevalence of prediabetes based on ADA criteria was roughly double the prevalence of prediabetes based on WHO criteria. More specifically, "Out of 8844 individuals, prediabetes was identified in 3492 individuals [...] according to ADA and 1382 individuals [...] according to WHO criteria."
If I was Kevin James and my healthcare provider told me I had prediabetes, my next question would be, "What are the chances that prediabetes will progress to diabetes?" According to the CDC, "Without taking action, many people with prediabetes could develop type 2 diabetes within 5 years." However, this ominous warning doesn't actually answer the question. How many is "many"? For far too long, these kinds of ambiguous, ominous claims were pretty much all we had to go on.
Fortunately, further research has helped elucidate the lifetime risk of developing type 2 diabetes for adults who have been diagnosed with prediabetes. Moreover, it indicates that the prediabetes threshold matters greatly when it comes to identifying those at high risk of type 2 diabetes. For 45-year-olds with ADA-defined prediabetes, the 10-year risk of diabetes was 14.2% for women and 9.2% for men. For 45-year-olds with WHO-defined prediabetes, the 10-year risk of diabetes was 23.2% for women and 24.6% for men.
This study suggests that the ADA prediabetes diagnostic criteria cast far too wide a net. Millions of Americans are told they are at risk for diabetes when in fact, the vast majority of them will never develop diabetes. Unfortunately, this kind of overdiagnosis and perceived fear-mongering can erode people's trust in the healthcare system.
Kevin James expands on this from the patient perspective. He says, "What's with the pre-? That's how this world operates. Pre-. Fear. You might. Almost. You don't know. [...] Everything's fear." Some may argue that a little dose of fear might motivate people to make healthier lifestyle choices. However, as clinicians, we should not resort to such tactics. Rather, it's our duty to provide patients with the most accurate information possible.
In the U.S., the threshold for what constitutes a medical condition and therefore necessitates medical treatment has been continuously lowered. Identifying this trend and simultaneously recognizing that other developed countries are resisting it are the first steps towards reevaluating our current practices.
Shannon Casey, PA-C, is a physician assistant and former assistant teaching professor in the Department of Family Medicine at the University of Washington. She writes at The Medical Atlas.
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