The Lie That's Killing Us: Pre-Diabetes

My proposition is that recognizing pre-diabetes as "Stage 1" Type 2 diabetes will get millions more people to take action to stop their diabetes from progressing.
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Pre-diabetes is a lie. Pre-diabetes is Stage 1 diabetes. And I'm taking a stand now advocating that we call it what it is.

Pre-diabetes doesn't exist. And the lie we tell that it does does incredible harm. It stops the nearly 80 million Americans we say have it from making the lifestyle changes necessary to prevent advanced Type 2 diabetes. Pre-diabetes is in truth the first stage of diabetes.

My proposition is that recognizing pre-diabetes as "Stage 1" Type 2 diabetes will get millions more people to take action to stop their diabetes from progressing.

About 80 million people is roughly the populations of California, Texas and New York combined. The International Diabetes Federation reports that in 2011, 280 million people worldwide were glucose intolerant (pre-diabetic). In only 17 years, 398 million people will be.

We clearly need a new strategy. The 25-year campaign the American Diabetes Association has waged to raise awareness of diabetes and pre-diabetes and urge preventive and healthful behaviors has been sadly, and enormously, unsuccessful.

Pre-Diabetes Is Stage 1 Diabetes

Pre-diabetes literally says you don't have diabetes -- but you do. Your blood sugars are higher than normal, a defining characteristic of diabetes.

A study performed at Crittenton Hospital Medical Center in Detroit showed 36 percent of people with pre-diabetes already had coronary artery disease, similar to the 42 percent with Type 2 diabetes and strikingly higher than the 21 percent with normal blood sugars. Higher than normal glucose levels impact hypertension (high blood pressure) and lipids like cholesterol and triglycerides. Plus, most people with pre-diabetes show signs of retinopathy (eye damage), nephropathy (kidney damage) and neuropathy (nerve damage), all diabetes complications.

Lynda Sardeson, a certified diabetes educator and registered nurse, wrote to me in an email, "We began diagnosing pre-diabetes and put it in practice guidelines around 2004 to try and 'catch' those with diabetes earlier to prevent more complications."

Exactly: "To catch those with diabetes earlier..." So let's call pre-diabetes what it is: Stage 1 diabetes. Why? Because it is. Because health care providers need to take it seriously and not soft pedal it. Because policy makers must decrease the health care costs of diabetes now poised to bankrupt us. Costs have risen $70 billion in the past five years with no end in sight. Last year the U.S. spent $245 billion health care dollars on diabetes -- the total GDP of Israel.

And, because for patients, hearing you have Stage 1 diabetes, like hearing you have Stage 1 cancer, has power and hope in it. The power of alarm to motivate behavior change -- and the hope of remission if you do.

Four Stages of Type 2 Diabetes

Since Type 2 diabetes is progressive for most people, it can be characterized like cancer, chronic kidney disease and Parkinson's as having stages.

Stage 1 -- The body's ability to regulate blood sugar is impaired and blood sugar is higher than normal. One may already have signs of diabetes complications. Treatment includes maintaining healthy body weight, eating healthfully, being physically active and possibly adding medication. With proper treatment one may go into remission, or be able to prevent or delay moving to Stage 2.

Stage 2 -- The body's ability to produce and use insulin is further impaired than in Stage 1. Complications are often present, particularly those that affect the circulatory and nervous systems. Metabolic syndrome is common. Poor management leads to increased severity of complications and reduced life expectancy.

Stage 3 -- Patients exhibit several and/or severe diabetic complications including neuropathy, vision loss, foot ulcers, amputation, blindness, kidney disease and heart disease. Quality of life is reduced and lifespan is shortened. Hospitalizations may be frequent.

Stage 4 -- Death due to diabetes-related cause. Diabetes is the seventh leading cause of death in the U.S. Two-thirds of people die from heart disease or stroke.

Current Diagnosis Criteria

Clinically, you are diagnosed with "pre-diabetes" when your fasting blood sugar is between 100 (5.5 mmol/l) and 125 mg/dl (6.9 mmol/l). You are diagnosed with Type 2 diabetes when your blood sugar is 126 mg/dl (7 mmol/l) and higher. Who are we kidding when one point stands between pre-diabetes and diabetes on tests that often need to be taken more than once?

I'm not being coy about a name change. While Shakespeare's Juliet said, "What's in a name, that which we call a rose by any other name would smell as sweet." There's enormous leverage in a name to either motivate action or not.

Currently more than one-fourth of our nation's population are standing idly, waiting to board the train to Stage 2 Type 2 diabetes. There, many will suffer the life-crippling complications of diabetes and die prematurely, as people with Type 2 diabetes do every day. Diabetes kills more Americans than breast cancer and AIDS combined.

Low Awareness of Pre-Diabetes

Approximately 1 in 3 U.S. adults age 20 and older have pre-diabetes. Yet 89 percent are unaware of it, according to Doctor YanFeng Li, Division of Diabetes Translation, Centers for Disease Control and Prevention.

Dr. Li and her colleagues concluded in their study that the critical first step to encourage people with pre-diabetes to make healthy lifestyle changes to prevent Type 2 diabetes is improving awareness of pre-diabetes.

I disagree. I believe the first critical step is a name change and a change in our national conversation.

If you are a health care provider, tell your next patient with pre-diabetes that he has Stage 1 diabetes. See what happens. I'm thinking he'll look up and listen hard. Let him know he's at the fork in the road. "Good day, Mr. Gottlieb, I have some bad news and some good news. The bad news is you have Stage 1 Type 2 diabetes. If you do nothing now you are working your way toward Stage 2. However, the good news is together we can work at reversing it, so you may never go on to Stage 2. In the worst case scenario we may be able to delay it for years."

The Grinding Slowness of Change

The results of the Diabetes Prevention Program (DPP) , heralded as a landmark study, were published in 2002 yet little has changed. The DPP proved that with a modest weight loss, about 7 percent of body weight (for most people about 15 pounds) and 30 minutes of moderate activity five days a week, people with pre-diabetes reduced their chances of developing Type 2 diabetes by 58 percent. Participants over age 60 reduced their risk by 71 percent.

Newer research shows that by treating people with "pre-diabetes" more aggressively, with lifestyle changes and medication, they can further minimize their chances of, or further delay, getting Type 2 diabetes.

It's clear: We are failing miserably at awareness-raising, behavioral change efforts and containment of health costs, says diabetes advocate David Edelman, founder of In his post, "Diabetes Alert Day, Why Do Cancer & AIDS Get More Support Than Diabetes?" he writes, "Why is diabetes tucked into the closet, door closed, and safely ignored? How many millions of lives will we sacrifice and how many billions of dollars will we waste before we act? "

We're not setting any precedent changing the diagnosis of pre-diabetes to Stage 1. We renamed "juvenile diabetes" Type 1 diabetes because adults get Type 1 diabetes. We renamed "adult-onset diabetes" Type 2 diabetes because now children get Type 2 diabetes.

So I'm calling on health care professionals and the American Diabetes Association, the World Health Organization, the Centers for Disease Control and Prevention, the International Diabetes Federation and our legislators to do what they want people with "pre-diabetes" to do -- take action.

Almost 10 years ago we called out "pre-diabetes." Now call out what it is -- "Stage 1" Type 2 diabetes -- and halt the killing.

What do you think?

Are we disempowering people telling them they have pre-diabetes?

Would you do something different hearing you have Stage 1 diabetes than pre-diabetes?


Riva's new book, Diabetes Do's & How-To's, is available in print and Kindle, along with her other books, 50 Diabetes Myths That Can Ruin Your Life and the 50 Diabetes Truths That Can Save It and The ABCs Of Loving Yourself With Diabetes. Riva speaks to patients and health care providers about flourishing with diabetes. Visit her website

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