The Potential of Prevention Against Chronic Diseases
America’s metabolism is broken, and doctors have a new strategy: diagnose patients before they become patients.
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Produced in partnership with PublicSource, a nonprofit media organization delivering in-depth and investigative reporting to serve the Pittsburgh region at publicsource.org.
Katelyn, with the help of her husband Tony, is working to make lifestyle changes to prevent the onset of diabetes and set a good example for their children, Vienna, 5, and John, 2. During her last pregnancy, Katelyn was diagnosed with gestational diabetes.
When Katelyn went to see Dr. Poornima Rao shortly after her second child was born, she was prepared to hear the worst.
During her pregnancy, she was diagnosed with gestational diabetes and one of the doctors overseeing her care told her she would probably be diabetic for the rest of her life.
“I knew it would be something I would have to deal with at some point in my life,” she remembers thinking. Her family has a history of diabetes. “But I expected [age] 50 or 60, not 29.”
Katelyn, now 32, went to Rao after her pregnancy to find out what the rest of her life would be like with diabetes.
But Rao, an endocrinologist at the Allegheny Health Network Center for Diabetes and Endocrine Health, had surprising news: Katelyn’s test results didn’t show full-blown diabetes.
Her blood sugar fell just below that level. Instead she was diagnosed with prediabetes.
There was hope.
About 70 percent of people diagnosed with prediabetes go on to develop diabetes. And whether or not Katelyn’s condition did progress would largely depend on what choices she made going forward.
Dr. Esa Davis examines William Miller Jr. at UPMC Montefiore Hospital in Oakland and keeps tabs on what he is eating.
The rise of predisease
The concept of “prediabetes,” now a decade old, is the latest in a recent trend of diagnosing prediseases to delay the onset of chronic diseases. In 1994, the term osteopenia was coined to describe patients who could develop osteoporosis. And in 2003, the diagnosis of prehypertension was given to patients with blood pressure just below full-blown hypertension.
The idea behind these early detection diagnoses is that if patients know early enough that they are at risk, they and their doctors can intervene before full disease hits. This early detection could not only help improve lives but also prevent patients from developing multiple chronic diseases.
Chronic diseases, such as diabetes and hypertension, account for a huge portion of the bloated healthcare spending in the United States. The Centers for Disease Control and Prevention has written that treatment of chronic diseases has to change if the country will ever get costs under control. For every dollar spent, 75 cents went towards treating patients with chronic disease, according to the CDC.
In Pennsylvania, there are 7.7 million people with chronic diseases; they are expected to cost the state $1.7 trillion over 15 years, according to the Partnership to Fight Chronic Disease, an international nonprofit committed to raising awareness about preventable chronic diseases.
Hypertension, which can lead to heart disease and strokes, plays a role in both of those — the first and fourth most common ways people die in Pennsylvania. And diabetes is the sixth leading cause of death.
In Allegheny County, located in the so-called “Diabetes Belt,” which stretches from the South through Appalachia, the problem is even more severe. The county has higher rates of heart disease, diabetes and strokes than the state and the nation.
The “predisease” diagnoses have not come without controversy. Some medical experts worry these new terms are pathologizing otherwise healthy people. Many of the people diagnosed with prediseases, they argue, will never develop the actual diseases.
“While it has the potential to help some, it always has a hidden danger: overdiagnosis — the detection of abnormalities that are not destined to ever bother us,” writes Dr. Gilbert Welch in the book “Overdiagnosed: Making people sick in the pursuit of health.”
Unnecessary diagnoses for those who may never develop the disease, critics such as Welch argue, could lead to unnecessary stress and stigma and will be used by the pharmaceutical industry to sell drugs to otherwise healthy people. It could actually increase the demands on healthcare workers. It has “huge workload implications for both primary care and community services,” wrote a group of researchers in BMJ (formerly called the British Medical Journal) in 2015. They argued that it was speculation whether these prevention strategies could save money in the long run.
Anthony Viera, the chair of the Department of Community and Family Medicine at the Duke University School of Medicine, codified the rules for when doctors should treat prediseases in a 2011 journal article: when the benefits of treating individuals are not outweighed by any larger harm at the population level.
For example, a group of researchers in Barcelona in 2008 found that a particular treatment for preosteoporosis prevented some patients from developing osteoporosis. But the overall benefit from doing the interventions was probably not worth it. “In other words,” they wrote, “up to 270 women with preosteoporosis might need to be treated with drugs for three years so that one of them could avoid a single vertebral fracture.”
But the primary treatment for prediabetes and prehypertension are lifestyle changes such as patients eating healthier and exercising more, rather than taking medications. These activities don’t have much of a downside, so diagnosing these prediseases has become a priority for many healthcare workers in Pittsburgh and beyond.
Dr. Raghu Tadikamalla oversees the hypertension program at West Penn Hospital. He says the problem isn’t overdiagnosing healthy people but normalizing unhealthy behavior. A typical American life right now might include going to work, sitting at a desk for eight hours, going home and watching TV and eating lots of processed foods, he says. As a result, Tadikamalla says, 90 percent of Americans will be diagnosed with hypertension at some point in their lives.
“We have normalized disease,” he says. “For many years, people thought it was natural to develop hypertension as we age … But we’ve begun to realize that’s not true.”
He pointed to a study of two Native American tribes in the Brazilian rainforest: one was exposed to Western food and one wasn’t. The tribe without exposure showed the same blood pressure levels at the age of 60 as when the tribe members were teenagers. The tribe that received Western food aid saw their blood pressure rise.
“We’re beginning to realize this increase of blood pressure over time that occurs in the U.S. — although it has become what is expected, it’s not normal,” he says.
Lifestyle changes such as eating healthier and exercising more can combat prediabetes and prehypertension. Take our Wellness Quiz to find out how you are doing.