Monday, October 28, 2019

What is "pre-illness" and what can you do about it?

OK, so you have been told you have “pre-diabetes” or “pre-hypertension.” What does that really mean? What should you do about it?
“Pre-disease” is a relatively new concept, unheard of when I started practice, but being applied more and more. It simply means that you have some measurement that is abnormal but does not meet the established criteria for a diagnosis. A friend of mine once observed that “there are no healthy people, simply those who have not had enough tests,” and this concept of our fragility seems to be applied more and more. Commonly used labels I have come across, in addition to pre-diabetes and pre-hypertension (now more commonly described as “Stage 1 hypertension”), include dyslipidemia, osteopenia and pre-cancer. The rationale for applying these labels is that catching a disease early, in its “pre-“ stage, and treating it, will somehow help avoid serious problems down the road. The evidence that this is true is very limited.
The CDC recently claimed that 84 million Americans had pre-diabetes – an enormous number, and an enormous potential group of customers for the pharmaceutical industry. An article in the journal Diabetes Care in 2016, however, found that only about 2% of pre-diabetics went on annually to have overt diabetes. At least a third in whom no intervention was carried out reverted to completely normal blood sugars, and the rest remained with mildly elevated sugar values. A more recent study in the same journal looked at 3313 black adults and defined pre-diabetes as a fasting sugar between 100 and 125 (below 100 being normal). They found no increased risk of cardiovascular disease in those with mildly elevated sugars.
Hypertension was previously defined as a BP persistently over 140/90, but values of 130-139/80-89 are now called “Stage 1 hypertension,” and it is estimated that one third of American adults have this “condition.” There are many problems with this labelling. One is that there is increasing evidence that office or clinic BP measurements are not truly representative of our usual BP and are frequently not even measured accurately. Another is that there is to date no evidence that treating this with medication does more good than harm.
Another common “pre-condition” is osteopenia, a bone density below normal but not severe enough to be osteoporosis. Some estimates claim osteopenia affects about 43 million U.S. adults, mostly women. How important is this? A study of 5000 older women with osteopenia found that after 10 years, only 5% had gone on to develop osteoporosis. If you want to estimate your risk of fracture, and you know your actual bone density numbers, you can go to https://www.sheffield.ac.uk/FRAX/ and run the numbers. (If you are a U.S. Caucasian, go to https://www.sheffield.ac.uk/FRAX/tool.aspx?country=9)
What should you do if you have been told you have one of these “pre-diseases.” What I would NOT do is begin medication. You may want to take this as a kick in the rear to motivate you to make some healthy lifestyle changes. Losing a few pounds or beginning a regular exercise program will usually reduce your sugar. Exercise, a more vegetarian diet and cutting down on alcohol will drop your blood pressure. Weight-bearing exercise and a diet rich in Vitamin D and calcium (but not supplements) and stopping smoking will strengthen your bones. Note the common thread in all of these?
Equivocal cancers are a whole other subject, which I will get to in another post.
Happy exercising!

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