December 16, 2017
Doctor checking patient
Be Well

Are You Pre-Sick?

by John Swartzberg, M.D.  

Are too many Americans being diagnosed with “pre-diseases”? In recent years millions have gotten such a diagnosis, but the vast majority of people with the following conditions don’t know they have them:

Prehypertension. The CDC estimates that one-third of American adults (about 75 million) have this condition, defined as blood pressure levels between 120/80 and 140/90—that is, higher than normal, but not yet in the hypertension range. Another one-third of adults have full-blown hypertension. People with prehypertension are at elevated risk for stroke.

Prediabetes. Similarly, the CDC estimates that slightly more than one-third of adults (86 million) have fasting blood glucose levels between 100 and 125—higher than normal but below the diabetic range. Without lifestyle changes, 15 to 30 percent of them will develop type 2 diabetes within five years.

Dyslipidemia. That’s the medical term for undesirable blood levels of lipids—that is, cholesterol and triglycerides. Though not officially a “pre-disease,” dyslipidemia increases the risk of heart disease, including heart attacks. The CDC estimates that about one-third of adults have high LDL (“bad”) cholesterol.

Osteopenia. This is characterized by moderate bone loss, but not enough to be considered osteoporosis. It’s estimated that nearly half of women over age 50 and perhaps 30 percent of men over 50 have osteopenia of the hip, which puts them at elevated risk for hip fractures.

Keep in mind that the line between good health and disease is often blurry. The exact cutoffs for key markers—say, a fasting blood glucose level of 125 for diabetes—are derived from data on large populations, are somewhat arbitrary, and have been much debated. And now, instead of a line between good health and disease, we often have a large gray area called a pre-disease, with equally murky endpoints.

Does it make sense to tell so many people they are, in effect, pre-sick? Is it any wonder that some of them suspect this is largely a strategy by the pharmaceutical industry to sell more drugs? The biggest risk posed by pre-diseases is that they often progress to the full-fledged diseases, unless people take preventive steps. But some pre-diseases, like prediabetes, pose health risks themselves, albeit less than the diseases.

Despite the uncertainties, I believe it’s very worthwhile to call attention to pre-diseases, which should serve as a wake-up call. If you know your blood pressure is inching upward, you can take steps to control it—such as consuming less sodium and losing excess weight. The same is true with prediabetes, undesirable cholesterol readings, and to a lesser extent low bone mineral density.

Clearly, it’s far better to treat pre-diseases via lifestyle changes (notably diet and exercise) than to take medication with potential side effects. There’s good evidence, for instance, that an intensive lifestyle pro­­gram can help prevent diabetes in many people with prediabetes. Current guidelines for the treatment of dyslipidemia emphasize the importance of making lifestyle changes before starting statin therapy, though often this is not stressed enough to patients.

When lifestyle changes don’t help enough despite repeated efforts, then drugs may be an option, depending on the pre-disease. Statin therapy is a proven risk reducer in people with undesirable lipid levels and other coronary risk factors. Drug treatment for prediabetes and prehypertension should be limited to only certain groups. Despite drug industry marketing a decade ago, bone-building drugs are rarely prescribed for osteopenia.