Fewer and fewer of us are deemed healthy it seems. We have “pre”-diabetes (also called glucose intolerance) and “pre”-hypertension. On the verge of osteoporosis, we have osteopenia, or thin bones that are “pre”-fracture. In the past decade, doctors have regularly redefined clinically desirable test results across a variety of biomarkers (blood sugar tests, blood pressure measurements, bone density scans). In doing so, they have created whole new medical categories characterized by the absence of physical symptoms and the presence of undesirable test results. More and more of us have become one of the “pre-bies.”

Visualization is courtesy of TheVisualMD.com

Is there a problem with this? Don’t we all believe in “pre”-vention? Shouldn’t we want, as patients, to be diagnosed and treated as early as possible? Shouldn’t we want our doctors to get ahead of our symptoms?

With an ever-growing array of tests—try escaping a doctor visit without blood-work or an imaging study of some kind—there are three “pre”-cautions to keep in mind as a patient. First, mild abnormalities in test results (all “pre” conditions fall into this category) are less likely to cause problems than severe abnormalities. The higher your blood pressure, the higher your risk of stroke. Second, the search for milder and milder elevations of blood sugar and blood pressure, and more modest thinning of bones to call abnormal, for instance, may raise new alarms, but shouldn’t define you as “sick.” Third, treatment for milder abnormalities is less likely to produce tangible benefits than treatment for more severe ones. For example, there’s no evidence that medication treatment for pre-hypertension or pre-diabetes reduces heart attack, stroke or risk of death at all.

Doctors like to prescribe medications (they’re less adept at offering behavioral counseling and non-pharmacological treatment, the relevant treatments for “pre-bies”). Medications can save lives in certain situations. Indeed the creation of “pre” conditions is a direct result of our medical successes. For example, we have many effective medications for symptomatic diabetes and severe hypertension. We should want to be treated when our blood pressure or blood sugar is high enough to put us at a real risk for having a life-threatening event. But medications save few lives if given to those (such as pre-bies) who are at low risk of dying or having any complications to begin with. Treatments are costly; they require return visits to the doctor; they require more lab tests.  And too often treatments have adverse effects—they make you tired or light-headed, or have you running to the bathroom; sometimes more serious effects can result like liver damage, or falling, or developing stomach ulcers. (Side effects never happen off to the side if they happen to you).

One benefit of the identifying “pre-bies” is that many (but not all) persons with pre-hypertension will in fact progress to hypertension if they do not change their eating and exercise habits. Ditto pre-diabetics. If and when these conditions develop, then they can be treated.  But remember: “pre-bies” do not have true medical diagnoses, they are pre-diagnosis.

We live in a medical world of over-diagnosis. Ruled by numbers that dictate the binary world of normal vs. abnormal, doctors label us. Your blood sugar was 99 (normal), but now it’s 101 (abnormal) and you’re suddenly a pre-bie, you are glucose intolerant. It’s disconcerting to be given a new diagnosis when you feel well. (This will undoubtedly get worse as we enter the era of widespread DNA testing when we’re all found to be carrying some risky genes). “Pre-bies” need to avoid viewing themselves as sick. “Pre-bies” need to understand the pros and cons of the reductionist goal of seeking better numbers through medication—and attempt behavioral changes to bring their test results into the “normal” range. As easy as it might be to accept a prescription once you’ve been given a medical name, it’s often safer to be skeptical, and decline. 

MD Stein

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