Speaking to Patients About Diabetes Risk: Is Terminology Important?

It is estimated that 79 million people in the United States (35% of adults ≥ 20 years of age and 50% of adults ≥ 65 years of age) have mild degrees of hyperglycemia and are thereby at risk for developing type 2 diabetes.1 Scientific jargon such as “impaired glucose tolerance” (IGT), “impaired fasting glucose” (IFG), and “elevated A1C” may be too technical or cumbersome to use with most patients. Accordingly, preferred terminologies such as “prediabetes” and “at high risk for diabetes” have entered the clinical lexicon and are felt to be simple enough to be understood by the average patient and also sufficiently motivating to encourage lifestyle change to prevent further deterioration to type 2 diabetes. However, there is debate in the literature regarding which term is most suitable to describe this stage in the development of diabetes. In 2009, the International Expert Committee criticized the term “prediabetes” because it suggests unequivocal progression to diabetes—not an inevitable occurrence2—and advocated for use of the “high risk” terminology instead. The American Diabetes Association, however, has continued to use “prediabetes,” considering it an appropriate description of this at-risk category.3 Other groups, including the World Health Organization and the International Diabetes Federation, have been using different terms for increased diabetes risk, such as “intermediate hyperglycemia,” as well as the more technical IGT and IFG.4,5 However, those descriptors are not routinely used by practitioners in the United States. The American Association of Clinical Endocrinologists preferred “prediabetes” in its 2011 guidelines.6 Prediabetes is usually an asymptomatic state. However, it has been associated with certain morbidities, including early stages of neuropathy and macrovascular disease.7 For health care providers (HCPs), recognition of this stage is essential because it provides opportunities for patient education about the importance of initiating evidencebased interventions to reduce the risk of diabetes and, potentially, decrease the risk of complications.7 Prediabetes, if not treated, indicates an early 5–10% risk per year of progression to diabetes;8 the risk may approach up to 50% in 5 years.9 Lifestyle interventions and certain pharmacological agents have been shown to delay or prevent the development of diabetes in individuals with prediabetes.10–12 Regular aerobic exercise and diet modification leading to weight loss resulted in a 58% reduction in the incidence of diabetes, whereas treatment with metformin was associated with a 31% reduction over a 3-year period.10 The effects of lifestyle change appear to be sustained for up to a decade,13 and both lifestyle and metformin have been demonstrated to be cost-effective.14,15 Unfortunately, data from the 2005–2006 National Health and Nutrition Examination Survey revealed that < 10% of patients with prediabetes documented by laboratory testing self-reported that they were aware of their condition.16 Furthermore, the survey also revealed that only one-third of these patients received a recommendation from their HCP regarding lifestyle interventions within the year preceding the survey.16 Clearly, we need to develop better strategies for communicating diabetes risks to our patients to empower them to enact lifestyle measures to improve their health. The purpose of this preliminary study is to assess which of the two currently used terms for diabetes risk (“prediabetes” vs. “at high risk for diabetes”) has a more profound impact on patients’ insight into the risk factor and on their subsequent willingness and enthusiasm to adopt required lifestyle modifications. Knowledge about patients’ understanding of diabetes terminology may assist practitioners in communicating more effectively with patients.