The Lie That’s Killing Us: Pre-Diabetes


Pre-diabetes is a lie. Pre-diabetes is Stage 1 diabetes. And I’m taking a stand now advocating that we call it what it is.

Pre-diabetes doesn’t exist. And the lie we tell that it does does incredible harm. It stops the nearly 80 million Americans we say have it from making the lifestyle changes necessary to prevent advanced Type 2 diabetes. Pre-diabetes is in truth the first stage of diabetes.

My proposition is that recognizing pre-diabetes as “Stage 1” Type 2 diabetes will get millions more people to take action to stop their diabetes from progressing.

About 80 million people is roughly the populations of California, Texas and New York combined. The International Diabetes Federation reports that in 2011, 280 million people worldwide were glucose intolerant (pre-diabetic). In only 17 years, 398 million people will be.

We clearly need a new strategy. The 25-year campaign the American Diabetes Association has waged to raise awareness of diabetes and pre-diabetes and urge preventive and healthful behaviors has been sadly, and enormously, unsuccessful. 


Pre-Diabetes Is Stage 1 Diabetes

Pre-diabetes literally says you don’t have diabetes — but you do. Your blood sugars are higher than normal, a defining characteristic of diabetes.

study performed at Crittenton Hospital Medical Center in Detroit showed 36 percent of people with pre-diabetes already had coronary artery disease, similar to the 42 percent with Type 2 diabetes and strikingly higher than the 21 percent with normal blood sugars. Higher than normal glucose levels impact hypertension (high blood pressure) and lipids like cholesterol and triglycerides. Plus, most people with pre-diabetes show signs of retinopathy (eye damage), nephropathy (kidney damage) and neuropathy (nerve damage), all diabetes complications.

Lynda Sardeson, a certified diabetes educator and registered nurse, wrote to me in an email, “We began diagnosing pre-diabetes and put it in practice guidelines around 2004 to try and ‘catch’ those with diabetes earlier to prevent more complications.”

Exactly: “To catch those with diabetes earlier…” So let’s call pre-diabetes what it is: Stage 1 diabetes. Why? Because it is. Because health care providers need to take it seriously and not soft pedal it. Because policy makers must decrease the health care costs of diabetes now poised to bankrupt us. Costs have risen $70 billion in the past five years with no end in sight. Last year the U.S. spent $245 billion health care dollars on diabetes — the total GDP of Israel.

And, because for patients, hearing you have Stage 1 diabetes, like hearing you have Stage 1 cancer, has power and hope in it. The power of alarm to motivate behavior change — and the hope of remission if you do.


Four Stages of Type 2 Diabetes

Since Type 2 diabetes is progressive for most people, it can be characterized like cancer, chronic kidney disease and Parkinson’s as having stages.

Stage 1 — The body’s ability to regulate blood sugar is impaired and blood sugar is higher than normal. One may already have signs of diabetes complications. Treatment includes maintaining healthy body weight, eating healthfully, being physically active and possibly adding medication. With proper treatment one may go into remission, or be able to prevent or delay moving to Stage 2. 

Stage 2 — The body’s ability to produce and use insulin is further impaired than in Stage 1.Complications are often present, particularly those that affect the circulatory and nervous systems. Metabolic syndrome is common. Poor management leads to increased severity of complications and reduced life expectancy.

Stage 3 — Patients exhibit several and/or severe diabetic complications including neuropathy, vision loss, foot ulcers, amputation, blindness, kidney disease and heart disease. Quality of life is reduced and lifespan is shortened. Hospitalizations may be frequent.

Stage 4 — Death due to diabetes-related cause. Diabetes is the seventh leading cause of death in the U.S. Two-thirds of people die from heart disease or stroke.


Current Diagnosis Criteria

Clinically, you are diagnosed with “pre-diabetes” when your fasting blood sugar is between 100 (5.5 mmol/l) and 125 mg/dl (6.9 mmol/l). You are diagnosed with Type 2 diabetes when your blood sugar is 126 mg/dl (7 mmol/l) and higher. Who are we kidding when one point stands between pre-diabetes and diabetes on tests that often need to be taken more than once? 

I’m not being coy about a name change. While Shakespeare’s Juliet said, “What’s in a name, that which we call a rose by any other name would smell as sweet.” There’s enormous leverage in a name to either motivate action or not.

Currently more than one-fourth of our nation’s population are standing idly, waiting to board the train to Stage 2 Type 2 diabetes. There, many will suffer the life-crippling complications of diabetes and die prematurely, as people with Type 2 diabetes do every day. Diabetes kills more Americans than breast cancer and AIDS combined.


Low Awareness of Pre-Diabetes

Approximately 1 in 3 U.S. adults age 20 and older have pre-diabetes. Yet 89 percent are unaware of it, according to Doctor YanFeng Li, Division of Diabetes Translation, Centers for Disease Control and Prevention. 

Dr. Li and her colleagues concluded in their study that the critical first step to encourage people with pre-diabetes to make healthy lifestyle changes to prevent Type 2 diabetes is improving awareness of pre-diabetes.

I disagree. I believe the first critical step is a name change and a change in our national conversation.

If you are a health care provider, tell your next patient with pre-diabetes that he has Stage 1 diabetes. See what happens. I’m thinking he’ll look up and listen hard. Let him know he’s at the fork in the road. “Good day, Mr. Gottlieb, I have some bad news and some good news. The bad news is you have Stage 1 Type 2 diabetes. If you do nothing now you are working your way toward Stage 2. However, the good news is together we can work at reversing it, so you may never go on to Stage 2. In the worst case scenario we may be able to delay it for years.” 


The Grinding Slowness of Change

The results of the Diabetes Prevention Program (DPP) , heralded as a landmark study, were published in 2002 yet little has changed. The DPP proved that with a modest weight loss, about 7 percent of body weight (for most people about 15 pounds) and 30 minutes of moderate activity five days a week, people with pre-diabetes reduced their chances of developing Type 2 diabetes by 58 percent. Participants over age 60 reduced their risk by 71 percent. 

Newer research shows that by treating people with “pre-diabetes” more aggressively, with lifestyle changes and medication, they can further minimize their chances of, or further delay, getting Type 2 diabetes. 

It’s clear: We are failing miserably at awareness-raising, behavioral change efforts and containment of health costs, says diabetes advocate David Edelman, founder of In his post, “Diabetes Alert Day, Why Do Cancer & AIDS Get More Support Than Diabetes?” he writes, “Why is diabetes tucked into the closet, door closed, and safely ignored? How many millions of lives will we sacrifice and how many billions of dollars will we waste before we act? “

We’re not setting any precedent changing the diagnosis of pre-diabetes to Stage 1. We renamed “juvenile diabetes” Type 1 diabetes because adults get Type 1 diabetes. We renamed “adult-onset diabetes” Type 2 diabetes because now children get Type 2 diabetes.

So I’m calling on health care professionals and the American Diabetes Association, the World Health Organization, the Centers for Disease Control and Prevention, the International Diabetes Federation and our legislators to do what they want people with “pre-diabetes” to do — take action.

Almost 10 years ago we called out “pre-diabetes.” Now call out what it is — “Stage 1” Type 2 diabetes — and halt the killing.

What do you think?

Are we disempowering people telling them they have pre-diabetes?

Would you do something different hearing you have Stage 1 diabetes than pre-diabetes? 

Originally published in The Huffington Post.

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8 years ago

Hummm, interesting, and life threatening at the same time. I think I am one of those early adopters. I was happy, healthy, ultra fit, then horribly exhausted for 12 years with no diagnosis, 25 Drs. Then 4 months ago began low carb high fat eating and felt glorious, quickly. Then I reviewed my 12 years of medical records and noticed borderline-ish fasting glucose, AIC 5.7, high BP, high lipids, expanding waistline 42+. So then I google insulin intolerance and end up at pre-diabetes. My Dr says no no not so fast like I’m not there yet, I say see ya… Read more »

Mary Dexter
Mary Dexter
9 years ago

I agree that prediabetes is a misnomer. However, your solution ignores those who are neither Type 1 nor Type 2. Before prediabetes became as well known, I was told my blood sugar was 126 but not to worry.  Years later I was initially diagnosed Type 2, because I was 48, then rediagnosed with LADA with GAD antibodies. Shakespeare was right: ” A rose by any other name….”  The problem is hyperglycemia.   People need to be able to test their blood sugar and interpret the results.  And if it’s too high, they need to know how to bring it down safely and quickly.  Too… Read more »

9 years ago

Your article makes a great point and recommendation. Even saying pre diabetes would scare me silly, and not sure why it doesn’t to others!

But Clare is so right. It is the advent of the low fat nonsense which has led us to this point. We need to stop fluffing around with low GI carbs and recommend a change to LCHF, low carb high fat. It is the way for all diabetics to be healthy, and for people who are metabolically challenged to lose weight! 

9 years ago

Clare I agree, the way diabetes is treated today could be vastly improved with simple dietary changes and yet nobody presents that. Riva your stated point was that pre diabetes is a misnomer from what I read. The more important point to me is to fix the current “cure” not the name we put on it. But then you are promoting your book I guess. I am a lay person but I know enough to realize that what dieticians spout about whole grains and low fat is NOT the way to treat insulin spikes. It would be nice to just have… Read more »

Riva Greenberg
9 years ago

Clare, thank you for your comment, but that wasn’t the point of this article. I agree with you that our over consumption of carbs, makes and keeps us ill. This point, and what to do about our nutrition, is well covered in my recent book, “Diabetes Do’s & How-To’s.”  The point of this article is that we need to take pre-diabetes seriously to help the millions upon millions of people from advancing to full blown Type 2, and this name change to Stage 1 Type 2 diabetes – which shifts our perception of pre-diabetes’ seriousness – is a good place to… Read more »

9 years ago

You missed the most important point. Thirty plus years ago the USA led the world in demanding people eat less fat and more carbohydrates. Thirty plus years ago the USA made a serious, some would call it deadly error, and have refused ever since, even when the proof is right there in front of their eyes – that carbohydrates and NOT saturated fats cause insulin/glucose to spike – and now we have a world wide epidemic of diabesity!   Sure change the name, but also change the diet accordingly. Lower carbs equates to lower sugar spikes which equates to lower insulin… Read more »

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