Comment by nradov | Hacker News Reader

Comment by nradov | Hacker News Reader

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If you're going to try an appeal to authority, then at least come up with a plausible authority instead of some random statistician who likely doesn't know the basics of physiology. The first thing you need to understand is that normal ≠ healthy. For example, a resting heart rate of up to 100 bpm is considered "normal" in the sense that it doesn't require urgent medical intervention. But of course anything over 60 bpm for an adult usually indicates some underlying pathology with a risk of premature morbidity and mortality.

The essence of type 2 diabetes is insulin resistance. Like many medical conditions it exists on a spectrum. The specific HbA1c thresholds of 5.7% for pre-diabetes and 6.5% for diabetes are inherently arbitrary and serve mainly to make communication easier. But there is a clear correlation between elevated HbA1c levels and higher all-cause mortality.

https://doi.org/10.1136/bmjopen-2017-015949

Also note that HbA1c tests aren't perfect for diagnosing type 2 diabetes and can have false positives or false negatives. If there is reason to suspect diabetes then it would be wise to conduct additional tests to get a better understanding of the patient's metabolic condition.

https://peterattiamd.com/ama15/

> Also note that HbA1c tests aren't perfect for diagnosing type 2 diabetes and can > have false positives or false negatives.

When we do workups on pts suspected of diabetes, we use the following criteria.

- Iron deficiency anemia workup to confirm accuracy of HbA1C

- HbA1C ≥6.5%

- FPG ≥126mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least eight hours

- Two-hour plasma glucose ≥200mg/dL (11.1 mmol/L) during an oral glucose tolerance test

- In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200mg/dL (11.1 mmol/L)

I would like to redo the diagnostic criteria to include their BMI.

Excellent. Thanks.

Is an A1C level sufficient, all by itself, sufficient to classify them as "pre-diabetic" or are other symptoms required? Or is that even a thing?

Usually, yes.

However, some PCPs / endo will order up A1c as well as glucose challenge, depending on certain factors (eg, family history, BMI, symptoms). If I were you, order up the following:

- A1C - 12 hour Fasting blood glucose levels - Two-hour glucose tolerance test: this test will measure blood glucose levels before and after ingestion of 75 g of glucose solution (if the results show blood levels that fall between 140 mg/dL to 199 mg/dL, it is diagnostic of prediabetes. - A random plasma glucose test

Personally, if you have a family history of diabetes/obesity, you should get checked often. Some providers have been writing rx's of GLP-1's to aid in weight loss, which reduces the risk of developing T2DM.

> some random statistician who likely doesn't know the basics of physiology.

since you know nothing about him, that's hardly called for. I could doxx him but he didn't consent to that. And he said his doctor thanked him for it.

And you have fuzzed the difference between "a disease" and "something to watch for." If ~50% of the US population needs to be watched, the doctor learns nothing by having a label put on their HbA1c level. The word added nothing to their understanding.

> If there is reason to suspect diabetes then it would be wise to conduct additional tests to get a better understanding of the patient's metabolic condition.

And finally, you just confirmed what I said. It's not "a disease" -- it's a risk factor. Like smoking, drinking, obesity, or sedentariness.

The more everyone objects without any logical argument, the more it's confirmed:

"if that biomarker, all by itself, predicts type 2 diabetes better than random chance, in the absence of any other risk factor, we're entitled to call it a disease."

Labeling insulin resistance as a "risk factor" is correct only in a narrow, technical sense. That's not helpful for patients and clinicians who need to make treatment decisions in the real world. The terminology is irrelevant. Instead of getting hung up on semantics you need to spend some time learning the basics of human metabolism and the endocrine system.

Insulin resistance is a risk factor in the same way that a growing malignant tumor is a risk factor: unless you expect to die soon from something else you should take urgent measures to fix it. While a HbA1c test isn't perfect, it's pretty good as a cheap and easy initial screening for insulin resistance. If you want to believe that it's some kind of "scam" then I don't know how to help you.

The average US person today has at least some level of metabolic problems. Playing games with statistics won't change that reality or the negative long-term outcomes.

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