Downloaded from http://science.sciencemag.

org/ on March 11, 2019

Published by AAAS
FEATURES

1026
 NEWS

DUBIOUS DIAGNOSIS
A war on “prediabetes” has created millions of new patients
and a tempting opportunity for pharma. But how real is the condition?

By Charles Piller;

T
he most common chronic disease diabetes has come at a cost. When told they
after obesity, afflicting 84 million Illustrations by Stephan Schmitz have the condition, many people face psycho-
Americans and more than 1 billion logical and financial burdens trying to ad-
people worldwide, was born as a dress it. ADA, CDC, and other groups have
public relations catchphrase. In Kahn, who left ADA in 2009 and is now at spent billions of dollars on research, educa-
2001, the PR chief of the American the University of North Carolina in Chapel tion, and health improvement programs—

Downloaded from http://science.sciencemag.org/ on March 11, 2019

Diabetes Association (ADA) ap- Hill. The World Health Organization (WHO) generally focused on weight loss and
proached Richard Kahn, then the in Geneva, Switzerland, and other medi- exercise—that have generated lackluster re-
group’s chief scientific and medical cal authorities have rejected prediabetes as sults, according to critics. Kahn makes the
officer, for help with a vexing problem, Kahn a diagnostic category because they are not point with rhetorical bluntness: Spending
recalls. ADA needed a pitch to persuade convinced that it routinely leads to diabetes vast sums of public money on such preven-
complacent doctors and the public to take or that existing treatments do much good. tion programs “has nearly the same effect
seriously a slight elevation in blood glucose, John Yudkin, a diabetes researcher and as burning it in a fire … overall, [it’s] a ter-
which might signal a heightened risk of type 2 emeritus professor of medicine at University rible waste of money.”
diabetes. Raising the alarm wasn’t easy, given College London, describes the ominous warn- To lower blood sugar, ADA has increas-
the condition’s abstruse name, impaired glu- ings about prediabetes from ADA and CDC ingly advocated more aggressive measures,
cose tolerance, and lack of symptoms. as “scaremongering.” such as prescription drugs—a push that has
Kahn invited half a dozen diabetes thought Yet ADA, a nonprofit that funds research, opened it to charges of conflicts of interest.
leaders to brainstorm at a National Institutes issues treatment standards, and raises pub- Science found that the group and its experts
of Health cafeteria in Bethesda, Maryland. lic awareness, has gradually broadened its who promote aggressive treatment of pre-
Surrounded by hungry federal employees, definition of prediabetes to encompass more diabetes accept large amounts of funding
many enjoying the kinds of fatty foods and people. “The public needs to know that right from diabetes drugmakers. So far, no drugs
sugary drinks tied to the diabetes epidemic, now, in the United States … one out of three have been approved specifically for pre-
they landed on a then–little-used term that may have some aspect of glucose abnor- diabetes, meaning that doctors are limited to
seemed sure to scare patients and doctors mality,” says William Cefalu, ADA’s current prescribing diabetes drugs or other medica-
into action: prediabetes. chief scientific and medical officer. “A great tions “off label” to treat the condition. But
“We went back to the ADA office right after percentage … particularly in select ethnic drug companies are testing dozens of drugs
lunch and started the change. Within a rela- groups, may have an increased chance, or a aimed at prediabetes in hopes of tapping a
tively short period of time we … eliminated higher rate of progressing [to diabetes].” potential worldwide market of hundreds of
‘impaired fasting glucose’ and ‘impaired glu- CDC has followed ADA’s lead, because millions of people.
cose tolerance’ and substituted ‘prediabetes’ “they set the primary standards of care in Given the avalanche of questionable
in all of our literature,” Kahn says. Soon, the the U.S.,” Albright wrote in a statement to spending and the wave of anxiety it has un-
term was enshrined in the Arlington, Vir- Science. (Albright declined interview re- leashed, Kahn now says he rues the day he
ginia, group’s standards of care—widely re- quests, and CDC would not permit Edward helped promote the term prediabetes, calling
garded as the bible of diabetes. ADA and the Gregg, Albright’s top epidemiologist, to it “a big mistake.”
Centers for Disease Control and Prevention comment for this story.) In the past, Albright
(CDC) in Atlanta declared war against pre- and CDC have said repeatedly that 15% to ACCIDENTAL AILMENT
diabetes, with CDC diabetes prevention chief 30% of untreated prediabetes patients prog- ADA’s current definition of prediabetes was
Ann Albright, an ADA board member from ress to diabetes within 5 years—a claim that born in 2009, after the group, along with
2005 to 2009, leading the charge. The two hospitals, professional organizations, and the European Association for the Study
groups labeled prediabetes a first step on the local and state health departments have of Diabetes (EASD) and the International
road to diabetes, which can lead to amputa- embraced and publicized. She backed away Diabetes Federation (IDF), convened an
tions, blindness, and heart attacks. from that number in response to a ques- expert committee to review research on a
In medicine, prevention is usually an tion from Science, saying, “We no longer diagnostic blood sugar test, A1c. It improves
unalloyed good. But in this case, other dia- use that statement to characterize risk.” on prior tests because it requires no fasting.
betes specialists argue, medical and epidemio- Indeed, CDC’s own data show progression Hemoglobin A1c is a form of the red blood
logical data give weak support, at most, for from prediabetes to diabetes at less than 2% cell protein bound to glucose; its level in-
increasingly dire prediabetes admonitions. per year, or less than 10% in 5 years. (Other dicates a person’s average blood sugar over
“Nobody really thought at the time, how studies show even slower rates.) the preceding 3 months. The expert commit-
‘pre’ is prediabetes for all these people?” says The push to diagnose and treat pre- tee urged that people with A1c readings of

SCIENCE sciencemag.org 8 MARCH 2019 • VOL 363 ISSUE 6431 1027

Published by AAAS
 NEWS | F E AT U R E S

6% or higher should be considered for pre- few months gave Yuan empathy for her own Several companies target prediabetes
ventive interventions. But it unanimously patients who don’t take medicines as pre- patients for sales of continuous glucose
rejected the term prediabetes, saying it scribed. “On random days, I would get these monitors that attach to the body and trans-
implies that prediabetic patients eventually horrible side effects and feel really sick,” she mit data to smartphones. Market analysts
will get diabetes and everyone else won’t— says. Even on good days, the diagnosis added say makers of the devices—which can cost
“neither of which is the case.” a tinge of anxiety to her life. thousands of dollars annually—could add
ADA went in the opposite direction. It kept In interviews and public statements over 25 million customers in the next 12 years in
the term and ratcheted down its prediabetes many years, Albright has suggested such the United States alone, with prospects of a
A1c threshold from 6.1% to 5.7%—a move its anxiety is warranted. She has described much larger global market, including China.
two partners in the expert report never em- prediabetes as a runaway train. Patients are Simpler home glucose testers, such as those
braced. Evidence favored the lower figure, “walking toward the cliff’s edge,” she said used in finger sticks, are a razors-and-blades
Cefalu says, noting that prediabetes com- at a 2016 medical conference. The media proposition. A starter model costs just $11.55
prises a “continuum of risk,” with higher A1c has reported, widely and with little skepti- on Amazon, but requires branded test strips.
readings warranting more aggressive treat- cism, that prediabetes as defined by ADA Writing recently in Psychology Today, a phy-
sician and nutrition consultant
touted home glucose testing after
Alarming increase every meal as the top medical ne-
As the prediabetes definition has broadened, the number of potential patients in the United States has greatly increased, cessity for everybody—regardless
according to Centers for Disease Control and Prevention (CDC) estimates. Diabetes authorities such as the American of health or blood sugar status.
Diabetes Association (ADA) now list drug options for those patients. As the market expands, indi-

Downloaded from http://science.sciencemag.org/ on March 11, 2019

vidual patients and society as
2004 2005 2010 a whole face a steep price tag.
100 ADA broadens CDC adopts ADA keeps prediabetes
prediabetes broadened label, further broadens
In 2014, failing to note its own
Prediabetes
defnition ADA standard. defnition using “A1c” role in widening the patient

CREDITS: (GRAPHIC) N. DESAI/SCIENCE; (DATA) AMERICAN DIABETES ASSOCIATION; U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION; D. NATHAN, DIABETES CARE, 32, 1327, (2009)
75 based on blood test. pool, ADA warned of “alarm-
Millions of people

fasting blood 2011 ing” U.S. prediabetes spending,

sugar test.
CDC adopts broadened estimated at $44 billion in 2012
50 ADA defnition of
(the most recent year for which
prediabetes.
Diabetes data are available)—about 1.6%
25 of all health care costs and 74%
higher than in 2007. Even if that
is an exaggeration, as some say,
0 costs are substantial and rising.
Cefalu says lower-cost inter-
2001 2003 2007 2009 2013 2019 ventions are needed, but he de-
ADA begins Prediabetes ADA begins to International ADA begins ADA says
to call slightly frst mentioned recommend experts reject to suggest weight loss drugs scribes many current programs
elevated in ADA metformin for prediabetes label other diabetes can also be as cost-effective, and a medical
blood sugar treatment some prediabetes as scientifcally drugs for considered for and moral necessity. In a recent
“prediabetes.” standards. patients. unsound. prediabetes. prediabetes.
article about diabetes prevention,
he invoked Winston Churchill’s
ment. ADA’s new A1c standard, combined and CDC is a serious health threat. Even wartime pronouncement: “It is no use say-
with its adoption of a similarly broad stan- Nutrition Action, a popular newsletter that ing, ‘We are doing our best.’ You have got to
dard on a different blood sugar test a few debunks outlandish health claims, depicted succeed in doing what is necessary.”
years earlier, created about 72 million poten- diabetes as the tip of an iceberg with the
tial new prediabetes patients in the United prediabetes behemoth lurking below. SCIENTIFIC CONFLICTS
States alone—and could create hundreds of The broadened definition of prediabetes Many scientists, however, question the need
millions more if embraced worldwide. has triggered far-reaching changes in the to identify and treat prediabetes as ADA de-
One of those Americans was Nance Yuan, medical landscape. CDC’s budget for dia- fines it. All endorse healthy diets and regular
a surgical resident in Los Angeles, Califor- betes prevention jumped from $66 million exercise and say substantially elevated glu-
nia. In 2018, amid a demanding career, Yuan in 2010 to $173 million in 2017—a 123% rise, cose levels can lead to diabetes. But research-
decided to freeze some of her eggs in case in constant dollars. (At the same time, the ers diverge over crucial questions: How often
she wanted to have a baby later. A blood agency’s cancer prevention budget plum- and how quickly does prediabetes progress to
test before the procedure led to unwelcome meted.) Many people diagnosed with pre- diabetes? Does prediabetes itself cause harm,
news: prediabetes. Her result was border- diabetes visit doctors more often for blood particularly when a person’s average glucose
line, so normally she would have been urged sugar tests and advice on diet and exercise. levels are at the low end of the test result
simply to improve her diet and to exercise And a major marketing opportunity has spectrum as defined by ADA?
more. But in light of her egg harvesting opened up. Companies have pressured the On one side are CDC and ADA, powerful
plans, Yuan’s gynecologist also prescribed Food and Drug Administration (FDA) for a financial gatekeepers and opinion leaders.
metformin, a drug often given to patients seal of approval on foods or supplements— ADA journals are the field’s most influen-
with full-blown diabetes. such as coffee, dairy products, and sugar tial, and the two organizations fund much
“It was a little bit of a shock,” says the substitutes—that they say can help prevent of the nation’s research and programs on
slim, 34-year-old physician. “I think of met- diabetes. A cottage industry of specialty fit- diabetes prevention. On the other side are
formin as something that middle-aged obese ness coaches emerged to serve a multitude public health and primary care authorities,
patients are on.” Using the drug for just a of worried prediabetes patients. including WHO, the U.K. National Institute

1028 8 MARCH 2019 • VOL 363 ISSUE 6431 sciencemag.org SCIENCE

Published by AAAS
for Health and Care Excellence, EASD, and doubts about whether its results justify treat- style changes or metformin reduced heart
IDF. Those groups either do not use or do not ing everyone diagnosed with prediabetes. disease and stroke—key complications of
emphasize the term prediabetes, and they David Nathan, a diabetes specialist at full-blown diabetes—but those interven-
normally advise treatment only when blood Harvard Medical School in Boston and chair tions have had no impact on mortality.
sugar levels approach those of frank diabetes. of the DPPOS research group, explained to Women in the control group did have more
Researchers skeptical of the ADA defini- Science that the researchers chose a rela- microvascular changes—seen in tiny blood
tion point to a comprehensive 2018 review of tively high-risk cohort “so we could study vessels—which can eventually damage eyes,
103 studies by the Cochrane Library in Lon- a manageable/affordable-sized population kidneys, and nerves, than those in the life-
don, which showed that most people who over a realistic period of time.” The data, style intervention group. But that effect
qualify as prediabetic never progress to dia- he added, showed treatment benefits across was barely statistically significant, and the
betes over any period studied. People who do all ethnicities. opposite pattern emerged in men. “If after
progress usually start out at the higher end of Yet 38% of the lifestyle treatment group 15 years of follow-up, the rate of eye, kidney,
the ADA prediabetes test range. The review failed to maintain the strict regimen after just and nerve damage is exactly the same in all
also noted that studies of people labeled pre- 6 months. That outcome was despite costly, three groups,” Yudkin says, “then there are
diabetic often fail to account for weight, age, intensive medical, psychological, and exer- 2000 people being treated with no benefit.”
and physical activity, which can all affect glu- cise support, which community-based pro- Cefalu says that in other studies, research-
cose, as can daily stress, inflammation, and grams can’t provide. Henry Kahn (no relation ers have found a relationship between hav-
other factors. According to the review, up to to Richard Kahn), a former CDC physician ing an average blood glucose level within the
59% of prediabetes patients returned to nor- who retired from Albright’s staff in 2018, says ADA prediabetes range and cardiovascular
mal glycemic values over 1 to 11 years with no the DPPOS demonstrated “efficacy—I won’t disease many years later. But many of the

Downloaded from http://science.sciencemag.org/ on March 11, 2019

treatment whatsoever. say ‘effectiveness’—to delay diabetes through studies were observational, based on medical
“Doctors should be careful about treating very intensive and expensive education for a records, and such studies are generally con-
prediabetes because we are not sure whether sidered weaker than controlled trials such as
this will result in more benefit than harm,” the DPPOS. Most of the studies did not show
the Cochrane authors concluded, “especially
when done on a global scale.”
“Doctors should be harm at statistically significant levels.
Cefalu and Albright cited another paper—
Kahn adds that even people whose ele-
vated blood sugar does lead to diabetes prog-
careful about a long-term Chinese study of people diag-
nosed with prediabetes published in 2014 in
ress slowly. “If you screen for diabetes every
3 to 5 years, you’re fine,” he says. Prediabetes
treating prediabetes The Lancet—that Albright said “showed life-
style changes improved cardiovascular out-
itself does not raise the risk of cardiovascular
disease or other complications of diabetes,
because we are not comes.” After 23 years, the study researchers
found fewer deaths overall and fewer deaths
says former ADA President Mayer Davidson,
a physician now at Charles R. Drew Univer-
sure whether this will from cardiovascular causes than in the con-
trol group. But the study was small, just
sity of Medicine and Science in Los Angeles. result in more 577 people, and the benefit was marginally
To support the value of aggressive treat- significant and seen only for women.
ment, ADA and CDC cite a landmark clinical benefit than harm.”
trial of prediabetes, the Diabetes Prevention Cochrane Library DRUG OPTIONS
Program Outcomes Study (DPPOS), which While the scientific dispute simmers, drug
began in 2002 and is still collecting data. companies are racing to fill the demand cre-
Sponsored by the National Institute of Dia- selected group.” He says the relevance of the ated by ADA’s prediabetes definition. The
betes and Digestive and Kidney Diseases and DPPOS findings to the real world is unclear. federal registry ClinicalTrials.gov lists human
conducted by researchers at 25 centers across Richard Kahn goes further. “There’s never tests for more than 100 drugs, supplements,
the nation, it included nearly 3000 predia- been a study to show that a population can and other prediabetes remedies, including
betic subjects randomly separated into three lose sufficient weight and keep it off over devices such as gastric bands. Drugmakers,
groups. One received intensive diet and exer- more than a few years in order to prevent ADA, and others have funded trials for at least
cise interventions, one took metformin, and a diabetes over the long run. Never. Not one.” 10 classes of drugs.
control group got neither. Fewer people in the Gojka Roglic, a physician responsible for So far, FDA has approved no drug or
treatment groups progressed to diabetes over WHO’s diabetes program, says ADA’s pre- device for prediabetes. Approval timelines
6 years—5.3% per year in the lifestyle group diabetes definition sharply increases the remain hazy because the agency has yet to
and 6.4% for the metformin group, compared number of people said to be at risk despite define clear therapeutic goals, says Todd
with 7.8% in the control group, DPPOS scien- the lack of “a preventive intervention that Hobbs, U.S. medical officer for Novo Nord-
tists reported in 2009 in The Lancet. has been shown to work for people identi- isk, a leading diabetes drugmaker based in
The study’s patients were selected on the fied by these criteria.” Bagsværd, Denmark. “Is it delaying of pa-
basis of a glucose tolerance test, now rarely Cefalu acknowledges that “it’s a differ- tients who have normal glucose from devel-
used, whose results are inconsistent with ent approach in the real world. There’s a oping prediabetes? … Is it a lower percentage
those of today’s more common A1c. On av- lot of additional hurdles—social-economic of people who have prediabetes going on to
erage, the people studied were less healthy concerns, finances, adherence, compliance.” develop type 2 diabetes in a defined period
than most people within ADA’s broad defi- But he and Albright told Science the DPPOS of time?” he asks. Hobbs says FDA eventu-
nition of prediabetes—obese, with blood showed that, in principle, lifestyle changes ally will pick some criteria. Prediabetes “is
glucose levels near the cusp of diabetes. can delay or prevent diabetes. “We need to already an important issue, and the obesity
The sample also skewed to ethnicities find ways to ensure that these programs can epidemic is clearly driving this,” he says. “It
more prone to diabetes. To critics such as be [successful],” Cefalu says. will certainly only increase in focus.”
Yudkin, those features of the study raise The DPPOS has yet to report whether life- Meanwhile, doctors can treat prediabetes

SCIENCE sciencemag.org 8 MARCH 2019 • VOL 363 ISSUE 6431 1029

Published by AAAS
NEWS | F E AT U R E S

with a rising number of drugs prescribed effects, and lack of persistence in effect” weighed against the potential harms of
off label—most approved for diabetes or but does not advise against prescribing the continual treatment. And several pre-
obesity. In 2007, ADA began to recommend drugs, as it did in the past. diabetes options described by ADA and oth-
metformin as a relatively safe, inexpensive, Some physicians are trying new drug op- ers present serious hazards. Pioglitazone, a
long-term option for prediabetes patients tions on ADA’s list. For example, a 2018 ob- drug to lower blood sugar developed by the
with other risk factors for diabetes, such as servational study in The Lancet looked at Tokyo-based Takeda Pharmaceutical Com-
obesity. Then, in 2013, ADA joined other ad- 222 prediabetes patients in a Southern Cali- pany under the brand name Actos, carries
vocates of aggressive diabetes prevention in fornia community medical practice who on its label a “black box” side effect warn-
listing more powerful, costlier drug options. tested, on average, at the very low end of ing of the risk of congestive heart failure.
Cefalu says ADA still discourages using ADA’s A1c scale—barely prediabetic. They The drug can also raise the risk of bone
any drug except metformin for prediabetes. were given a cocktail of either two or three fractures and cancer. Exenatide (branded
But since 2013, ADA standards of care have diabetes drugs. On average, their blood sugar Bydureon by Cambridge, U.K.–based Astra-
consistently listed a variety of diabetes and decreased slightly. Zeneca), which reduces blood glucose and
obesity drugs that it says may decrease the Any drug for prediabetes would likely suppresses appetite, has a black box warn-
incidence of diabetes among prediabetics. have to be taken for years, perhaps a life- ing for thyroid cancer. Liraglutide (sold as
ADA urges doctors to consider “cost, side time, so such modest benefits must be Victoza by Novo Nordisk) also carries warn-

Downloaded from http://science.sciencemag.org/ on March 11, 2019

ILLUSTRATION: STEPHAN SCHMITZ

1030 8 MARCH 2019 • VOL 363 ISSUE 6431 sciencemag.org SCIENCE

Published by AAAS
ings of potentially lethal side effects. diabetes patients, such as pioglitazone, ex- of specific interventions that [guideline au-
Yudkin says the growing emphasis on enatide, and liraglutide. DeFronzo declined thors] have direct conflicts of interest with,”
drugs for prediabetes reflects in part a false to comment about whether those earnings he says. “It’s really very worrisome.”
sense of urgency about its health risks. might have influenced his views. ADA’s expanded prediabetes definition
WHO’s Roglic also doubts that the benefits Many physicians who wrote the 2018 ADA is a financial win for physicians, companies
of taking a diabetes drug for prediabetes out- standards of care for prediabetes, which rec- that conduct lab tests, drug companies, de-
weigh the risks. “It seems counterintuitive ommend that doctors consider prescribing vice and app developers, clinics, and hospi-
to take a medicine in order to prevent some- those same three drugs, also received large tals, says Victor Montori, a diabetes clinician
thing for which you would take that medi- sums from drugmakers. Seven of the 14 ADA at the Mayo Clinic in Rochester, Minnesota.
cine. The reasoning is a bit twisted.” experts got between $41,000 and $6.8 mil- “The people who lose are the people who go
lion between mid-2013 and 2017 from makers from being a healthy person to being a pa-
FINANCIAL CONFLICTS of diabetes drugs or candidate prediabetes tient. Now, they have the sick role. They have
The push for drug treatments for pre- medicines or devices. The payments covered to go for checkups and tests and treatments,”
diabetes takes place in an environment rife consulting, travel, and research and included often at considerable expense.
with financial conflicts of interest. For years, an average of $276,000 for personal fees. Yuan, the surgical resident, had her eggs
ethicists have criticized ADA for financial de- Guillermo Umpierrez, who served on the frozen after a few months of prediabetes
pendence on diabetes drugmakers. In recent ADA standards panel and is an endocrino- treatment. With great relief, she stopped tak-
years, ADA says, it has received $18 million to logist at Emory University in Atlanta (he ing metformin—which several diabetes and
$27 million annually from drug companies, was also a member of the AACE-ACE panel), fertility experts say was overtreatment in her
including many donations of $500,000 to received the most during that period, ac- situation. But the prediabetes diagnosis and

Downloaded from http://science.sciencemag.org/ on March 11, 2019

$1 million per year. The group also gets up to cording to Open Payments: $6.8 million— prescription remain on her medical record,
$500,000 annually from each of more than including about $123,000 in consulting and which could affect her future insurance pre-
a dozen other firms in the diabetes and pre- travel fees. About $5.3 million came from miums. Other people given a prediabetes di-
diabetes markets, including makers of con- the makers of drugs in the classes that ADA agnosis face greater challenges: For example,
sumer and medical products, testing labs, according to a recent study, Medicare reim-
insurance companies, and drug retailers. burses just a small fraction of costs for its
The American College of Physicians re-
cently reviewed the diabetes and prediabetes
“I just don’t think own diabetes prevention program.
The insurance problem is one sign of what
treatment guidelines from several authori-
ties and assessed each for financial conflicts
we [prevent diabetes] happens when a borderline medical test re-
sult becomes “medicalized,” turning many
of interest with drug companies. It rated by making every basically healthy people into stressed-out pa-
ADA’s conflicts as among the most extreme. tients, critics of ADA’s prediabetes definition
An ADA representative wrote in an email to healthy person a patient.” say. “Seventy to 80% of them are never going
Science that its funders have no influence to get diabetes, so is it unnecessary stress?”
Victor Montori, Mayo Clinic
over “the final outcome” of ADA’s work. asks Davidson, the former ADA president.
Many prominent physicians who now rec- Many public health organizations believe a
ommend drugs for prediabetes also received now recommends as options for prediabetes, mainly clinical approach to diabetes preven-
large payments in recent years from compa- for research or consulting on drugs in those tion is ineffective. WHO, for example, favors
nies whose sales could be affected by such classes. Umpierrez told Science that he plans societywide solutions, which aim to address
endorsements. Science documented some to dispute some figures in Open Payments, the health impacts of social stratification
of that compensation by examining data which has sometimes included errors, but he and failures of urban planning. It endorses
from mid-2013 through 2017 in Open Pay- gave no details. Umpierrez said drug com- laws that help reduce consumption of sugary
ments, a federal database that tracks money pany payments did not influence him. drinks and unhealthy foods.
that drug- or devicemakers give to clini- ADA says it does not regard as conflicts of A 2011 study in JAMA examined health
cal professionals for consulting, teaching interest any drugmaker-provided research outcomes in women living in stressful, low-
fees, travel, and other purposes. The data- funding, funds received before the year its income housing projects who had been
base also shows funds funneled through guidelines were written, or payments under randomized into three groups: One got a
their institutions for research. $10,000. Even by those narrow criteria, 41% voucher for better housing and help moving,
Ralph DeFronzo, an endocrinologist at the of the authors of its standards of care during one a voucher for moving to any area without
University of Texas Health Science Center in the past 5 years were conflicted, according help, and a control group got neither. Women
San Antonio and a co-author of treatment to ADA. The group can require such panel- who got the most housing assistance suffered
guidelines for the American Association of ists to recuse themselves from discussion or the least obesity and diabetes—over 20 years,
Clinical Endocrinologists (AACE) and the voting, but in the past 2 years, none did so. about 15% had become diabetic, compared
American College of Endocrinology (ACE), is John Ioannidis, a physician and expert on with 20% in the control group.
one of the most influential diabetes research- evidence-based medicine at Stanford Univer- “None of those people got advice on lifestyle
ers. His papers discussing wider use of drugs sity in Palo Alto, California, calls prediabetes changes. None got advice on dietary changes
for prediabetes—including the Southern a classic example of how clinical guidelines or activities. None got diabetes drugs,” Mon-
California study in The Lancet—have been from groups such as ADA can escalate costs tori says. Diabetes can and should be pre-
cited more than 3000 times. DeFronzo got to society, to the benefit of specialty practi- vented, he says. “I just don’t think we do that
about $5 million from diabetes drugmakers, tioners and drug companies. “You have a by making every healthy person a patient.” j
including $1.3 million in fees paid directly to combination of two forces. One is to expand
him for consulting, advice, and travel. About the definition of disease and to get more Jia You and Meagan Weiland contributed
half of the total was for work associated with people classified as being sick or in need of reporting. This story was supported by the
drugs he has cited as effective for some pre- treatment. And second, direct endorsement Science Fund for Investigative Reporting.

SCIENCE sciencemag.org 8 MARCH 2019 • VOL 363 ISSUE 6431 1031

Published by AAAS
Dubious diagnosis
Charles Piller

Science 363 (6431), 1026-1031.

DOI: 10.1126/science.363.6431.1026

Downloaded from http://science.sciencemag.org/ on March 11, 2019

ARTICLE TOOLS http://science.sciencemag.org/content/363/6431/1026

RELATED http://stm.sciencemag.org/content/scitransmed/7/311/311ra174.full
CONTENT
http://stm.sciencemag.org/content/scitransmed/9/394/eaah4477.full
http://stm.sciencemag.org/content/scitransmed/11/475/eaau3441.full
http://stm.sciencemag.org/content/scitransmed/6/257/257ra139.full
PERMISSIONS http://www.sciencemag.org/help/reprints-and-permissions

Use of this article is subject to the Terms of Service

Science (print ISSN 0036-8075; online ISSN 1095-9203) is published by the American Association for the Advancement of
Science, 1200 New York Avenue NW, Washington, DC 20005. 2017 © The Authors, some rights reserved; exclusive
licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. The title
Science is a registered trademark of AAAS.