Archive for the ‘Preventative medicine’ Category

New recommendations out of a recent conference in Austria as reported by the Heart.org.  This comes on the heels of the most recent changes in BMI recommendations, as we reported last month.

As reported by Steve Stiles over at the Heart.org,  in”Case made for metabolic bariatric-surgery eligibility criteria,”  new evidence and recommendations suggest that surgery should be done earlier in the course of the disease process (diabetes) in patients with lower BMIs.  Currently the BMI restriction criteria enforced in North America and Europe prevent the majority of diabetic patients from receiving gastric bypass surgery, which is the only proven ‘cure’ for diabetes.  That’s because the majority of type II diabetic patients are  overweight but not morbidly obese.

As reported previously on this site, Latin American bariatric surgeons have been at the forefront of the surgical treatment of diabetes.  Many of the surgeons previously interviewed for numerous projects here at Cartagena Surgery were involved in several early studies on the effects of surgery in moderate overweight patients with diabetes.

More interestingly, researchers at the conference are also suggesting possible gastric bypass procedures for patients with ‘pre-diabetes’ or patients with an hemoglobin A1c greater than 5.7 % but less than 6.5% (6.5% is the cut off for diagnosis of diabetes.)

This is wonderful news – it means committees and such are finally getting around to following all of the research that has been published and presented over the last ten years..  But then it just one more important step…

Call it by its name

So I have my own suggestion to doctors and researchers – and it’s one that I’ve made been – a nomenclature change.  We need to stop calling it “pre-diabetes”, because the name is a falsehood – and leads everyone (patients, nurses and doctors astray.)

– Greater than 95% of patients with ‘pre-diabetes’ will develop diabetes – so without a drastic intervention (far beyond diet and exercise)  it’s pretty much a certainty.

– Many of the devastating complications of diabetes develop during this so-called pre-diabetic period.

– Doctors are now recommending surgical treatment to cure this “pre” disease state.


if almost everyone who has ‘pre-diabetes’ gets diabetes, and it’s already causing damage PLUS we now recommend a pretty radical lifestyle change (surgical removal of most of the stomach) —> that sounds like a disease to me.  Call it early diabetes, call it diabetes with minimal elevation of lab values, but call it what it is….Diabetes..

This is critical because without this firm diagnosis:

insurance won’t pay for glucometers, medications, diabetic education, dietary counseling (or surgery for that matter).  That’s a lot of out-of-pocket expenses for our patients to bear, for something that is treated like a ‘maybe’.

– patients (and healthcare providers) alike won’t take it seriously..  Patients won’t understand how crucial it is to take firm control of glucose management, patients won’t be started on preventative regimens to prevent the related complications like renal failure, heart disease and limb ischemia.

– Patients may not receive important screening to prevent these complications – and we already know that at the time for formal diagnosis (usually SEVEN years after initial glucose derangements are seen) – these patients will already have proteinuria (a sign of kidney disease), retinopathies, vasculopathies and neuropathies..

I work with providers every day, and the sad fact is that too many of them (us) shrug their shoulders and say – yeah – he /she should eat better, get more exercise, shrug.. But they don’t treat the disease – they don’t start checking the glucose more often, they don’t start statin drugs, the don’t screen for heart disease and they don’t consult the specialists – the diabetic educators, the nutritionists, the endocrinologists – and yes, the bariatric surgeons…

Chances are if your doctors and your nurses don’t take it seriously; and don’t make a big deal out of it – and don’t talk to you, at length about what “pre-diabetes” IS and what it really means for your life and your health –

then neither will you.

For related content:  see the Diabetes & Bariatric tab

the Weight of a Nation: the obesity epidemic

Bariatric surgery and non-alcoholic fatty liver disease

The Pros & Cons of Bariatric Surgery

Gastric bypass to ‘cure’ diabetes goes mainstream


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As reported at the heart.org, in an article by Michael R’iodan, a recent study completed in the Netherlands showed a heightened risk of post-operative myocardial infarction (MI or heart attack) in the first few weeks after orthopedic surgery (Hip and knee replacement).  This study showed patients to have an up to a 25X increased risk of heart attack in this post-operative period – the risk was particularly acute in the elderly and in patients with previous diagnosis of cardiac disease.

This highlights the importance of pre-operative screening, aggressive medical management of co-morbid conditions during and after surgery, and detecting the sometimes ‘missed’ post-operative MI.  Patients should be carefully evaluated for the presence of angina, or risk factors contributing to the development of coronary artery disease such as hypertension, hypercholesteremia, peripheral vascular disease or diabetes.

Critical medications such beta blockers and statins should be continued during and after surgery.  Medications such as aspirin should be evaluated (and in many cases) continued.

Studies such as this shouldn’t surprise medical professionals – they just confirm what we already know, and should encourage evidence based practice and careful pre-operative screening and co-morbidity management.

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Update:  New article published on MSNBC –  25 May –underscores health benefits of coffee –  and further proves premise of optimal coffee ingestion at five to six cups.  (Previous studies showed the majority of benefits at five cups/ day.)

Posting this for a friend, who wasn’t quite convinced by my arguments for coffee..  Added the video just for a light-hearted touch..and who doesn’t like David Bowie..

Happily,  the majority of people have gotten away from the incorrect notion that coffee is somehow harmful, the “I gave up cigarettes and coffee” mentality.. It always irks me a bit when coffee drinking is lumped into a group of unhealthy behaviors….Stay away from coffee… and crack cocaine, people… But seriously, this is one beverage that has been mislabeled over the years – undeservedly.

With so many honest – to-  goodness harmful food additives,  fast food and other ‘junk‘ we put in our bodies – misidentifying coffee is a tragedy (albeit, a small one.)  Admittedly, it is hard on my dental enamel – but otherwise, it is a welcome part of my daily routine.

So today, we are going to review some of our previous posts and the latest published information on coffee and it’s health effects..

For starters, we are going back to a post dated March 2011 – where I first reviewed my love of the hot, rich beverage, along with a summary of health benefits..

We talked about preliminary research suggesting coffee may be protective against strokes.. An additional study on this was actually just published last month, as reported in Medscape.com, Moderate coffee intake protects against stroke, (11 May, 2012) on a meta-analysis presented at the European Society of Hypertension (ESH) European Meeting on Hypertension 2012 by Dr Lanfranco D’Elia. 

Then – a year ago (May 2011) we brought you more information about coffee as a potent anti-oxidant, and potential implications for preventing cancer (and refuting claims that it caused cancer.)

Following that – in July of 2011 – we went as far as proclaiming ‘superfood status’ when preliminary research suggested coffee ingesters were less likely to have MRSA colonization.

We haven’t even touched on the diabetes, and pancreatic cancer angle today, but suffice to say that research shows that the pancreas has a definite affinity for coffee..

Now, on the heels of reports of the underdiagnosis and increasing incidence of fatty liver disease – comes a study in the Annals of Hepatology entitled, “High coffee intake is associated with lower grade nonalcoholic fatty liver disease: the role of peripheral antioxidant activity.”  Translated for readers, this small study by Gutierrez – Grobe, et. al (2012) suggests that high coffee intake is actual beneficial and may have a protective effect on the liver.  Now – don’t get too excited – since it was just a very small study, of 130 subjects – coffee and noncoffee drinkers, 73 without liver disease and 57 with liver disease.  So clearly, we need to look at this more closely..

But in the meantime, you can keep drinking your coffee.

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The news about Metformin as a possible ally in the fight against cancer has finally taken wings.   (This was first reported in the literature several years ago.)

 As we’ve spoken about in the past – these discoveries about the ‘side benefits’ of this powerful oral anti-glycemic are finally getting some well-deserved press.  As a drug that’s often been shunted aside despite it’s low cost, and impressive safety profile for the more pricey and flashy (but less clinically-proven) alternatives (Yes, Byetta, I am talking about you) this could serve as a boon to consumers..

The other thing we should take from this research is that it remains critical to aggressively control diabetes – for more than just the usual cardiovascular risks but to reduce the risk of our patients developing cancer.  While insulin is a godsend to patients with uncontrolled glucose – metformin should remain on the menu even after the initiation of insulin therapies.  Too often, metformin falls off the roster.  We also need to impress upon our patients to potent nature of this innoculous sounding medication.  Frequently patients inform me that they have abandoned metformin for various reasons in favor of the more pricey, and heavily advertised medications.  Unfortunately, they are really just short-changing themselves: both their wallets and their health.

Coming soon – more about the ‘magic bullet’ of Aspirin – as both a cancer-fighter and an essential element for cardiovascular health.

Unleash Metformin: Reconsideration of the Contraindication in Patients with Renal Impairment – Wenya R. Lu, PharmD.

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Dr. Richard Embrey, Cardiothoracic surgeon and Chief Medical Officer at Princeton Baptist Hospital in Birmingham, Alabama

I write quite a bit about the doctors I met during my travels – and the innovative things they are doing – but it’s not often that I take the opportunity to talk about someone who I have so much esteem and respect for, my previous surgeon (and friend), Dr. Richard P. Embrey.

But first a little background:

Before there was a ‘Cartagena Surgery’ – there was just Kristin Eckland, a cardiothoracic nurse practitioner working at a small Duke-affiliated surgery practice in the charming Virginia town of Danville.  While it was town rich in history (Robert E. Lee’s last home is on my street) and southern traditions – it had also fallen on hard times after several large industries shuttered their doors and left the city adrift.

In the midst of all of this  – there was Dr. Richard P. Embrey, performing surgery every day and trying to make the world a better place.  As we watched our local hospital continue to struggle for a variety of reasons (sometimes all of those down home traditions get in the way of good business decisions), we worked together, shoulder to shoulder to do our best to provide world-class care.  We used to joke that it was our own brand of boutique care – and people in the community seemed to recognize and appreciate that our care and commitment went beyond the minimum standard. Many people who could have chosen to go elsewhere for their care – to the main Duke hospital down the road, to Centra, to the big institutions in Roanoke, Richmond or Greensboro made conscious choices to stay and be treated close to home, because they trusted us.  We had taken care of their mothers, brothers, sisters and aunts – and they respected us, and loved us for it – so when they needed surgery themselves – they always came back.  Sometimes they came back for other things; just to talk/ visit or to share their news with us or a referral to a orthopedist, a dentist or primary care provider …

For the people without that choice – the uninsured and the disenfranchised – well, we were always there for them too.  That’s the beauty of being affiliated with a behemoth like Duke – is that you get to take care of all the other people we hear about in the news every day, the ones that ‘fall through the cracks’ of the health care systems.  Too young for Medicare, ten dollars too much income for Medicaid, and other similar tragedies.

We were very proud of our practice, but it never stopped us from having a critical eye, as we looked to see how we could further improve and better serve our patients.  Often when we rounded in the hospital we would see things we thought should be better.  “There must be a better way,” we would muse.  Except Dr. Embrey never mused – He never said, “someone should fix that” or “something should be done to make this process better.”  Whether it was streamlining the patient admission process to make it faster & easier on patients coming to the hospital for surgery, developing protocols to prevent complications, or encouraging forays into new technologies and medical advances – Dr. Embrey would ALWAYS say, “I know we can improve this, and here’s how.”  Then he would spearhead the committee (hospitals require committees for everything), research the data, and come up with a comprehensive plan to address whatever he had first identified..  Unfortunately, while this was usually a pretty speedy process when it involved just our patients – hospital-wide changes usually took a LOT longer.  Some dinosaur of a physician would complain for the sake of complaining, “this has worked since I started in 1972,” forgetting of course, that he himself had probably complained about it since then – before giving up and resigning himself to it.

But Dr. Embrey resigned himself to accepting nothing less than excellence, so he would continue to persevere – and get things done.  He was always, always reading a book, an article, a review on how to improve, how to implement and plenty of other ‘heady’ topics.  “Dr. Embrey,” I asked one day, “don’t you ever read normal books?  You know, novels and stuff.”  He just laughed and started telling me the great organization leadership and change book he was reading…

Ultimately, despite have a wonderful collegial relationship with Dr. Embrey (probably the best in my career), I ended up leaving the practice – there were too many ups – and downs with Duke.. Would the program close, or would it stay open?  Not something I wanted to have to ponder as I laid awake in my little bed, in my house on Main Street, (yes, really – I did live on main street.. It’s that kind of picket fence town.)

But even after I left – I always looked back, to see how he was doing.  When he told me about becoming a hospital administrator – I was torn – I love surgery, he is an absolutely excellent surgeon and I hated to see him leave the field..  But on the other hand – I knew that if there was one doctor in a million who could successful bridge that gap between medicine and business without leaving the patient’s needs behind – it would be Dr. Embrey.

So I have watched with so much pride at the accomplishments he’s made in just the few short years since.  I watched as his hospital, Princeton Baptist became a dedicated ‘Chest Pain Center’. Then a certified Heart Failure center.. and then, several months ago.. I saw just a quick blurb in an on-line medical journal about this hospital in Alabama and their new protocols for reducing infection.. and I knew.. The article may have downplayed the facility (it was a northern based journal, and southern animosity runs deep) but I knew this was big, big news – and that it was about Princeton Baptist.  It was just a short paragraph – but the article was eye-opening.. (I wish I could find it to post to it – confirming that the biggest discoveries are sometimes just a blip in the radar..)

Now – the news is finally filtering out. This week 27 other hospitals join Princeton Baptist in the hand washing – infection reduction program.  Now Dr. Embrey and his efforts are receiving some of the accolades  (including a 2012 VHA leadership award)and attention (that he has always deserved, in my opinion.)

Using technology to reduce infections

There are so many other wonderful things I could say about Rich – he was endlessly supportive and patient, and encouraging of all my endeavors – but instead I’ll just say, “Outstanding, Dr. Embrey!  Keep up the amazing work!”

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Not as innocent as the Corn Refiners Association would have you believe.

In a courtroom in Los Angeles, a fierce battle is being pitched right now – one that affects almost every person in this nation..    It’s a lawsuit from the nation’s sugar producers accusing the corn industry of false advertising.. That’s right – it takes industry giants to take on those ridiculous, and mis-leading ads.

You know, those ads that ridicule consumers for their health concerns related to the use of high-fructose corn syrup?  (We’ve discussed these health concerns previously in a series of posts that you can see here  and here.)

Link to ad by Corn Industry

But, here (finally) is a response to those ads – that uses science, not fallacy to refute those claims.

At the same time, the Corn Refiners Association has filed a petition with the Food & Drug Administration to change the name of their product from ‘High-fructose corn syrup” to the more innocuous-sounding “Corn Sugar,” which is just another attempt to deceive the American public.

This move comes just as a new medical study links the consumption of a single daily soda with a 20% increase in heart attacks in men.  There’s a great article over at the Heart.org that summarizing these findings, which I have re-posted below for readers.  (the original study was published in Circulation).

Unfortunately, corn syrup in our everyday products in not usually so easy to identify.

A soda a day raises CHD risk by 20% – Lisa Nainggolan

March 12. 2012

Boston, MA – Sugary drinks are associated with an increased risk of coronary heart disease (CHD) as well as some adverse changes in lipids, inflammatory factors, and leptin, according to a new analysis of men participating in the Health Professionals Follow-up Study, reported by  Dr Lawrence de Koning (Children’s Hospital Boston, MA) and colleagues online March 12, 2012 in Circulation [1].

Even a moderate amount of sugary beverage consumption—we are talking about one can of soda every day—is associated with a significant 20% increased risk of heart disease even after adjusting for a wide range of cardiovascular risk factors,” senior author Dr Frank B Hu (Harvard School of Public Health, Boston, MA) told heartwire. “The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda, not only in the US but also increasing very rapidly in developing countries.”

The increased risk is quite substantial, and I think has important public-health implications given the widespread consumption of soda.

The researchers did not find an increased risk of CHD with artificially sweetened beverages in this analysis, however. “Diet soda has been shown to be associated with weight gain and metabolic diseases in previous studies, even though this hasn’t been substantiated in our study,” says Hu. “The problem with diet soda is its high-intensity sweet taste, which may condition people’s taste. It’s still an open question whether diet soda is an optimal alternative to regular soda; we need more data on this. ”

Hu says water is the best thing to drink, or coffee or tea. Fruit juice is “not a very good alternative, because of the high amount of sugar,” he adds, although if diluted with water, “it’s much better than a can of soda,” he notes.

And Hu says although the current results apply only to men, prior data from his group in women in the Nurses’ Health Study [from 2009] were comparable, “which really boosts the credibility of the findings.”

Inflammation could be a pathway for impact of soda upon CHD risk

Hu and colleagues explain that while much research has shown a link between the consumption of sugar-sweetened beverages and type 2 diabetes, few studies have looked at the association of these drinks with CHD.

Hence, they analyzed the associations of cumulatively averaged sugar-sweetened (eg, sodas) and artificially sweetened (eg, diet sodas) beverage intake with incident fatal and nonfatal CHD (MI) in 42 883 men in the Health Professionals Follow-up study. Beginning in 1986 and every two years until December 2008, participants answered questionnaires about diet and other health habits. A blood sample was provided midway through the study.

There were 3683 CHD cases over 22 years of follow-up. Those in the top quartile of sugar-sweetened-beverage intake had a 20% higher relative risk of CHD than those in the bottom quartile (RR 1.20; p for trend <0.001) after adjustment for age, smoking, physical activity, alcohol, multivitamins, family history, diet quality, energy intake, body-mass index, preenrollment weight change, and dieting.

Adjustment for self-reported high cholesterol, high triglycerides, high blood pressure, and diagnosed type 2 diabetes only slightly attenuated these associations, which suggests that drinking soda “may impact on CHD risk above and beyond traditional risk factors,” say the researchers.

Consumption of artificially sweetened drinks was not significantly associated with CHD (multivariate RR 1.02; p for trend=0.28).

Intake of sugar-sweetened drinks, but not artificially sweetened ones, was also significantly associated with increased triglycerides and several circulating inflammatory factors—including C-reactive protein, interleukin 6 (IL-6), and tumor-necrosis-factor receptor 1 (TNFr1)—as well as decreased HDL cholesterol, lipoprotein (a) (Lp[a]), and leptin (p<0.02).

“Inflammation is a key factor in the pathogenesis of cardiovascular disease and cardiometabolic disease and could represent an additional pathway by which sugar-sweetened beverages influence risk,” say Hu et al.

Cutting consumption of soda is one of easiest behaviors to change

Hu says that one of the major constituents of soda, high-fructose corn syrup, is subsidized in the US, making such drinks “ridiculously cheap” and helping explain why consumption is so high, particularly in lower socioeconomic groups.

Doctors should be advising people with heart disease or at risk to cut back on sugary beverages; it’s almost a no-brainer.

“Doctors should set an example for their patients first,” he stresses. “Then, for people who already have heart disease or who are at high risk, physicians should be advising them to cut back on sugary beverages; it’s almost a no-brainer, like recommending that they stop smoking and do more exercise. The consumption of sugary beverages is a relatively easy behavior to change.”

And although this particular study included mostly white subjects and there are few data on the risk of cardiovascular disease associated with the consumption of soda in people of other ethnicities, there are data on its effect on type 2 diabetes in these groups, he says.

“It has been shown for minority groups—such as African Americans and Asians—that they are more susceptible to the detrimental effects” of sugary drinks on diabetes incidence, he notes.

And if you think soft drinks are the only culprits containing high-fructose corn syrup – you’ll be surprised.  Livestrong has published a list of corn syrup containing products – and you’ll see with even a quick glance, that it’s everywhere, and in everything.

Another blog talking about the harm of Corn Syrup

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I met with Dr. Asad Khan for lunch at a recent medical conference.  Dr. Khan and I are old friends from our training days back in West Virginia.  I was a new nurse practitioner (still wet behind ears) in Cardiothoracic Surgery, and Dr. Khan was completing his last year of his nephrology [kidney] fellowship. At that time, West Virginia University had a robust cardiothoracic surgery program and performed cardiac surgery on a large ESRD (end-stage renal disease) population [patients on dialysis.]

As I worked with the soft-spoken Karachi-born physician, I came to rely on him frequently for his excellent clinical judgement and insight.  Now that I have the chance to sit down and catch up with Dr. Khan – I take the opportunity to find out more about his current practice as the Director of six Davita hemodialysis centers in and around College Station, Texas, and to ask Dr. Khan to talk about ways people can prevent and treat renal insufficiency / kidney damage.

Cartagena Surgery: Wow.. It’s good to see you.  It’s been a long time.  Would you tell me more about your current practice?

Dr. Khan:  As I mentioned previously, I am now the Director of several dialysis centers in Texas.  These free-standing clinics have a lot of expanded programs that are very different from the hospital dialysis program [where we trained.]

Cartagena Surgery:  Earlier you mentioned something about bedtime dialysis.  Would you tell me more about that?  I know dialysis can be exhausting – it sounds like an interesting program.  Do patients show up in their pajamas?

Dr. Khan:  Actually, despite the fact that Davita’s nocturnal dialysis programs exist nationwide, not very many patients chose this option.  But it is a good alternative to standard daytime programs, because it allows patients to maximize their time.  By dialysing at night while sleeping, patients are free to pursue their normal activities during the day; work, school or other activities of daily living without interrupting their daily schedule for dialysis.  And yes, some of them do arrive in their pajamas.

Cartagena Surgery:  What steps can people take to protect their kidneys, and prevent chronic kidney disease?

Dr. Khan:  Well the best way people can prevent kidney damage is to prevent and treat the two main diseases that cause kidney damage; namely hypertension and diabetes.   By remaining physically active, eating healthy foods (and following a low- salt diet), and maintaining a healthy weight (BMI less than 25) people can reduce the risk of developing both of these harmful diseases.

Even if they already have high blood pressure or diabetes – these basics tenets of health & wellness can help people control these conditions with the addition of medications.  We know through decades of cardiovascular research such as the Framingham Study and the more recent NHANES surveys that hypertension and diabetes play a big role in the development of coronary disease.  But the results regarding the role of hypertension and kidney disease were surprising.

Several recent cardiac risk studies showed that not only did kidney disease accelerate the development of coronary artery disease (CAD) and dramatically increase the risk of cardiac death – but that even minor elevations of blood pressure over time were correlated with greatly increased risk of chronic kidney disease (CKD).

Most people don’t realize that even a ten point increase in baseline blood pressure (from 130 systolic to 140 systolic) translates to kidney disease/ kidney failure occurring SEVEN years earlier.

Studies also show that one of the most important ways to prevent on-going kidney disease is medication compliance.  When people take the anti-hypertensive medications as prescribed, there is a significant reduction in the development and advancement of chronic renal disease.

Cartagena Surgery:  You mentioned the role of diabetes and hyperglycemia in the development of kidney disease.  Would you explain a bit more about that?

Dr. Khan:  As you know, diabetes is diagnosed relatively late in this country.  The average person has already had diabetes for over seven years prior to receiving a formal medical diagnosis, and this doesn’t even include the vast numbers of people who are told that they have ‘pre-diabetes’ but aren’t given any medications to control it.  All of these people – these undiagnosed people – ALREADY have kidney damage.  I know you give a lecture on the role of diabetes and CAD – and  talk about the importance of treating and preventing proteinuria.  This proteinuria, or protein in the urine is a sign of the damage that is already occurring in this population.   While the detection of this condition is relatively easy – from a simple urine sample – it’s often overlooked.  By the same token, the treatment of this condition, using relatively inexpensive medications called ace-inhibitors (or ARBS) is essential, but not often stressed to patients.  Many of these patients don’t even know WHY these medications have been prescribed for them.  If you don’t know why you are taking something – then you are less likely to take it regularly.

[cartagena surgery: as we discussed in a previous post – these medications are a type of blood pressure medication, but are often used for other reasons such as the prevention of diabetic nephropathy – aka diabetes-related kidney disease.]

Cartagena Surgery: well, thank you for all your time today, I know you have to get back to your conference – you’ve given us some great information. 

Readers – if you have questions or want to know more, (or if you have kidney disease) you can contact Dr. Khan directly.  (He also an internal medicine specialist – and was a primary care physician for several years before becoming a nephrologist, so he’s an expert at treating hypertension, diabetes and other chronic medical conditions besides kidney disease.)

Dr. Asad Khan, MD

Bryan Kidney Center Inc

2110 E Villa Maria Rd

Bryan, TX  77802

 (979) 402-3152

In related news –

a new article published in Medpage Today reports that aggressive treatment for pre-diabetes (including a hemoglobin A1C of 5.7% ) is more cost-effective in long run (by preventing costly diabetes-related complications.)

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