BMJ  2007;335 (8 September), doi:10.1136/bmj.39329.634931.47

Editor's Choice

Editor's Choice

Focus on diabetes

Diabetes affects more than 2 million people in the United Kingdom and more than 170 million across the world. Type 2 diabetes accounts for over 90% of cases. The burden of this condition for patients, their families, and healthcare systems is immense and growing. WHO estimates that global prevalence of diabetes will more than double over the next quarter century to affect 366 million people by 2030.

As diabetes becomes more of a global problem, the debate on whether to introduce population based mass screening is hotting up. Two papers in this week's BMJ from Helen Eborall and colleagues (doi: 10.1136/bmj.39303.723449.55, doi: 10.1136/bmj.39308.392176.BE) explore the psychological effect of screening and find that, with a stepwise approach, it's unlikely to have important adverse effects. This adds wind to the sails of the pro-screening flotilla, but as Ronald Stolk points out in his editorial (doi: 10.1136/bmj.39323.395336.BE), we shouldn't forget that we don't yet know whether population screening actually works. The crucial underlying question—whether treating asymptomatic hyperglycaemia will help prevent cardiovascular disease—has yet to be answered. The trial that may provide an answer (a multicentre European trial from which Eborall et al's data on psychological impact are drawn) is due to finish next year. In the meantime, Stolk advises sticking to current practice of waiting until people present with thirst and polyuria.

For patients and clinicians who have worked hard to establish self monitoring of blood glucose, the DIGEM randomised trial we published back in June was a sobering read. Farmer et al found no evidence that blood glucose self monitoring affected glycaemic control in type 2 diabetes (BMJ 2007;335:132, doi: 10.1136/bmj.39247.447431.BE). At the time, Simon Heller noted in his editorial that patients' views needed to be taken into account (BMJ 2007;335:105-6, doi: 10.1136/bmj.39276.549109.47). This week we have the patients' perspective from Elizabeth Peel and colleagues (doi: 10.1136/bmj.39302.444572.DE). Their longitudinal qualitative study found that patients were confused about the meaning and value of self monitoring, partly due to lack of sustained interest from their doctors, who tended to focus instead on Hb_A1C results.

As Peter Burrill said in a rapid response (19 June, www.bmj.com/cgi/eletters/334/7606/1236-a#169088), many health professionals are glucocentric in their handling of people with diabetes, presumably because diabetes is diagnosed on the basis of blood glucose concentrations. The heartening re-emergence of metformin after the false dawn of some of the newer drugs may help to change this. The evidence seems to suggest that its beneficial effects on outcomes related to diabetes can't be entirely explained by its effects on blood glucose, and these benefits extend now to people with diabetes and heart failure, according to Dean Eurich et al's systematic review (doi: 10.1136/bmj.39314.620174.80) and the review by AA Tahrani and colleagues (doi: 10.1136/bmj.39255.669444.AE).

This is the first of the BMJ's new research focused theme issues. The five research articles (including the one by Farmer et al) were selected from more than 100 submitted in response to our call for papers in May. Publication has been timed to coincide with the annual meeting of the European Association for the Study of Diabetes in Amsterdam later this month. Our next themed issue is planned for Spring 2008 and will focus on hypertension. The call for papers will follow shortly.

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Metformin, heart failure, and lactic acidosis: is metformin absolutely contraindicated?

A A Tahrani, G I Varughese, J H Scarpello, and F W F Hanna
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