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Rapid Responses: Rapid Responses published:
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diet & exercise control of diabetes
- Michael Coulson (25 September 1998)
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UKPDS -a model in ethics and diabetes public health
- K M Venkat Narayan (25 September 1998)
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Publishing important findings in two journals
- Jonathan Richards (30 September 1998)
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Query regarding numbers needed to treat
- Stefan M Groetsch (15 October 1998)
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Deficiencies of UKPDS
- Paul Neeskens (18 November 1998)
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Michael Coulson, journalist self-employed
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As a layman who makes the effort both to understand my diabetes and to control it effectively, I read with interest the UKPDS study results in the 12/9/98 edition of the BMJ. All cost-effective efforts to reduce blood pressure to acceptable levels for Type 2 diabetics (and enhance control of blood glucose levels at the same time) are greatly appreciated, as is improving understanding of the relationship between the two. My own experience tells me that tight control of blood pressure for a Type 2 diabetic can be achieved whilst reducing medication - and lead to improved control of diabetes, so long as it is combined with a programme of regular, vigorous exercise and a strictly healthy diet of adequate energy and nutritional balance to support the exercise. A brief historical summary to begin with ; I was diagnosed with Type 2 diabetes in August 1993. By November `96, I had a peak blood pressure reading of 172/104, my fasting blood glucose results were levelling off at 6.3 - and I was on daily glibenclamide (1.25 mg/day) for diabetes and on ramipril (5 mg/day) for the blood pressure. Almost 2 years down the road, the situation has improved dramatically, thanks to 3 - 5 sessions per week of vigorous exercise (road running, aerobic endurance & weight training) and a rigorously implemented healthy diet (with energy-source targets of complex carbohydrates 55%, fats 28% and protein 17%). I began this programme in June 1997 ; by early September `97, I was taken off glibenclamide and the following November, the ramipril was reduced to 1.25mg/day. Over the 15 months that I have enjoyed this programme, my BMI is down to 22.5 (from 28.9) , blood pressure has stabilised at 122/72, blood glucose is down by 12.5%, serum cholesterol is down to 4.3 and my HDL/LDL ratio is 1.3. A resting heart rate of 62- 65 (cf 85 in mid `97) and improved aerobic fitness ("comfortable energy use" in aerobic workouts is 11kcal/min) + greater muscular strength emphasis the improvements I have achieved. The lessons to be learnt are:- - Relatively intense vigorous exercise (using interval training is a useful way for Type 2 diabetics to lose weight - Backing up regular exercise with a healthy diet is essential - Most Type 2 diabetics lack motivation to enjoy vigorous exercise and use "cooking-from-scratch" skills (though some older diabetics may be incapable of intense exercise) The BDA estimate that only 20% of Type 2 diabetics are on diet and exercise control suggests that there is a long way to go in improving this situation. It would be interesting to make a cost- effectiveness comparison between the sort of programme that I am on (including exercise costs) and the control of diabetes through medication + general health & fitness regimes. Mike Coulson |
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K M Venkat Narayan
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Sir- The United Kingdom Prospective Diabetes Study (UKPDS) has shown over 10 years of follow-up that persons with newly diagnosed type 2 diabetes can maintain excellent glycemic control (HbA1c of 7.0%), and that such control can significantly reduce microvascular complications.1 The study has also shown that strict blood pressure control can significantly reduce mortality as well as microvascular and macrovascular complications among these persons.2 Thus, the UKPDS successfully answered its primary research questions. The design of the study was such that several secondary questions could not be answered convincingly.3 However, several important lessons in ethics and public health can be learned from the UKPDS. The fact that the comparison group maintained a relatively low HbA1c level (7.9%) over 10 years of follow-up suggests that the researchers were ethical to the point of risking a null finding. This is refreshing because in their enthusiasm to establish the efficacy of specific treatment(s) some investigators replace standard drug therapy with an inactive placebo.4 Another remarkable aspect of the UKPDS is that the researchers continuously adapted the intervention to changes in scientific knowledge and clinical practice, adaptations that are reasonable and justifiable in a 20-year trial which chooses to adhere to sound ethical principles. The UKPDS was conducted in primary health care settings rather than specialist centers or university hospitals, and thus, the results are likely to be closer to what would be found in clinical practice than would those from other large clinical trials. 5 By simulating clinical practice as closely as possible, the UKPDS has given data on effectiveness that are more suitable for translating into public health practice than are efficacy data collected in highly controlled and ideal environments. In including a blood pressure control trial,2 the investigators acknowledged that diabetes complications are multifactorial in aetiology; glycemic control is but one aspect. The vast population burden of diabetes complications can be effectively and efficiently tackled only if risk factors like high blood pressure, dyslipidaemia, and smoking receive at least as much attention as glycemic control. The biggest impact of the UKPDS results may be toward better management of blood pressure among people with type 2 diabetes.2 Finally, the fact that conventional glycemic treatment for persons in the comparison group of the UKPDS resulted in a relatively low HbA1c level suggests that some attributes (e.g., universal health-care, emphasis on primary care, relationship between primary and specialist care, patient education) of the U.K. model of health-care may be particularly suitable for managing chronic diseases. Countries like the United States may benefit from examining some of these attributes, and modifying their approaches to chronic disease management accordingly. Sincerely, K. M. Venkat Narayan, M.R.C.P. Gloria L.A. Beckles, M.B.B.S. Edward. W. Gregg, Ph.D David. F. Williamson, Ph.D J. Saaddine, M.D. Michael M. Engelgau, M.D. Frank Vinicor, M.D. Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. REFERENCES 1. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53. 2. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes:UKPDS 38. Br Med J 1998; 317:703-13. 3. Nathan DM. Some answers, more controversy, from UKPDS (Editorial). Lancet 1998;352:832-33. 4. Maggs DG, Buchanan TA, Burant CF, et al. Metabolic effects of troglitazone monotherapy in type 2 diabetes mellitus: a randomized, double -blind, placebo-controlled trial. Ann Intern Med 1998;128:176-85. 5. DCCT Research Group. The effect of intensive diabetes treatment on the development and progression of long-term complications in insulin- dependent diabetes mellitus: The Diabetes Control and Complications Trial. N Engl J Med 1993; 329: 978-86 |
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Jonathan Richards, Chair, Bro Taf Primary Care Audit Group Morlais Medical Practice, Merthyr Tydfil, CF48 3AL
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The findings of the UK Prospective Diabetes Study Group have been eagely awaited by interested clinicians in Primary Care for some time. All through the summer we said to one another at audit meetings: "The issues will be clarified when the UKPDSG's latest research is published." Consequently I was very surprised to discover that some papers were published in the BMJ, some in The Lancet. Why was this done? The Lancet is not as available to clinicians in Primary Care as the BMJ (I have only met one colleague who subscribes, whilst many receive the BMJ) and is not available electronically to non-subscribers. Our Audit Group is collating and summarising the findings from both journals knowing that the Lancet papers are not as accessible for critical appraisal. Who chose which journal each paper would appear in? How will the correspondence generated by the papers be integrated? Who will critically evaluate the effects of the decision to publish in this way? Yours sincerely, Jonathan Richards |
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Stefan M Groetsch
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Editor- We were very interested to learn of the results from the UK Prospective Diabetes Study Group regarding tight blood pressure control and type 2 diabetes.1 Many of our patients share similar characteristics as the study population, and this information is highly applicable to our practice. In utilizing an evidence-based medicine approach, we attempted to calculate the numbers needed to treat based upon the data presented. We are concerned that there is a discrepancy between the numbers needed to treat which are stated in the article, and those that can be calculated. The study states that the number needed to treat over 10 years to prevent any complication is 6.1 and to prevent death from a diabetes related cause is 15.0. In calculating the numbers needed to treat by using the values in figure 4 (based upon a median follow up of 8.4 years), we conclude that the number needed to treat to prevent any complication is 11, and to prevent death is 20. The following table describes our method: clinical end point tight control absolute risk less tight control absolute risk absolute risk reduction number needed to treat any diabetes related end point 259/758= 34.2% 170/390=43.6% 9.4% 1/0.094~ 11 death related to diabetes 82/758= 10.8% 62/390=15.9% 5.1% 1/0.051~20 Again, we appreciate the quality of the patient-oriented research conducted in this study. However, we would have found it more useful if an explanation were included that described the authors' derivation of the numbers needed to treat. Stefan M Groetsch, MD Resident Joseph T LaVan, MD Resident John W Epling, MD Family Physician Department of Family Practice Naval Hospital Jacksonville 2080 Child Street Jacksonville, Florida 32214 USA Fax Number : 904-777-7988 e-mail: jak0sxg@jak10.med.navy.mil 1. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317: 703-713. (12 September.) |
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Paul Neeskens, General Practitioner Hervey Bay QLD AUSTRALIA
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I read with interest the results the reports from UKPDS.My person interest is in Epidemiology and its relevance to coal face General Practitioners, whose task is to decide what is relevant for the patient in front of them. There is one glaring omission from the reports. I have not seen any reference to the side effects of medication, no mention of metformin diarrhoea, no mention of ACEI cough, no mention of atenolol tiredness. Similarly there is no mention of patient satisfaction with insulin injection nor the guilt syndrome imposed on patients whose "diabetic numbers" do not meet the Guidelines set by specific disease issue crusaders. The primary care clinician must decide whether the morbidity induced ( fear of the label, cost/pain of tests, multiple visits to the doctor, side effects of medication) is worth the morbidity that only MIGHT be prevented. In the BP arm of this trial with tight control there were 42 cardiovascular events per 1000 patient years and 59 per 1000 in the less tight group. This is a difference of only 17 per 1000 treatment years. How many per 1000 had side effects? and how many patients would object if they knew that the effort of optimising the BP only benefited 1.7% per annum?. It is no wonder many GP's do not seem to reach the Guidelines set by "Experts" as many of us intuitively sense that the effort is not worth the benefit for the individual. Lastly it is a great same that such a large GP based trial has lost total objectivity by not looking at the other side of the equation. |
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