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PRIMARY CARE: Graeme Wylie, A Pali S Hungin, and Joanne Neely Impaired glucose tolerance: qualitative and quantitative study of general practitioners' knowledge and perceptions BMJ 2002; 324: 1190 [Abstract] [Full text]

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The primary role of bed-side evaluating "diabetic constitution" in the war against Diabetes Mellitus

Sergio Stagnaro, Via Erasmo Piaggio N.23/8, 16037 Riva Trigoso (Genoa) Italy.   (17 May 2002)

Parameters

Harry Isenberg   (5 June 2002)

Unrealistic

Samuel F Romero   (10 June 2002)

Are we at risk of becoming a pill-popping nation?

Trudi A Deakin   (12 October 2002)

The primary role of bed-side evaluating "diabetic constitution" in the war against Diabetes Mellitus 17 May 2002
Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. , Via Erasmo Piaggio N.23/8, 16037 Riva Trigoso (Genoa) Italy. Send response to journal: Re: The primary role of bed-side evaluating "diabetic constitution" in the war against Diabetes Mellitus	Sir, Wylie G et al conclude their interesting paper stating that “General practitioners remain to be convinced that they have a role in attempting to reduce the incidence of type 2 diabetes by targeting interventions at patients with impaired glucose tolerance”. As a matter of fact, general practitioners are reluctant to screen patients for impaired glucose tolerance for a variety of reasons, including lack of awareness of IGT. Given the fact that microvascular disease is already present in many individuals with undiagnosed or newly diagnosed type 2 diabetes, we must recognize "promptly" individuals at "real" risk of DM , surely a long time before IGT occurs(2, 3, 4). In my opinion, starting diet, correct lifestyle, and treatment when IGT is already present, although a remarkable enterprise, is not sufficient enough to prevent both DM and, particularly, the well known diabetic complications. In other words, our present knowledge of the early stages of hyperglycemia, i.e. IGT, post- prandial hyperglycemia, a.s.o., are clearly inadequate to prevent both DM and its complications, notwithstanding they portend the diagnosis of diabetes and the recent success of major intervention trials, clearly show that individuals at high risk can be identified and diabetes delayed, if not prevented. At the begin of third millennium, doctors can evaluate in a “quantitative” way the “diabetic constitution”, I described previously, using a new physical semeiotics (See my site HONCode ID N. 233736 http://digilander.iol.it/semeioticabiofisica, Practical Application, Diabetes Mellitus and Diabetic Constitution) The cost-effectiveness of such an intervention strategies nowadays unclear, can be reduced to a great extent by applaying the biophysical semeiotics, since huge burden resulting from the complications of diabetes and the potential ancillary benefits of some of the interventions suggest that an effort to prevent diabetes may be worthwhile, particularly when general practitioners are engaged in screening individuals with “diabetic constitution”, and not expensive methods are applyed. 1) Wylie G., Hungin PS., Neely J. Impaired glucose tolerance: qualitative and quantitative study of general practitioners' knowledge and perceptions. BMJ 2002;324:1190 ( 18 May ). 2) Stagnaro S.-Neri M., Stagnaro S., Sindrome di Reaven, classica e variante, in evoluzione diabetica. Il ruolo della Carnitina nella prevenzione del diabete mellito. Il Cuore. 6, 617, 1993. 3) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica: la manovra di Ferrero-Marigo nella diagnosi clinica della iperinsulinemia-insulino resistenza. Acta Med. Medit. 13, 125, 1997. 4) Stagnaro S., West PJ., Hu FB., Manson JE., Willett WC. Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. [PubMed –indexed for MEDLINE].
Parameters 5 June 2002
Harry Isenberg, G.P. 5 Totnes Walk, London N2 OAD Send response to journal: Re: Parameters	The article is most interesting. However, no indication is given as to what constitutes this condition. What are the parameters?
Unrealistic 10 June 2002
Samuel F Romero, Internal Medicine RE Thomason GH. El Paso Tx 79907 Send response to journal: Re: Unrealistic	First: it is my understanding that in the latest version of Standards of Care for diabetes provided by the ADA (2002), the use of OGTT has been discouraged to the primary care provider. It has been mentioned and stressed that risk factor assesment and fasting glucose should be used to screen the general population. This way the concept of Impaired Fasting Glucose is in a sense displacing the concept of Impaired Glucose Tolerance. Second: lifestyle intervention is a wonderful concept. The efficacy of such approach was documented in the multicenter study Diabetes Prevention Program. During this study the researchers had very sofisticated teams involving multiple disciplines such as psycologists trained in behavior modification, dietitians, nurses, diabetes educators etc.; full baseline education to patients; intense, sustained and prolongued follow ups including frequent phone calls. The results of this study were clear. Lifestyle intervention works. But how do you expect that the general practitioner can achieve all this in 15 min visits?
Are we at risk of becoming a pill-popping nation? 12 October 2002
Trudi A Deakin, Diabetes research Dietitian Burnley, Pendle & Rossendale PCT, Burnley General Hospital, Casterton Avenue, Burnley, BB10 2PQ Send response to journal: Re: Are we at risk of becoming a pill-popping nation?	Editor - I recently attended the annual conference of the European Association for the Study of Diabetes (EASD) and departed feeling both excited by the possibility of new and emerging treatments and health service delivery, but also concerned regarding other possible developments. Presentations from the two leading diabetes prevention studies, the Diabetes Prevention Study (DPS), Finland and the Diabetes Prevention Programme (DPP), USA, conclusively showed that diets leading to 5 –7 % weight loss and 30 minutes of daily physical activity delayed or prevented the onset of type 2 diabetes in individuals with impaired glucose tolerance (IGT) by 58%.1;2 We also heard how certain medications (Acarbose, Metformin and Xenical) seemed to help delay/prevent diabetes but to a much lesser extent than lifestyle intervention.2-4 The DREAM study is now researching the diabetes prevention properties of ramipril and rosiglitazone. If people are given a choice, weight loss and physical activity or taking medication, what do you think the majority would choose? Indeed it has been stated that for many patients there would be greater hope (and compliance) in following drug regimes than altering diet and physical activity and thus changing a lifetime of comfortable sedentary habits.5 Medications are expensive and have possible adverse effects. These would only be treating the symptoms and not the cause of IGT. Rather than becoming a pill-popping nation, wouldn’t it be better to work together and use the resources to counteract the current ‘obesogenic’ environment in which we live today. This would not be easy - but the above studies demonstrate that the allocation of resources to promote healthier lifestyles in a safer environment, backed by government guidance, a more enlightened food industry and supportive media – can pay handsome dividends. What would start the ball rolling? Education, education, education..................... - Public health education because people at high risk of developing diabetes often feel that they have no control over developing the condition and therefore do not even attempt a protective lifestyle.6 - Health professional education because 47% of UK general practitioners were shown to be unaware that IGT leads to Type 2 diabetes.7 Also training to ensure the delivery of consistent evidence-based messages. - Above all, education of young people at school to try to prevent the risk occurring in the first place. Can we take on this challenge NOW – before the forecast doubling the prevalence of type 2 diabetes occurs? Trudi Deakin Diabetes Research Dietitian Burnely, Pendle & Rossendale PCT Tel: 01282 474631 Email: trudi@bdeakin.fsnet.co.uk Reference List 1. Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine 2001;344:1343-50. 2. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. [see comments.]. New England Journal of Medicine 2002;346:393-403. 3. Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M et al. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 2002;359:2072-7. 4. Torgerson JS, Arlinger K, Kappi M, Sjostrom L. Principles for enhanced recruitment of subjects in a large clinical trial. the XENDOS (XENical in the prevention of Diabetes in Obese Subjects) study experience. Controlled Clinical Trials 2001;22:515-25. 5. Anderson A. Lifestyle interventions - how joined up are we? Journal of Human Nutrition & Dietetics 2002;15:241-2. 6. Harwell TS, Dettori N, Flook BN, Priest L, Williamson DF, Helgerson SD et al. Preventing type 2 diabetes: perceptions about risk and prevention in a population-based sample of adults > or =45 years of age. Diabetes Care 2001;24:2007-8. 7. Wylie G, Hungin AP, Neely J. Impaired glucose tolerance: qualitative and quantitative study of general practitioners' knowledge and perceptions. BMJ 2002;324:1190.