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EDITORIALS: K M Venkat Narayan, Giussepina Imperatore, Stephanie M Benjamin, and Michael M Engelgau Targeting people with pre-diabetes BMJ 2002; 325: 403-404 [Full text]

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Beyond Pre-Diabetes: Biophysical-Semeiotic Diabetic Constitutions.

Sergio Stagnaro   (23 August 2002)

Should we add "pre-diabetes" to the BMJ list of non-diseases?

Elizabeth C Goyder   (24 August 2002)

Lifestyle modification to tackle pre-diabetes

Sheela Krishnaswamy   (24 August 2002)

Targeting South Asian people with pre-diabetes: lessons from the Newcastle Heart Project

Raj S Bhopal   (18 September 2002)

Beyond Pre-Diabetes: Biophysical-Semeiotic Diabetic Constitutions. 23 August 2002
Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genoa) Italy Send response to journal: Re: Beyond Pre-Diabetes: Biophysical-Semeiotic Diabetic Constitutions.	Sirs, we all must apparently agree with K M Venkat Narayan’s conclusive statement ( Editorial, Targeting people with pre-diabetes, BMJ 2002;325:403-404; 24 August ): “... prevention of diabetes through lifestyle modification among people with pre-diabetes has arrived, and this new challenge needs to be met”. In my opinion, however, to prevent efficaciously both type 2 DM onset and its dangerous complications, doctors, all around the world, have to go beyond pre-diabetes. In fact, for instance, it is generally admitted that non-insulin-dependent diabetes mellitus (i.e. more than 90% of diabetic disorders) may occur at least 12 years before the clinical diagnosis of DM is made, and, for instance, retinopathy can develop at least 7 years before the diagnosis. In other words, I think that national screening programmes ,e.g., for diabetic retinopathy, should be intended for people who don't present any clinical and laboratory diabetic symptomatology, at the moment. Actually, during the time that diabetes is "undiagnosed" and untreated, complications, that could be avoided by a different, really efficacious prevention, are developing (1). In a few words, bed-side detecting people with “diabetic constitution” (See my site, HONCode 233736, http://digilandere.libero.it/semeioticabiofisica; Biophysical-Semeiotic Constitutions). Interestingly, we nowadays do not need laboratory methods, as oral glucose tollerance test, in order to recognize individuals at “real” risk of type 2 diabetes mellitus (1). Thanks to a new physical semeiotics, illustrated in above-cited site, doctors can recognize and quantitatively evaluate the "diabetic constitution", by means of bed-side assessing microcirculatory conditions of the Langheran's islets, as I described previously (2,3). In facts, in both absorptive and post- absorptive state, we can "clinically" assess pancreatic histangium acidosis, correlated with local microcirculatory blood-flow situation or more precisely evaluating local Microcirculatory Functional Reserve (MFR) in Langheran's islets: in day-to-day practice, in healthy, lasting cutaneous pinching of VI thoracic dermatomere, brings about gastric aspecific reflex (See in the site: Practical Page N°1) after a latency time (lt) of 12 sec. exactly, which is the measure of local histangium acidosis. By contrast, in subjects at risk of type 2 diabetes and obviously in diabetic patients, reflex latency time is less than 12 sec, in inverse relation to pancreatic islets impairement.In addition, biophysical-semeiotic preconditioning (doctor assess for a second time the same parameters after an intervall of exact 5 sec.)give useful information: in healthy, lt more than 12 sec.; on the contrary in subject at real risk of type 2 diabetes lt either appears unchanged (“real” risk of type 2 DM) or clearly reduced in overt DM. (4). Sergio Stagnaro ,Member NYAS 1) Stagnaro S., Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. letter [PubMed indexed for MEDLINE]. 2) Stagnaro-Neri M., Stagnaro S., Semeiotica Biofisica: valutazione clinica del picco precoce della secrezione insulinica di base e dopo stimolazione tiroidea, surrenalica, con glucagone endogeno e dopo attivazione del sistema renina-angiotesina circolante e tessutale Acta Med. Medit. 13, 99, 1997. 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.-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 (Pub-Med indexed for Medline).
Should we add "pre-diabetes" to the BMJ list of non-diseases? 24 August 2002
Elizabeth C Goyder, Lecturer in Public Health Medicine School of Health and Related Research, University of Sheffield, S1 4DA Send response to journal: Re: Should we add "pre-diabetes" to the BMJ list of non-diseases?	Narayan et al put forward some very good reasons why people identified as at high risk of developing type 2 diabetes could benefit from evidence-based primary prevention measures. But even if blood tests are demonstrated to be a cost-effective method of identifying high risk individuals, it seems unhelpful to give individuals the label of "pre-diabetes" on the basis of either a fasting or two-hour glucose measurement. High intra-individual variation in glucose tolerance, as demonstrated in the Hoorn study which the authors cite(1), means that many people who are labelled with "pre-diabetes" today will no longer have "pre-diabetes" if re-tested just six weeks later. Many people with impaired glucose tolerance will not develop diabetes, even if followed up for many years. Maybe more importantly, there will be a large number of sedentary overweight individuals at high (and modifiable) risk of diabetes, some of whom might well be falsely reassured by a negative screening test for "pre -diabetes".(2) Should we therefore add "pre-diabetes" to the BMJ list of non- diseases?(3) References: 1. Vegt F, Dekker JM, Jager A, Hienkens E, Kostense PJ, Stehouwer CDA, et al. Relation of impaired fasting and postload glucose with incident type 2 diabetes in a Dutch population: the Hoorn study. JAMA 2001; 285: 2109- 2113. 2. Stewart-Brown S, Farmer A. Screening could seriously damage your health. BMJ 1997; 314: 533. 3. Smith R. In search of "non-disease". BMJ 2002;324:883-885
Lifestyle modification to tackle pre-diabetes 24 August 2002
Sheela Krishnaswamy, Managing Partner NICHE, Bangalore - 560025, India Send response to journal: Re: Lifestyle modification to tackle pre-diabetes	Sir, I agree with Dr Venkat Narayan's view that lifestyle modification among people with pre-diabetes has arrived, and this new challenge needs to be met. Awareness of pre-diabetes has to be increased. In my experience of preventive nutrition work for Corporates in Bangalore, India, individual counselling for those with risk factors brings in awareness among the young adults. However, just one counselling session might not be effective enough because they fall off the wagon, often. Lecture sessions, blood tests, healthy meal choices in the cafeteria, are some of the other activities that add to the effect of individual counselling. Sheela Krishnaswamy Managing Partner NICHE www.niche4nutrition.com
Targeting South Asian people with pre-diabetes: lessons from the Newcastle Heart Project 18 September 2002
Raj S Bhopal, Professor of Public Health Public Health Sciences, University of Edinburgh, Edinburgh EH89AG Send response to journal: Re: Targeting South Asian people with pre-diabetes: lessons from the Newcastle Heart Project	Editor, Venkat Narayan and colleagues make a powerful case for following the American Diabetes Association’s recommendation to screen for pre-diabetes in people over 45 years (1). Pre-diabetes is defined as either impaired glucose tolerance (2-hour glucose concentration of 7.8-11 mmol per litre after a glucose load) or impaired fasting glucose concentration of 6.1-6.9 mmol/l. Those screening positive would be counselled on weight loss and increasing physical activity. This recommendation has profound implications for the health care of South Asian populations, originating in the Indian Subcontinent, in urban settings for they have an extremely high prevalence of pre-diabetes (2). In the Newcastle Heart Project, which examined the prevalence of diabetes and prediabetes in South Asians (n=680, 25-74 years), Chinese and white European origin populations, the prevalence of both impaired fasting glucose and of impaired glucose tolerance was 19% in South Asians (3). As the groups did not wholly overlap, the prevalence of pre-diabetes on either definition was 30.5% in South Asians. Only 12.9% of the study subjects had had a clinical diagnosis of diabetes. On the glucose tolerance test, the prevalence of diabetes was 20.1% and on the ADA criteria, 21.4% (on either, 23.4%). Only 48.8% of the population was normal using either the oral glucose tolerance test or ADA criteria. A programme of care would be needed for 50.2% of the South Asian population in the 25-74 age group, a formidable task complicated by issues relating to validity of measurement of obesity, the South Asian public’s understanding of diabetes and perceptions of ideal weight, and low prevalence of exercise. Narayan would prioritise screening in those with a BMI of 25 or more. BMI is a marker for excess adipose tissue. Markers of obesity including BMI do not have equivalence across ethnic groups (4). South Asians in the UK, in most studies, have slightly lower BMI but higher waist-hip ratio and greater skinfold thicknesses. It is likely that BMI is an inexact indicator of adiposity in South Asians, and that if it is to be used a much lower cut-off point for overweight is necessary, perhaps as low as 22. As Narayan et al say, if interventions are to work people need to perceive risk and benefits accurately. In the Newcastle Heart Project, there was a mismatch between South Asian women’s perceptions of their own weight and guidelines on being overweight and obese (5). A substantial proportion of South Asian women who were overweight perceived themselves as normal weight, but European origin women had the opposite problem – perceiving themselves as overweight when they were not. This mismatch was seen in both those with, and without,diabetes and pre-diabetes. This preliminary observation requires confirmation elsewhere. South Asians’ knowledge of diabetes and heart disease causation and prevention in nearby South Tyneside was extremely poor (6). Finally, lack of physical exercise poses a huge challenge (7), particularly among women. We can make few assumptions about the effectiveness of interventions in South Asian populations though the principles derived from studies of white European origin populations need to be used pending the acquisition of ethnic group specific data. While the task of halting the process of pre-diabetes becoming diabetes is an urgent one, careful evaluation of screening and of interventions is essential. References 1. Venkat Narayan, K M, Imperatore G, Benjamin S M, Engelgau M M. Targeting people with pre-diabetes: Lifestyle interventions should also be aimed at people with pre-diabetes. BMJ 2002;325:403-4 2. Bhopal, R S, Unwin N, White M. et al. Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi and European origin populations: cross sectional study. BMJ 1999;319:215-220 3. Unwin N, Alberti K G M M, Bhopal R, Harland J, Watson W, White M. Comparison of the current WHO and the new ADA criteria for the diagnosis of diabetes in three ethnic groups in the UK. Diab Med 1998;15:554-557 4. Patel S, Unwin N, Bhopal R, White M, Harland J, Ayis, S A, Watson W, Alberti K G M M. A Comparison of proxy measures of abdominal obesity in Chinese, European and South Asian adults. Diabetic Medicine 1999; 16: 853-60 5. Patel, S, Bhopal, R, Unwin, N, White, M, Alberti, K.G. and Yallop, J. Mismatch between perceived and actual overweight in diabetic and non- diabetic populations: a comparative study of South Asian and European women. Journal of Epidemiology Community Health 2001;55: 332-333. 6. Rankin J, Bhopal R. Understanding of heart disease and diabetes in a South Asian community: cross sectional study testing the `snowball' sample method. Pub Health 2001; 115: 253-260. 7. Hayes L, White M, Unwin N, Bhopal R, Fischbacher C, Harland J et al. Patterns of physical activity and relationship with risk markers for cardiovascular disease and diabetes in Indian, Pakistani, Bangladeshi and European adults in a U K population. Journal of Public Health Medicine 2002;24:170-78