Prevention of diabetes
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38996.709340.BE (Published 12 October 2006) Cite this as: BMJ 2006;333:764
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The concern expressed by Heneghan et al[1] that drug therapy to
prevent diabetes may not be as attractive as it first appears, maybe
justified as far as rosiglitazone, but not for metformin which is
effective,safe and cheap.
While the 31% reduction in new cases of diabetes in the Diabetes
Prevention Programme (DPP)[2] with metformin, appears unimpressive in
comparison to the lifestyle groups 58%; in certain subgroups metformin was
more impressive. Reductions of incidence of diabetes in the young (under
45) was 44% and the obese (BMI >35) was 53% (lifestyle 48% and 51%
respectively). It would be interesting to see an analysis of the "young
and obese", considering it is in this group much of the concern about the
future lies.
It should be remembered that the subjects in the DPP were highly
selected, to be appropriate for a trial of intensive lifestyle
modification. For instance smoking prevalence was only 7%. We are unlikely
to see the same gains from lifestyle intervetion in the real world.
While Heneghan et al[1] points out, rosiglitazone was associated with
a non-significant 37% increase in cardiovascular end-points in the DREAM
study[3]; metformin appears safe. The UKPDS[4] showed a 36% reduction for
all-cause mortality, and 42% for diabetes-related death with metformin in
the obese (BMI above 25.6) .
Regarding cost, lifestyle intervention in the DPP cost $2,780/ person
over 3years. The drug treatment cost with 8mg rosiglitazone/day (as per
DREAM)for 3years, would be nearly £2000[5], but metformin 850mg twice
daily (as per DPP), would cost less than £40. Furthermore cost
effectiveness analyasis of the UKPDS showed overall cost savings from
reduced hospital costs with metformin.
While the UKPDS is considered a diabetes study, entry criteria was a
fasting glycaemia above 6.0mmol/l, or what we now consider as impaired
fasting glycaemia. We should be prepared to follow the clear evidence base
and prescribe metformin to any overwieght patient with abnormal fasting
glucose, after 3month of lifestyle advice.
1. Heneghan, C., M. Thompson, and R. Perera, Prevention of diabetes
10.1136/bmj.38996.709340.BE, in BMJ. 2006. p. 764-765.
2. Diabetes Prevention Program Research Group. Reduction in the
incidence of type 2 diabetes with lifestyle intervention or metformin. N
Engl J Med 2002;346: 393-403
3. DREAM (diabetes reduction assessment with ramipril and
rosiglitazone medication) Trial Investigators; Gerstein HC, Yusuf S, Bosch
J, Pogue J, Sheridan P, Dinccag N, et al. Effect of rosiglitazone on the
frequency of diabetes in patients with impaired glucose tolerance or
impaired fasting glucose: a randomised controlled trial. Lancet 2006;368:
1096-105
4.UK Prospective Diabetes Study Lancet 1998 sept12 352(9131):854-65
5.Drug Tariff
Competing interests:
None declared
Competing interests: No competing interests
The Diabetes Prevention and Care can be divided into Primary,
Secondary and Tertiary prevention.
1.PRIMARY PREVENTION- The two strategies suggested for the primary
prevention are
a) POPULATION BASED STRATEGY- The development of prevention
programmes for Diabetes based on the elimination of environmental risk
factors is possible. The prevention of development of even the risk
factors so called, primordial prevention, should be implied.
b) HIGH RISK STRATEGY- Correction of risk factors once they appear
like sedentery life style, over-nutrition , obesity, smoking, high blood
pressure and elevated cholestrol will reduce the risk of diabetes. It
targets the high risk target population.
2. SECONDARY PREVENTION- This implies the adequate treatment of
Diabetes once detected. Treatment can be based on diet alone , diet and
anti-diabetic drugs or diet and insulin. Routine check up of blood sugar,
body weight, urine for proteins and ketones and visual acuity should be
done to effectively reduce complications. The methods used in it can be
a) Patient self-care.
b) Home Blood glucose monitoring.
c) Glycosated Hemoglobin Estimations at half yearly intervals.
3. TERTIARY PREVENTION- At the tertiary level the special Diabetes
clinics should be organised and establishment of units capable of
providing diagnostic and management skills of high order should be done.
All the ways of prevention can work in unison to reduce the mortality
and morbidity associated with Diabetes , but in the coming times the
stress should be on the primordial and the primary prevention.
Competing interests:
None declared
Competing interests: No competing interests
It continues to astonish me how it is that people fail to see the
obvious.
In New Zealand we are required to fence swimming pools at great expense in
order to prevent a very small number of children from drowning.
In New Zealand we are able to buy the most dangerous and addictive drug
known (tobacco) from any outlet including petrol stations despite the fact
that driver distraction (alone) arising from the lighting of cigarettes
is as dangerous as the distraction from cell phones.
In New Zealand we hand out money ad libertum to the poor and uneducated
and expect them to make healthy food choices in the face of an environment
awash with cheap and sugar laden alternatives.
In New Zealand we allow supermarkets to place the most destructive foods
within easy view and reach of children - especially at the checkout
counters.
Now I invite your readers to a simple thought experiment.
Firstly - some education. In the Vietnam war 50% of theAmrican troops used
heroin. Upon repatriation less than 3% reamined addicted.
So why not replace the candy with heroin?
An argument could easily be constructed which would support such a move
It is well beyond time that doctors, the people and goverments ceased to
produce specious arguments in support of gradualism and advocated
immediate and outright control of this most dangerous of all substances.
Competing interests:
None declared
Competing interests: No competing interests
I read the timely article by Heneghan et al[1] with lots of interest.
They have rightly advocated balance in approach to prevention of
diabetes—especially in light of the DREAM trial[2]. However, their
argument against the use of composite endpoint (new onset of diabetes plus
all cause mortality) in this important trial is debatable. It is well
documented that increase in glucose either on therapy or otherwise is an
important risk factor for all cause and cardiovascular mortality[3].
Therefore, adoption of this composite endpoint-- however contentious--is
understandable[4], especially, when glucose is a risk factor for both
diabetes as well as all cause mortality.
They do not support, and rightly so, the use of pharmacotherapy in
primary prevention of diabetes due to its greater adverse-at times serious
- events, and consequently high attrition rate. However, it needs to be
highlighted that pharmacotherapy as compared to lifestyle modifications
is not cost-effective nor it is comparable- if not better—to lifestyle
modification in sustainability of benefits after discontinuation of
therapy, or in-term of prevention of other important cardiovascular
outcomes.
Lifestyle modifications, on the other hand, often have been stated to
less practical purely on the basis of the complex intervention as in
DPP[5]. However, most of the other studies had interventions, which were
much simpler and perhaps easily transferable to the general practice
setting e.g. in Finish diabetes prevention[6] study there were on average
16 session for median follow-up of 3.2 years in sharp comparison with DPP
which had 16 curriculum session in first 6 months. In Da-Qing[7] and
Indian diabetes prevention study[8], again the lifestyle interventions are
not that complex, and can be translated in general practice-- although
with some costs and efforts, and may be with slightly lower reduction in
diabetes development.
In summary, the lifestyle modification is cheap and effective
intervention, benefits of which, persists beyond the intervention as well
as is on cardiovascular outcomes. Their implementation in the general
clinical practice need not be hampered due to misplaced fear of either its
labour intensive nature or costs.
1. Heneghan, C., M. Thompson, and R. Perera, Prevention of diabetes
10.1136/bmj.38996.709340.BE, in BMJ. 2006. p. 764-765.
2. Gerstein, H.C., et al., Effect of rosiglitazone on the frequency of
diabetes in patients with impaired glucose tolerance or impaired fasting
glucose: a randomised controlled trial, in Lancet. 2006. p. 1096-105.
3. Dunder, K., et al., Increase in blood glucose concentration during
antihypertensive treatment as a predictor of myocardial infarction:
population based cohort study, in Bmj. 2003. p. 681.
4. Schulgen, G., et al., Sample sizes for clinical trials with time-to-
event endpoints and competing risks. Contemp Clin Trials, 2005. 26(3): p.
386-96.
5. Knowler, W.C., et al., Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metformin, in N Engl J Med. 2002. p. 393-
403.
6. Tuomilehto, J., et al., Prevention of type 2 diabetes mellitus by
changes in lifestyle among subjects with impaired glucose tolerance, in N
Engl J Med. 2001. p. 1343-50.
7. Pan, X.R., et al., Effects of diet and exercise in preventing NIDDM in
people with impaired glucose tolerance. The Da Qing IGT and Diabetes
Study, in Diabetes Care. 1997. p. 537-44.
8. Ramachandran, A., et al., The Indian Diabetes Prevention Programme
shows that lifestyle modification and metformin prevent type 2 diabetes in
Asian Indian subjects with impaired glucose tolerance (IDPP-1), in
Diabetologia. 2006. p. 289-97.
Competing interests:
None declared
Competing interests: No competing interests
Drugs to prevent the onset of diabetes patients at risk do
work. However their effectiveness seems to be inferior to
intensive life style interventions. The authors point to labour
intensive programms involving up to 16 one to one sessions to promote
healthier behaviour and correctly ask if those standarts are
economical to offer to larger populations. There is furthermore
concern if healthy behaviour is maintained after active intervention
has ceased.
Comparing both approaches misses one point. Many patients would
opt for the soft way of taking a pill when given the choice.
Financial resources in medicin all over the world are increasingly
restricted and rationing will ask question of effectiveness,
appropriateness and justice.
Health behaviour modification fits all three categories and if
patients were to have no choice but to take part in a well
balanced life style intervention its effectivity would be even
greater.
Competing interests:
None declared
Competing interests: No competing interests
Cost of risk reduction
In addition to the clinical effectiveness of lifestyle interventions
vs drugs to prevent diabetes, Americans face another challenge--the ever-
present "cost to the public."
A recent analysis of the results of counseling vs drug use in the New
York Times, Oct 17, included the helpful observation by the medical
director of a healthcare consulting company that "if a large health plan
decided to offer [individualized counseling] for its members at risk for
diabetes, the plan's price for every member would rise by 1%."
Thus, the public is once again being made a pocketbook voter in the
choice of medical care. "Those people"--in this case, those at risk for
diabetes--will cost YOU money if they're counseled rather than simply take
their pill.
The question is not whether reducing health risks is a good idea--who
could disagree with that?--but rather, the use of financially driven
public pressure to make healthcare decisions.
Competing interests:
None declared
Competing interests: No competing interests