Impaired glucose tolerance: qualitative and quantitative study of general practitioners' knowledge and perceptions
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7347.1190 (Published 18 May 2002) Cite this as: BMJ 2002;324:1190
All rapid responses
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?
Competing interests: No competing interests
The article is most interesting. However, no indication is given as
to what constitutes this condition. What are the parameters?
Competing interests: No competing interests
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].
Competing interests: No competing interests
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.
Competing interests: No competing interests