Should we screen for type 2 diabetes: Yes
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e4514 (Published 09 July 2012) Cite this as: BMJ 2012;345:e4514
All rapid responses
Dear editors,
The screening test need not be invasive and expensive (like: Fasting and Post-prandial sugar or Hb A1c). Simple test like urine can be done for sugar. But urine tests will have less sensitivity as many false negatives are there. So another screening tools like Canrisk1, FINDRISC2 and WHOSTEP3 QUESTIONAIRES or their combination or modifications can be used after adapting for the particular country's population and validation.
References:
1. http://www.diabetes.ca/documents/for-professionals/NBI-CANRISK.pdf
2. http://www.bjpcn-cardiovascular.com/pdf/3142/Vol5_Num5_September-October...
Competing interests: No competing interests
Screening for diabetes is a question of cost more than it is a question of who should be screened. The increase in this chronic non-‐communicable disease which has become a public health concern of the westernized world and calls for aggressive and effective measures to stem its prevalence. In England, where one-‐quarter of an estimated 3.1 million persons living with diabetes are undiagnosed, universal screening would be ideal. In the developing countries of the Caribbean where the prevalence rate exceed the global estimate of 6.6%; Barbados, 10.1% and Jamaica 8%, respectively, (Wilks et al 2008; IDF, 2010) there has been no call for universal screening. A cost -‐effective analysis revealed targeted screening more cost-‐effective than universal screening (Hoerder, 2004).
Screening in the early third and fourth decades of life when persons are in the prime of their productive years would certainly be of value in the detection and treatment of diabetes. Persons could have had the disease long before diagnosis and may have started to suffer from the complications of the disease; 7 % of those diagnosed in the United Kingdom have retinopathy at time of diagnosis ( Med Princ Pract ,2005 cited in Gillies, 2008; Harris 1993 cited in Wareham 2001).However, the targeted screening of hypertensive patients for diabetes was more cost-‐effective in 55-‐ 75 age group. (Hoerger et al, 2004).
In Jamaica, for example, though screening is not routinely done, it is recommended that patients, 45 years and over who are obese, should have a screening test done for diabetes. “The fasting plasma glucose (FPG) is the recommended screening test. The 75 gram Oral Glucose Tolerance Test (OGTT) is more sensitive for detecting glucose intolerance but is not recommended for screening as it is more expensive and less practical.” Caribbean Health Research Council (2006). World Health Organization has recently recommended the use of the glycolysated haemoglobin to diagnose diabetes (World Health Organization 2011 as cited in Khunti &. Davies, 2012). This test would be very expensive for the average client who is being diagnosed. The National Health Fund subsidizes the cost of the test, only after the diagnosis is made.
In conclusion, the cost factor is undoubtedly the major barrier to universal screening. Though universal screening would be ideal in detecting diabetes at an early age, there is not a strong case for this. Instead, it is more cost-‐effective to screen persons who have one or more risk factors.
Conflict of Interest: None declared
References
Caribbean Health Research Council (2006). Managing diabetes in primary care in the Caribbean. Retrieved from http://www.chrc-‐ caribbean.org/Portals/0/Downloads/Publications/Clinical%20Guideline s/Diabetes%20Guidelines.pdf
Gillis, C.L., Lambert P.C., Abrams K.R., Sutton, A.J., Cooper, N.J., Hsu, R.T., et al. (2008). Different strategies for screening and prevention of type 2 diabetes in adults: Cost effectiveness analysis. British Medical Journal 336:1180-5. doi:10:1136/bmj.39545.585289.25
Hoerger, T.J., Harris, R., Hicks, K.A., Donahue, K., Sorensen, S., Engelgau M., Screening for type 2 diabetes mellitus: A cost-effectiveness analysis. Annal of Internal Medicine. 140(9): 689-699.
Khunti, K. & Davies, M.(2012). Should we screen for diabetes?:Yes. Department of Health Sciences. British Medical Journal 345 doi:10.1136/bmj.e45i4 Wareham, N.J., Griffin S. J. (2001). Should we screen for type 2 diabetes?
Evaluation against national screening committee criteria. British Journal of Medicine 322:986-8.
Wilks, R., Younger, N., Tulloch-Reid, M., McFarlane, S., & Francis D. (2008). Jamaica Health and Lifestyle Survey 2007-8 Technical Report. Epidemiology Research Unit, University of the West Indies.
Andrea McPherson
Assistant Lecturer
The University of the West Indies School of Nursing (UWISON)
The University of the West Indies, Mona Campus, Kingston, Jamaica
(Research Intern, Great Lakes University, GLUK, Kenya) July 27, 2012
Competing interests: No competing interests
It would seem sensible to act to prevent or certainly delay the onset of Type 2 diabetes and there is plenty of evidence from around the world to suggest that this can be achieved1. There is also some evidence of population-based prevention from Cuba from their desperate ‘special period’ in the early 1990’s2. Economic conditions due to the collapse of the Soviet Union forced serious food supply and energy problems on the country. The decline in incidence of heart disease (35%) and diabetes(51%) was put down to the increased exercise forced upon the peopleand decreased calorie intake.
Screening is only useful if an effective intervention is available for those identified . And from my experience, this is difficult. I ran a research project based on best practice weight management and lifestyle techniques combined with the comprehensive internet resources of a major UK supermarket diet programme(this was to try to get round the problem of lack of dieticians in the NHS)3. The results led on to collaboration between the supermarket and primary care. The patient paid for a reduced rate internet subscription and the GP was funded for participation, but only after that participation had happened and then pro rata for follow up. I wrote to all of our identified people with pre-diabetes states informing them of the potential prevention of their condition and that local treatment was available, be it the funded scheme or any other initiative. Out of 79 letters there was not one reply.
This is a small local example highlighting the problem of engagement. There seems little point in identifying your population if then the population does not necessarily want that intervention. Perhaps it is in the way you sell it but marketing and advertising at least to match the food industry may be needed. Whilst we may have all the evidence, we need the back–up of resources from government or industry so that we can take the message to the people. From my experience the supermarkets are not going to lead this but will follow it if the incentive is right. We could make a start on by giving tax breaks on proportions of healthy food sold (all supermarkets have this data, it is only a matter of defining the list, and this has been done)4. It may be more productive than taxing ‘junk foods, ’ which manufacturers always seem to get around.
1 Lancet. 2006 Nov 11;368(9548):1673-9.Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lindström J, Ilanne-Parikka P, Peltonen M, Aunola S, Eriksson JG, Hemiö K, Hämäläinen H, Härkönen P, Keinänen-Kiukaanniemi S, Laakso M, Louheranta A, Mannelin M
2http://www.ncbi.nlm.nih.gov/pubmed/17881386
Competing interests: No competing interests
Without doubt Professors Khunti and Davies (1) wish to screen the UK population for type 2 diabetes to prevent the devastating consequences of this disorder. However, those given a diagnosis will surely be swept into a medicalised roller coaster of diets, which make little sense - followed by failure of their regime, and rapid progression into polypharmacy.
Professors Khunti and Davies mention the imminent publication of the National Institute for Health and Clinical Excellence’s guidance on identification and prevention of type 2 diabetes in people at high risk.
Apparently the guidance makes pragmatic recommendations to help people make long term lifestyle changes to reduce risk and delay onset of type 2 diabetes. (2)
A perusal of the list of stakeholders involved in this consultation makes interesting reading. (3) What new ideas will they bring forward to the diabetic table? High carb/low carb, high fat/low fat, high fibre, high veg, very low calorie diets, special herbs, barely tested drugs with unknown side-effects? It has all been done before. How about some good old fashioned individualised attention to people and not payment by results? Anyone with any common sense can see that T2DM can be reversed by sensible lifestyle, whilst a small percentage may need medication (with good safety record). There is an insatiable appetite to find those with pre-diabetes and type 2 diabetes. Many will be misdiagnosed. The modern protocol offered to those diagnosed does not necessarily prevent the devastating complications of type 2 diabetes.
How can the basic human need for proper and consistent nutrition matched by appropriate exercise be a priority in diabetes prevention, when commercial interests are touting for a lucrative solution, be it drugs or slimming products? The undeniable international commercial interest in type 2 diabetes continues to be a massive barrier to prevention of this lifestyle disorder.
The question is where would the funding for prevention come from without commercial interest?
The National Diabetes Audit reported up to 24,000 deaths from diabetes could be avoided in England alone every year, if patients and doctors controlled the condition better. (4)
Health services cannot cope with the type 2 diabetics already diagnosed; the care of type 1 diabetics is also seriously compromised. The lack of expertise in diabetes care represents serious cause for concern.
These unnecessary deaths are just the tip of the iceberg, as the tragedy of poor management of diabetes unfolds around the world.
(1) Khunti K, Davies M. Should we screen for type 2 diabetes: Yes. BMJ. 2012 2012-07-09 11:51:03;345
(2) NICE. Preventing type 2 diabetes—risk identification and interventions for individuals at high risk: draft guidance consultation. NICE, 2012
(3) NICE. Preventing type 2 diabetes—risk identification and interventions for individuals at high risk: draft guidance consultation. NICE, 2012. Type 2 diabetes: preventing the progression from pre-diabetes - list of registered stakeholders
(4) Susan Mayor News: Poor care leads to 24 000 premature deaths from diabetes in England each year BMJ2011; 343:d8081
Competing interests: No competing interests
Khunti and Davies face an unenviable task in putting the case for screening for diabetes given the paucity of supporting evidence, (1) and they rely to a large extent on (notoriously inaccurate) economic modelling. But it must have taken real chutzpah to cite, in support of their argument, the ACCORD study of intensive glucose lowering. The ACCORD trial was most notable for its early termination because of an increase in all-cause mortality of 22% in the intensive glycaemic control arm. (2)
1. Khunti K, Davies M. Should we screen for type 2 diabetes: Yes. BMJ. 2012 2012-07-09 11:51:03;345.
2. Effects of Intensive Glucose Lowering in Type 2 Diabetes. New England Journal of Medicine. 2008;358(24):2545-59.
Competing interests: No competing interests
Re: Should we screen for type 2 diabetes: Yes
The cited web-link to CANRISK is actually to the study questionnaire: the resulting multi-ethnic CANRISK diabetes risk scores were published in the Chronic Diseases and Injury in Canada, Dec 2011, located here: http://www.phac-aspc.gc.ca/publicat/cdic-mcbc/32-1/ar-04-eng.php
The discordance between traditional glucose-based diagnostic tests (FPG,OGTT) and hemoglobin A1c (glycated protein) is described here: http://www.bmj.com/content/343/bmj.d7163/rr/569969
Competing interests: No competing interests