Targeting people with pre-diabetes
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7361.403 (Published 24 August 2002) Cite this as: BMJ 2002;325:403All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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).
Competing interests: No competing interests
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
Competing interests: No competing interests