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Rapid Responses: Rapid Responses published:
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Ethical consideration
- Philipp Andreas Conradi (14 October 2006)
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Lifestyle modfication remains the gold standard in primary prevention of diabetes
- Ajay K Gupta, Dr Jaya Ahuja (14 October 2006)
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PREVENTION AND INTERVENTION
- ANDREW MONTGOMERY (15 October 2006)
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PREVENTION AND CARE OF DIABETES
- Sameer Chadha, Shikha Mehta, Medical Student, MAULANA AZAD MEDICAL COLLEGE (15 October 2006)
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Lifestyle and Metformin the way forward in Diabetes Prevention
- John S Ashcroft (16 October 2006)
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Cost of risk reduction
- Joan McClusky (19 October 2006)
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Philipp Andreas Conradi, General Practitioner Otto-Dix-Ring 98 01219 Dresden, Germany
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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 |
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Ajay K Gupta, Clinical Research Fellow International Centre for Circulatory Health, NHLI, Imperial College London, W2 1PG, Dr Jaya Ahuja
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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 |
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ANDREW MONTGOMERY, locum Auckland
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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 |
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Sameer Chadha, Medical Student MAULANA AZAD MEDICAL COLLEGE, Shikha Mehta, Medical Student, MAULANA AZAD MEDICAL COLLEGE
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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 |
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John S Ashcroft, GP Old Station Surgery, Heanor Rd,Ilkeston,Derbyshire DE78 ES
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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 |
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Joan McClusky, medical writer New York, NY 10003
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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 |
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