can Diabetes Association’s position statement on. prevention of diabetes has recommended screening to diabetes were attributable to impaired glucose tolerance. …
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Targeting people with pre-diabetes
K M Venkat Narayan, Giussepina Imperatore, Stephanie M Benjamin and Michael M Engelgau BMJ 2002;325;403-404 doi:101136/bmj3257361403
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5 UNICEF Action to assist war-affected children in Sierra Leone proposed by special representative for children in armed conflict Press release HR/4432, 14 September 1999 wwwunorg/News/Press/docs/1999/ 19990914hr4432dochtml accessed 24 Jul 2002 UNICEF Child labour in the carpet weaving industry in Punjab Punjab: UNICEF, 1992 Islam S In the clutches of an invisible enemy Star Weekend Magazine 1998;3105:5-11 The Daily Star, City Publishing House Ltd, Dhaka World Health Organization Children at work: special health risks WHO Technical Report Series 756 Geneva: WHO, 1987 Amnesty International War children tell their stories Amnesty November/December 2000;104:4-7
Editorials
6 7 8 9
10 Naidu US, Parasuraman S Health situation of working children in Greater Bombay A report of the World Health Organization Bombay: Tata Institute of Social
Sciences, 1985 11 UNICEF The state of the worlds children 1997 Focus on child labour Oxford: Oxford University Press, 1997 12 Haspels N, Jankanish M Action against child labour Geneva: International Labour Office, 2000 13 International Labour Organisation Preventing bonded labour in Pakistan Geneva: International Programme on the Elimination of Child Labour, 2001 wwwiloorg/public/english/standards/ipec/about/ factsheet/facts15htm accessed 24 Jul 2002
Targeting people with pre-diabetes
Lifestyle interventions should also be aimed at people with pre-diabetes
hree major randomised controlled trials, conducted in diverse countries, settings, and populations, confirm that effective lifestyle intervention can prevent or delay the progression to type 2 diabetes in groups at high risk, such as overweight people with impaired glucose tolerance glucose concentration 78-111 mmol/l, two hours after a 75 g loading13 In the largest of these trials, the diabetes prevention programme in the United States, a lifestyle modification programme was delivered with the goals of at least a 7 weight loss and at least 150 minutes of physical activity per week4 At 24 weeks, 50 of the participants in the
lifestyle intervention group had achieved the weight loss goal and 74 had achieved the activity goal In this trial, lifestyle intervention reduced the incidence of diabetes by 58, and one case of diabetes was prevented for every 69 people treated for three years3 In response to this impressive evidence, the American Diabetes Associations position statement on prevention of diabetes has recommended screening to detect people with impaired glucose tolerance or impaired fasting glucose fasting glucose concentration 61-70 mmol/l during healthcare office visits by people aged over 45–particularly those with a body mass index of 25 or more4 People found to have impaired glucose tolerance or impaired fasting glucose collectively referred to as pre-diabetes will be given counselling on weight loss as well as instruction on increasing their physical activity4 Type 2 diabetes has long been linked with behavioural, environmental, and societal factors such as overweight, physical inactivity, sedentary behaviour, and unhealthy dietary habits5 It may be intuitive and tempting to argue that programmes designed to prevent diabetes should be aimed at the underlying determinants of lifestyles in
society and therefore should be delivered to the population at large6 There are, however, several reasons, based on epidemiology, pathophysiology, and patterns of human behaviour, why we should focus our energy and effort on prevention programmes for people at high risk for diabetes, such as those with pre-diabetes Firstly, the relation between glycaemia and incidence of diabetes is non-linear, with the risk threshold coinciding with the onset of pre-diabetes In the Hoorn study, risk for conversion to diabetes during 65 years of follow up was more than 10 times higher in people with impaired glucose tolerance 579/1000 person years or impaired fasting glucose 514/1000
T
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person years than in people with normoglycaemia 7/1000 person years7 Secondly, although 8 of people in the Hoorn study had impaired glucose tolerance, 40 of cases of incident diabetes were attributable to impaired glucose tolerance Similarly, 10 had impaired fasting glucose, but 42 of cases of diabetes were attributable to impaired fasting glucose The risk of conversion to diabetes is equivalent for impaired glucose tolerance and impaired fasting glucose, but these two abnormalities overlap only
20-257 This is why the American Diabetes Association has defined pre-diabetes as either impaired glucose tolerance or impaired fasting glucose4 Approximately 17 million people in the United States–about as many as have diabetes–have pre-diabetes Thirdly, clinical trials have shown evidence of benefit that is, prevention or delay of diabetes only for people with pre-diabetes13 Fourthly, all people who develop diabetes go through pre-diabetes, although the length of this phase may vary5 Effectively delivering lifestyle intervention to people with pre-diabetes will therefore ensure that most, if not all, future cases of diabetes are targeted Fifthly, patterns of human behaviour also support focusing on people with pre-diabetes The health belief model suggests that for people to comply with participatory preventive interventions, they will need to perceive both risk and potential benefit8 People with pre-diabetes are at very high risk for diabetes,7 and evidence points to high potential benefit from lifestyle interventions13 According to the theory of diffusion of innovations, a new intervention is best applied to a small proportion of the population that is likely to adopt it; then,
societal forces will facilitate spreading such interventions to others in a sequential manner9 Consistent with these behavioural theories, focusing efforts on people with pre-diabetes, who comprise over 20 of overweight people over 45 and who are most likely to adopt a challenging intervention, is a strategically sound approach to preventing diabetes The compelling evidence for success in preventing or postponing type 2 diabetes should be viewed as a catalyst for promoting lifestyle modifications across society Undoubtedly, population based public health efforts will be needed to encourage and support healthy lifestyles Such societal approaches are complementary to, and not at odds with, a clinical approach of targeting and treating people who have pre-diabetes6 For a primary care practitioner, focusing on detecting people with pre-diabetes and delivering
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primary care doctors,11 needs to be raised, and guidelines for its management are urgently needed K M Venkat Narayan adjunct professor
kav4@cdcgov
effective lifestyle intervention to them is an immediate and difficult challenge
Further assessment will be needed to determine whether detection will require opportunistic screening with fasting glucose alone, with an oral glucose tolerance test, or with simpler and cheaper methods such as a multivariate diabetes risk score10 Similarly, lifestyle interventions can be delivered in many ways: individual counselling, group counselling, and workplace based programmes Regardless of all these factors, prevention of diabetes through lifestyle modification among people with prediabetes has arrived, and this new challenge needs to be met Awareness of pre-diabetes, which is low among
1 Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, et al Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and diabetes study Diabetes Care 1997;20: 537-44 Tuomilehto J, Lindstorm J, Eriksson JG, Valle TT, Hamalainein H, IlanneParikka P, et al, for the Finnish Diabetes Prevention Study Group Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance N Engl J Med 2001;333:1343-50 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 American Diabetes Association and National Institutes of Diabetes, Digestive and Kidney Diseases The prevention or delay of type 2 diabetes Diabetes Care 2002;25:1-8 Knowler WC, Narayan KMV, Hanson RL, Nelson RG, Bennett PH, Tuomilehto J, et al Preventing non-insulin-dependent diabetes mellitus Diabetes 1995;44:483-8
Giussepina Imperatore medical epidemiologist Stephanie M Benjamin epidemiologist Michael M Engelgau chief, epidemiology and statistics branch
Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Mailstop K-10, 4770 Buford Highway NE, Atlanta, GA 30341, USA
Rose G The strategy of preventive medicine Oxford: Oxford University Press, 1993 7 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;285:210913 8 Janz NK, Becker MH The health belief model: a decade later Health Educ Q 1984;2:1-47 9 Rogers EM Lessons for guidelines from the diffusion of innovations Jt Comm J Qual
Improv 1995;21:324-8 10 Stern MP, Williams K, Haffner SM Identification of persons at high risk for type 2 diabetes mellitus: do we need the oral glucose tolerance test? Ann Intern Med 2002;136:575-81 11 Wylie G, Hungin APS, Neely J Impaired glucose tolerance: qualitative and quantitative study of general practitioners knowledge and perceptions BMJ 2002;324:1190-5 6
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BMJ USA is now available online
n editorial in the 17 February 2001 issue spoke of the two US sisters of the BMJ, the Western Journal of Medicine and the newly released BMJ USA1 We bring bad and good news about the sisters The bad news is that the Western Journal of Medicine, a popular publication among doctors in the western United States, has succumbed to the economic pressures faced by todays medical journals The BMJ Publishing Group and the University of California regret that they were unable to keep this impressive journal in circulation The good news is that BMJ USA remains vibrant and growing and now has online access BMJ USA is a monthly journal that is circulated to some 100 000 primary care doctors in the United States Its editors assemble articles from the weekly
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Rack–a special feature in BMJ USA–summarises the findings of recently published studies from major journals and practice guidelines of interest to American doctors With this issue we announce an important new feature of BMJ USA: online access Readers familiar with the bmjcom home page will notice a link to BMJ USA that brings the full text of this journal to readers in America and elsewhere We think internet access will make BMJ USA more accessible to primary care doctors in the United States, and perhaps general practitioners in other countries will find the site useful Articles that appeared originally in the BMJ, which are already available on bmjcom, will look the same in the online BMJ USA; and bmjcom will sometimes offer users the opportunity to click on special tables and resources that BMJ USA has inserted to Americanise these articles And, of course, online BMJ USA will offer readers complete access to new articles that never appeared in the BMJ Visit wwwbmjcom/bmjusa to see more Richard Smith editor BMJ
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