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Impact of “screen and treat” diabetes policy questioned

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The health service’s “screen and treat” policy for preventing type 2 diabetes is unlikely to have a substantial impact on the growing epidemic of the condition, according to UK researchers.

NHS England’s National Diabetes Prevention Programme currently advocates a screen and treat approach to prevention, in which people are identified as “high risk” and offered individual intervention.

“Many people will receive an incorrect diagnosis and be referred, while others will be falsely reassured”

Study authors

Australia and the US have also previously adopted the same model to try and tackle the growing epidemic of type 2 diabetes, in contrast to a population-wide approach via public health policies.

However, the authors of a new study argue that the screen and treat model is only effective if a test exists that correctly identifies those at high risk, while also excluding those at low risk – and that an intervention exists that is acceptable to patients and clinicians.

The researchers, from Oxford University, assessed the diagnostic accuracy of screening tests for so-called “pre-diabetes” and the effectiveness of interventions in preventing the onset of type 2 diabetes in those with pre-diabetes.

Led by Professor Trish Greenhalgh, a GP and primary healthcare expert, they analysed the results of 49 studies of screening tests and 50 intervention trials.

Screening tests included fasting plasma glucose and raised HbA1c, and interventions were lifestyle change or treatment with metformin.

“Adherence to lifestyle advice remained poor”

Norman Waugh

They found that the diagnostic accuracy of tests used to detect pre-diabetes in screening programmes was low – fasting glucose was specific but not sensitive, and HbA1c was neither sensitive nor specific.

The finding suggested that large numbers of people would be unnecessarily treated or wrongly reassured, depending on the test used, said the study authors in the British Medical Journal.

“As screening is inaccurate, many people will receive an incorrect diagnosis and be referred on for interventions, while others will be falsely reassured and not offered the intervention,” they said.

University of Oxford

Impact of “screen and treat” diabetes policy questioned

Trish Greenhalgh

Meanwhile, lifestyle interventions lasting three to six years showed a 37% reduction in relative risk of type 2 diabetes, equating to 151 out of 1,000 people developing diabetes, compared with 239 of 1,000 in the control group. It fell to 20% in follow up studies.

Use of metformin showed a relative risk reduction of 26% while participants were taking this drug, translating to 218 out of 1,000 developing diabetes while taking metformin, compared with 295 of 1,000 not receiving it.

The researchers concluded that “screen and treat” policies would benefit some but not all people at high risk of developing diabetes.

The approach should be complemented by population-wide approaches for effective diabetes prevention, they said.

In an editorial in the same journal, Professor Norman Waugh, from Warwick Medical School in Coventry, claimed adherence to lifestyle change across whole populations was the key to prevention of type 2 diabetes.

Warwick Medical School

Impact of “screen and treat” diabetes policy questioned

Norman Waugh

He criticised use of the controversial term “pre-diabetes”, arguing that many patients labelled with it did not go on to develop diabetes.

Professor Waugh also said he believed there was a balance to be struck between screening and treating of individuals and changing behaviour in the whole population at risk.

However, he acknowledged that “adherence to lifestyle advice remained poor”. He concluded that “preventing or delaying type 2 diabetes requires effective measures to motivate the general population to protect their own health”.

About 3.2 million people have type 2 diabetes in the UK and by 2025 it is predicted that this will increase to five million, at an estimated cost of £23.7bn to the NHS.

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