单靠筛检与治疗无法预防第二型糖尿病


  【24drs.com】根据在线发表于1月4日BMJ期刊的一篇统合分析,不太可能单靠预防第二型糖尿病的两种策略之一-「筛检与治疗」即有很大的影响。
  
  这个由英国国家糖尿病预防计划和在美国及澳洲之计划推动的方法,可辨识那些糖尿病风险高的人,并导致以metformin治疗或生活型态介入。
  
  这种替代策略是一种以人群为基础的方法,每个人都是公共卫生政策(如改变交通方式与使用绿色空间)的目标。
  
  英国牛津大学Nuffield初级照护健康科学系Eleanor Barry等人分析了46篇筛检检测研究与50项介入试验。
  
  他们进行了两篇统合分析 — 一篇分析是针对已确定糖尿病前期者之筛检测试的准确性(与口服葡萄糖耐受测试比较),另一篇是评估进行生活介入或使用metformin之后发生糖尿病的相对风险。
  
  他们发现,不论某人是否会发展为第二型糖尿病,筛检(测量HbA1c值与空腹血浆葡萄糖值)是不佳的预测因子,可能导致错误的信心或不必要的治疗。
  HbA1c值对于预测高风险(敏感度为49%)或低风险糖尿病者(专一度为79%)都是无效。
  
  空腹血浆葡萄糖值的平均敏感度为25%、专一度为94%。
  
  进行3-6年的生活型态介入显示,从第6个月到6年时,第二型糖尿病的相对风险降低36%,在追踪研究期间降低到20%。但是,作者们承认他们对这些估计只有中度到非常低的信心,因为研究质量通常偏低。
  
  使用metformin的患者在服用该药期间,其相对风险降低26%。
  
  此外,分析发现,国际上对于什么是前期糖尿病的定义并不一致。作者们指出,如果研究者使用美国糖尿病协会(ADA)而非世界卫生组织(WHO)的定义,前期糖尿病人数将会加倍。
  
  WHO和国际专家委员会建议,对那些空腹血浆葡萄糖值6.0-6.9 mmol/L与HbA1c值42-47 mmol/mol (6.0–6.4%)的人诊断为前期糖尿病。
  
  相对的,ADA使用的阈值是:空腹血浆葡萄糖值5.6 - 6.9 mmol/L或HbA1c 值39 - 47 mmol/mol (5.7–6.4%)。
  
  Barry医师等人结论指出,筛选测试是不佳的预测因子,但是,对于有动机且有社会支持维持改变的人,介入方式在减少病程进展为糖尿病方面有一些成功 。
  
  不过,他们承认,这些人数很少,所以他们建议进行更多人口的介入方式研究。
  
  寻找正确的预防策略是很重要的,因为全世界的流行率上升。作者们写道,有4亿2200万成年人患有糖尿病,而在2005-2030年间,预期死于其并发症的人数将会倍增。
  
  如果单看英国的资料,已经有320万人诊断患有第二型糖尿病,到了2025年,此数据预期增加至500万,将占英国国家健保局支出达237亿英镑(约302亿美元) 。
  
  在编辑评论中,英国Coventry Warwick大学Warwick医学院公卫医学暨健康科技评估教授Norman Waugh认为,因为以前的研究发现,在一般人口中进行筛检是准确和有成本效益的,需要更多研究探讨不同的、非空腹的检测方法。
  
  他表示,监于HbA1c与空腹血浆葡萄糖值的缺陷,遗憾的是,没有针对非空腹50 g葡萄糖挑战测试的更多研究,它大多是用于筛检妊娠糖尿病,但是很少用于筛检第二型糖尿病或葡萄糖耐受不佳。
  
  他建议,在筛检及治疗个人和鼓励改变生活型态之政策与维持整个人口的这些变化之间取得平衡,不过,他也承认,遵守生活型态建议的比率是很低的。
  
  他表示,政策改变可以包括对一些食物和含糖饮料征税,或将自行车车道与交通车车道分开。
  
  Waugh医师写道,预防或延迟第二型糖尿病需要有效的措施,以激励一般民众保护自己的健康。
  
  资料来源:http://www.24drs.com/
  
  Native link:'Screen and Treat' Alone Unlikely to Prevent Type 2 Diabetes
  

'Screen and Treat' Alone Unlikely to Prevent Type 2 Diabetes

By Marcia Frellick
Medscape Medical News

"Screen and treat," one of two strategies for preventing type 2 diabetes, is unlikely on its own to have much of an impact, according to a meta-analysis published online January 4 in the BMJ.

That approach, promoted by the United Kingdom's National Diabetes Prevention Programme and programs in the United States and Australia, among others, identifies those at high risk for diabetes individually and leads to treatment with metformin or lifestyle intervention.

The alternate strategy is a population-based approach where everyone is targeted through public-health policies, such as changes to transportation and use of green spaces.

Eleanor Barry, MBBS, of the Nuffield Department of Primary Care Health Sciences at University of Oxford in the United Kingdom, and colleagues, analyzed 46 studies of screening tests and 50 intervention trials.

They did two meta-analyses — one to study the accuracy of screening tests (compared with the oral glucose tolerance test) in identifying prediabetes and another to assess relative risk of developing diabetes after lifestyle interventions or metformin.

They found that the screenings (measuring HbA1c levels and fasting plasma glucose) were poor predictors of whether someone would develop type 2 diabetes and could lead to false confidence or unnecessary treatments.

HbA1c was ineffective both at predicting people at high risk (sensitivity levels of 49%) or low risk for diabetes (specificity 79%).

Fasting plasma glucose had a mean sensitivity of 25% and specificity of 94%.

Lifestyle interventions spanning 3 to 6 years showed a 36% drop in relative risk of type 2 diabetes from 6 months to 6 years, which fell to 20% in follow-up studies. But the authors acknowledge: "We have only moderate to very low confidence in these estimates, however, because study quality was often low."

Patients using metformin saw a relative risk reduction of 26% while taking the drug.

In addition, the analysis found inconsistency internationally as to what constitutes prediabetes. The authors note that prediabetes numbers would double if researchers used the American Diabetes Association's (ADA) cutoffs rather than the World Health Organization (WHO) cutoffs.

WHO and the International Expert Committee recommend diagnosis of prediabetes for those with a fasting plasma glucose of 6.0 to 6.9 mmol/L and HbA1c of 42-47 mmol/mol (6.0–6.4%).

By contrast, the ADA uses a cutoff for fasting plasma glucose of 5.6 to 6.9 mmol/L or HbA1c of 39 to 47 mmol/mol (5.7–6.4%).

Dr Barry and colleagues conclude that screening tests are poor predictors, but interventions have some success in reducing progression to diabetes for those who have the drive and the social support to sustain the changes.

However, those numbers will be small, they acknowledge, so they recommend more research into populationwide interventions.

422 Million Adults Living With Diabetes

Finding the right prevention strategy is critical as the prevalence surges worldwide. The authors write that "422 million adults are living with diabetes, and the number expected to die from its complications is predicted to double between 2005 and 2030."

Looking at the United Kingdom alone, already 3.2 million people have been diagnosed with type 2 diabetes. By 2025, that number is expected to grow to 5 million, at a cost of £23.7 billion ($30.2 billion) to the National Health Service.

In an accompanying editorial, Norman Waugh, MBChB, professor of public-health medicine and health-technology assessment at Warwick Medical School, University of Warwick, Coventry, United Kingdom, suggests more studies on a different, nonfasting test, given that previous studies have found it accurate and cost-effective for screening in the general population.

"Given the imperfections of HbA1c and fasting plasma glucose, it is a pity that more research has not been done on the nonfasting 50-g glucose challenge test, much used in screening for gestational diabetes but rarely used in screening for type 2 diabetes or impaired glucose tolerance," he says.

He suggests a balance of screening and treating individuals and policies that encourage changing lifestyle and maintaining that change across whole populations, although he acknowledges adherence to lifestyle advice is low.

Policy changes can include taxing some foods and sugary drinks or separating bike lanes from traffic lanes, he says.

"Preventing or delaying type 2 diabetes requires effective measures to motivate the general population to protect their own health," Dr Waugh writes.

The study authors and Dr Waugh declare no relevant financial relationships.

    
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