Screening for Prediabetes

There are several good reasons why measurement of blood glucose can be used as an effective screening tool. Firstly, as described above, it can be helpful in predicting risk for two important and common diseases, T2D and CVD, and screening for pre-diabetes will inevitably identify a group of individuals with asymptomatic T2D. Secondly, the mechanisms by which hyperglycaemia is involved in the pathophysiology of these diseases are increasingly well understood, ensuring that the screening test is directly relevant to the disease process. Thirdly, pre-diabetes (and T2D itself) has a prolonged (asymptomatic) preclinical phase during which intervention strategies may be instituted. Fourthly, measurement of blood glucose is an acceptable, reliable and relatively cheap method of identifying this prolonged preclinical phase. Finally, as summarized above, there is now evidence that intervention in the preclinical phase (evidence base predominantly in middle-aged obese subjects with IGT) can delay or prevent disease, although the current evidence is predominantly for T2D rather than CVD.

However, trials have not yet been performed to determine whether or not a screening programme per se can reduce the incidence of or complications from T2D, and there is still no clear consensus on who should be screened and how often. Furthermore, a screening programme must be cost-effective but it is not yet known if the costs of earlier identification and intervention will be offset by future reductions in healthcare costs resulting from reduced morbidity and mortality from T2D and CVD. The ADA Position Statement on 'Prevention or Delay of Type 2 Diabetes' published in 2004 (American Diabetes Association, 2004b) concludes that 'men and women > 45, particularly those with BMI > 25, are candidates for screening to detect pre-diabetes (IFG or IGT)'. In addition, it is also acknowledged that screening should be considered in younger individuals with BMI > 25 who have additional risk factors including first-degree relative with T2D, habitual physical inactivity, member of 'high risk' ethnic population, history of gestational diabetes, hypertensive, atherogenic lipid profile, history of vascular disease and history of polycystic ovary syndrome. It is proposed that re-screening at 3-year intervals 'is reasonable' in subjects with normoglycaemia, and that either fasting plasma glucose or 2-h post-glucose load level could be used as screening tools, with confirmatory measurements on a separate day (although fasting plasma glucose would be preferred from a resource viewpoint). If pre-diabetes is confirmed, it is suggested that monitoring for development of T2D should be performed every 1-2 years. While the Position Statement strongly backs the use of lifestyle intervention in pre-diabetes, it falls short of recommending pharmacological treatment, stating that there is insufficient evidence to support the cost-effectiveness of such an approach (this issue is discussed in more detail in previous sections).

While the cost-effectiveness of community screening has yet to be tested, it could be argued that this approach would serve to enhance public awareness about both T2D and CVD and help to encourage healthy living at a population level in terms of diet and exercise. From a commonsense standpoint, there is much to be said in support of population health initiatives with Government backing linked to positive incentives (e.g. cheaper healthy foods, free use of community leisure facilities), but this would require significant investment of time and resources in a relatively healthy generation in an attempt to prevent morbidity and mortality several decades in the future, a concept that is unlikely to be welcomed by politicians whose careers depend on being re-elected at 4-year intervals.

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