Screening For Obesity To Prevent Type 2 Diabetes

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The primary prevention of type 2 diabetes is an urgent issue and weight control in the population seems to be the most important part of the preventive process. The drastic predictions concerning the time trends of obesity and type 2 diabetes call urgently for research aimed at finding a solution or more probably several solutions to the problem. One approach could be a mass screening programme examining the whole population for body weight and offering obese individuals the opportunity to participate in a weight management programme. Another approach could be a selective screening procedure where only some especially high-risk segments of the population are examined.

Type 2 Diabetes and its Complications—a Serious Health Problem

People with diabetes have a substantially reduced life expectancy. Atherosclerosis is the most common long-term complication of diabetes, at least in Caucasian populations. People with diabetes are two to three times more likely to die from coronary heart and cerebrovascular disease than are people without diabetes. The relationship is even more accentuated in peripheral artery disease, which is four times more common among diabetes patients. Retinopathy develops in about 60% of those with type 2 diabetes (25) and seems to be present prior to the clinical onset of the disease in 10—30% of individuals (26). In the USA, kidney disease was 17 times more common in diabetic than in non-diabetic individuals, and diabetic kidney disease is considered the leading cause of renal disease requiring dialysis or transplantation. More than 50% of all non-traumatic lower-limb amputations conducted in the USA are associated with diabetes and the overall risk of amputation is 15 times greater in diabetic than in non-diabetic individuals (25).

Impaired Glucose Tolerance—an Intermediate Stage in the Development of Type 2 Diabetes

Both insulin resistance and beta cell dysfunction seem necessary for an individual to develop type 2 diabetes mellitus. Controversy exists about which of the two pathogenic mechanisms is the primary one. Genetic as well as environmental factors participate in the process. Using the two-step model for diabetes proposed by Saad, the diabetic process can be divided into a first step, which includes the transition from the normal to impaired glucose tolerance (IGT) and where insulin resistance seems to be the main determinant. The second step is the worsening from IGT to type 2 diabetes, where beta cell dysfunction seems to play a major role (27). In six prospectives studies the worsening of IGT to diabetes varied from 3.6% to 8.7% per year (28). In the combined analysis of all six studies, but not in all of the separate studies BMI was associated with the diabetes incidence independently of fasting and post-load glucose levels. Family history of diabetes was not associated with the progression of IGT to diabetes. It has been estimated that by the time the diagnosis of diabetes is determined according to a criterion of a fasting plasma glucose level of above 7.7 mmol/L (compare the new threshold of 7.0 mmol/L), 75% of the beta cell function has been lost (29).

A few long-term intervention studies, with the intention to prevent diabetes by treating IGT subjects, have been conducted. In the Malmo study, a combination of diet and exercise reduced the progression from IGT to diabetes during a 6-year period from 29% in the control group to 11% in the treatment group (30). The Chinese Da Qing IGT and Diabetes study showed similar results with a decrease in the incidence of diabetes in the diet and exercise treatment group of 42% compared to the control group at follow-up after 6 years (31). These two studies show that long-term lifestyle intervention may prevent or at least postpone the worsening of IGT to type 2 diabetes.

Taken together, many indications suggest that once the diagnosis of the diabetes is made, the reversibility of the diabetic state is lost, a state which probably has been present as a glucose—insulin feedback disturbance for 5—10 years (32), and what remains is to use all efforts possible to diminish further deterioration in beta cell function and diabetes disease. In contrast, lifestyle interventions have been shown to prevent the progression of IGT to diabetes. Furthermore, the effect on future macro-vascular disease, due to a state of insulin resistance and hyperinsulinaemia for several years before the diagnosis of diabetes is made, must also be included in the discussion of primary prevention.

An important point that must be considered in a screening programme aimed at preventing type 2 diabetes is how the distribution of BMI in the population affects the screening procedure. In the population a majority of people will be of normal weight or have a slight excess of body fat (overweight). A few will be seriously obese. Since the number of diabetic cases that will develop is dependent on both the relative risk and the number of people sharing that risk, one may argue from a population perspective that most diabetic cases will develop among the many having a slight increase in risk and

Obesity Screening Cpt

Reference

Table 5.2 Comparing the distribution of new diabetes cases at three different levels of body mass index in two populations

Reference

Body mass index

Diabetes cases (% of total)

Person-years of follow-up (% of total)

Body mass index

Diabetes cases (% of total)

Person-years of follow-up (% of total)

Colditz (33)a

>27

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