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Comment

1888 www.thelancet.com 

Vol 370 December 8, 2007

As a starting point therefore, a global governance

mechanism should be established and coordinated by amultilateral agency with a global-health mandate to set

goals and targets that are acceptable worldwide, and to

create a mechanism for synchronising stakeholders’

efforts. Synchronisation can be achieved through

the creation of multilateral agreements, institutional

and programmatic relations, and partnerships to

derive an agreement for stakeholders and their roles

and obligations. Multisource funding also needs to

be established; possible options include multilateral

mechanisms for grants, private-sector funding,

and most importantly the creation of a financingmethod that will enhance the partnership’s ability to

catalyse country allocations for non-communicable

diseases—an approach to which country investment

from WHO can bring substantial value. WHO would

also be an important stakeholder by offering technical

assistance to countries to promote sustainable

and integrated public-health models that will

strengthen the prevention of non-communicable

diseases. Work should also begin to coordinate and

harmonise civil society’s response to the challenge of

non-communicable diseases and to develop a commonunderstanding of, messaging about, and strategies

related to these diseases. Possible medium-term

deliverables of this effort could include a framework

for the partnership, a portfolio of agreements outlining

the roles of stakeholders, and the creation of the fund

itself, with initial seed funding.The establishment of this arrangement as a first step

towards developing the global non-communicable dis-

ease partnership would counter some of the concerns

about the current neglect of such diseases. However, the

establishment of safeguards against ethical, method-

ological, accountability, sustainability, and governance

issues will be essential. Lessons from earlier experiences

with infectious disease partnerships can be instructive.7-9

Sania Nishtar 

Heartfile, Chak Shahzad, Islamabad 44000, Pakistansania@heartfile.org

I declare that I have no conflict of interest.

1 Adeyi O, Smith O, Sylvia R. Public policy and the challenge ofnon-communicable diseases. 2007. http://siteresources.worldbank.org/INTPH/Resources/PublicPolicyandNCDsWorldBank2007FullReport.pdf(accessed Aug 29, 2007).

2 Global Prevention Alliance bulletin. 2006. http://www.iaso.org/docu ments/GlobalPreventionAllianceBulletin1.pdf (accessed Aug 29, 2007).

3 Oxford Health Alliance. http://www.oxha.org/ (accessed July 27, 2007).

4 John Hopkins Bloomberg School of Public Health, Institute for Global TobaccoControl. http://www.jhsph.edu/global_tobacco (accessed July 27, 2007).

5 Sweet Resolution. Ovations launches global partnership to address chronicdisease. 2007. http://sweetresolution.wordpress.com/2007/05/04/ovations-launches-global-partnership-to-address-chronic-disease (accessedAug 29, 2007).

6 WHO. Preventing chronic diseases: a vital investment. Geneva: WHO, 2005.7 Buse K. Governing public-private infectious disease partnerships .Brown J World Affairs 2004; 2: 225–42.

8 Nishtar S. Public-private partnerships in health—a global call to action.Health Res Policy Syst 2004; 2: 5.

9 Widdus R. Public private partnerships for health require thoughtfulevaluation. Bull World Health Organ 2003; 81: 235.

Screening for diabetes and prediabetes

The Health Technology Assessment report by

Norman Waugh  and colleagues,1  on screening for

type 2 diabetes challenges the health sector, and primary

care in particular, to be more proactive in the detection

and treatment of both diabetes and prediabetes. The

conclusions are firmer than those of the UK National

Screening Committee after a previous review.2  Waugh

comes to this new view mainly as a result of the increasing

prevalence of obesity and consequent type 2 diabetes,

and the potential to reduce cardiovascular risk, especially

with cheap generic statins. We welcome the attention

given to prediabetes (impaired glucose tolerance and

impaired fasting glucose).

We suspect that an absence of clear guidelines

or acceptability for screening for diabetes has kept

prediabetes in the shadows. Impaired glucose

tolerance increases the risk of cardiovascular disease by

about 60%, and impaired fasting glucose does the same

by around 30%.3,4  Furthermore, for every person with

diabetes, there are four with prediabetes.5  Although

almost half of those with prediabetes progress to

diabetes, this process can be prevented or slowed by

diet, exercise, and several drugs that are used to treat

diabetes.6  Waugh and colleagues’ modelling predicts

that screening for and treating impaired glucose toler-

ance would be cost effective, particularly when lifestyle

interventions are used to treat identified cases.

Waugh and colleagues note that three of the

National Screening Committee criteria are still not

met. First, current management of diabetes is still less

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Comment

www.thelancet.com 

Vol 370 December 8, 2007 1889

than optimal. Second, current staffi ng levels might

not meet an increased workload from new diagnoses.Third, there is no evidence from randomised trials

that screening for diabetes results in benefits in terms

of cardiovascular disease or mortality, although a trial

currently underway will have results in about 7 years.

We suggest that efforts to improve diabetes care will

always continue and that staffi ng levels often follow

rather than precede new diagnoses. If we wait until

diabetes management is perfect, until staff levels are

ahead of requirements, and for a trial to be reported

in 7 years, we could rightly be accused of fiddling while

β-cell function burns.We also suspect that screening for both diabetes

and prediabetes has been inhibited by uncertainty

over which test to use. Waugh and colleagues state

that there is no perfect test. A fasting plasma-glucose

test will detect diabetes and impaired fasting glucose

but will miss impaired glucose tolerance. A random

plasma-glucose test lacks sensitivity and specificity. An

oral glucose-tolerance test is widely presented as a burden

for patients and has poor reproducibility. Glycosylated

haemoglobin (HbA1c) is not part of the formal diagnostic

criteria for impaired fasting tolerance, impaired glucosetolerance, or diabetes, but correlates with all three and is

used to monitor management of glycaemia in diabetes.

Previous lack of standardisation of the HbA1c test has now

largely been resolved, although some conditions such as

haemoglobinopathies might still affect the result.7

Increasing concentrations of blood glucose, starting

well below the diabetic range, measured by fasting

glucose8 or HbA1c,9 are linearly related to cardiovascular

disease outcomes and mortality (and also related to

microvascular outcomes10). Avoidance of such outcomes

is largely the purpose of diagnosis. Waugh and colleagues

suggest that more people would be tested and identified

at risk if HbA1c was used rather than glucose tests, and

suggest a cut-off HbA1c of 5·9% to identify diabetes and

most prediabetes. The gain from this more convenient

test and consequent increased uptake by patients could

outweigh any disadvantages of the HbA1c test.

Waugh and colleagues suggest that screening be

in two stages. The first step is selection of people at

increased risk on the basis of age, body-mass index,

or waist circumference, and other cardiovascular risk

factors such as hypertension. We would add ethnic

origin, family history of diabetes, and increased lipid

concentrations. Various risk scores have been developed.

The second step would be the blood test, such as HbA1c.Admittedly some uncertainties remain. How often

should screening be done if the initial screen is negative?

The number of intensive lifestyle programmes that

would be needed to treat large numbers of people with

prediabetes are not yet in place. The alternative is to use

drugs, which are less effective but might be the preferred

choice for many patients.

Primary-care providers need a strong message that

the detection and treatment of prediabetes is in their

domain of activity. Ideally, risk scores would be relevant

to local populations and supported by computerisedcalculators and reminders. Health planners might view

these steps as a further strategy to reduce the health

inequalities seen in most countries, because the rate of

prediabetes, diabetes, and cardiovascular disease tends

to disproportionately affect socially and economically

disadvantaged groups in society, including indigenous

peoples and minorities. It is time for prediabetes to

come out of the primary-care closet.

Tim Kenealy, C Raina Elley, *Bruce ArrollDepartment of General Practice and Primary Health Care,

University of Auckland, Auckland 1142, New Zealand

b.arroll@auckland.ac.nz

BA is on the advisory board for Pharmac educational seminars; Pharmac is the

Government-funded pharmaceutical-purchasing agency in New Zealand. BA is

also on the primary care committee of the Future Forum and educational

foundation funded by Astra Zeneca (UK). TK and CRE declare that they have no

conflict of interest.

1 Waugh N, Scotland G, McNamee P, et al. Screening for type 2 diabetes:literature review and economic modelling. Health Technol Assess 2007; 11.http://www.hta.ac.uk/fullmono/mon1117.pdf (accessed on Sept 14, 2007).

2 Wareham NJ, Griffi n SJ. Should we screen for type 2 diabetes? Evaluationagainst National Screening Committee criteria. BMJ 2001; 322: 986–88.

3 The DECODE Study Group. Glucose tolerance and mortality: comparison ofWHO and American Diabetes Association diagnostic criteria. Lancet 1999;354: 617–21.

4 Coutinho M, Gerstein HC, Wang Y, et al. The relationship between glucoseand incident cardiovascular events: a metaregression analysis of publisheddata from 20 studies of 95 783 individuals followed for 12·4 years.Diabetes Care 1999; 22: 233–40.

5 Decode Study Group. Age- and sex-specific prevalences of diabetes andimpaired glucose regulation in 13 European cohorts. Diabetes Care 2003;26: 61–69.

6 Padwal R, Majumdar SR, Johnson JA, et al. A systematic review of drugtherapy to delay or prevent type 2 diabetes. Diabetes Care 2005; 28: 736–44.

7 Genuth S, Alberti KGMM, Bennett P, et al. Follow-up report on thediagnosis of diabetes mellitus. Diabetes Care 2003; 26: 3160–67.

8 Lawes CMM, Parag V, Bennett DA, et al. Blood glucose and risk of cardiovasculardisease in the Asia Pacific region. Diabetes Care 2004; 27: 2836–42.

9 Khaw KT, Wareham N, Luben R, et al. Glycated haemoglobin, diabetes, andmortality in men in Norfolk cohort of european prospective investigationof cancer and nutrition (EPIC-Norfolk). BMJ 2001; 322: 15–18.

10 Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia withmacrovascular and microvascular complications of type 2 diabetes

(UKPDS 35): prospective observational study. BMJ 2000; 321: 405–12.

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