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Screening for Type 2 Diabetes – The ADDITION Netherlands Study
received routine care. However, two to three years after diagnosis the increased cardiovascular risk,
23,24
the need to perform the OGTT in
experienced psychological burden did not differ between the two general practice should be re-considered. Using only the fasting
groups. It may be assumed that distress in patients in the routine glucose levels will fail to diagnose approximately 30% of people
care group is delayed, since they were not confronted with rigorous with diabetes, with an even greater failure rate in an older
treatment shortly after diagnosis. These findings suggest that even in population.
25,26
Of the 285 people with diabetes detected in our
the long run intensive treatment is feasible. It should be noted that four-step screening procedure, 36 (12.6%) were found to have an
patients in the intensified treatment group were treated by diabetes initial non-diabetic fasting glucose value. This finding questions
nurses who had enough time to motivate patients. Therefore, it may whether it is acceptable that screening for diabetes in general
be disputable whether treatment targets as achieved in our trial are practice is based on fasting glucose testing alone. Without
also achievable in daily practice. However, in many general practices performing an OGTT, persons with IGT will not be recognised at all.
specialised nurses are already involved in daily diabetes care, making Since the first step in the deterioration of glucose homeostasis
the implementation of intensified treatment feasible. corresponds to a loss of post-prandial glycaemic control,
27
detection of persons with type 2 diabetes will be delayed by
Persons with Impaired Glucose Tolerance and measuring fasting glucose values only.
Impaired Fasting Glucose
After three years of follow-up, screened subjects with an elevated risk Conclusions
score but without diabetes had comparable cardiovascular event In order to identify patients with undiagnosed diabetes, opportunistic
rates to patients with diabetes. Screened people without diabetes are screening in general practice seems more appropriate than
at risk of lacking optimal medical care in order to control for population-based screening. The increased cardiovascular risk of
cardiovascular risk factors. They should not be reassured by the fact hyperglycaemia is notably present in overweight persons. Screening
that they do not have diabetes. Since this sub-study of the ADDITION should not be targeted at hyperglycaemia alone but rather at
study was not prospectively designed to investigate differences in the cardiovascular risk profiles. Intensified multifactorial treatment of
occurrence of cardiovascular events between the glucose regulation screening-detected type 2 diabetes patients in general practice will
categories, these findings should be interpreted with some caution. reduce the levels of cardiovascular risk factors without worsening
health-related quality of life. n
Implications for Policy and Practice
Given its increasing prevalence, screening for diabetes and adverse
Guy EHM Rutten is a Professor of Diabetology in general
cardiovascular risk has become a societal issue. In particular, obesity,
practice at the Julius Centre for Health Sciences and
physical inactivity, dietary habits and smoking may be considered as Primary Care at the University Medical Centre Utrecht.
matters of public health. Preventing unhealthy lifestyle behaviours is
He has been a general practioner (GP) since 1982 and
continues to work as a GP for two days per week. His
not solely an issue to be managed in primary care. Nevertheless, GPs
research activities focus on diabetes and cardiovascular
could play an important role. complications and diabetes primary care. Professor
Rutten has authored more than 100 original articles in
national and international peer-reviewed journals. He
The cardiovascular risk of people with impaired glucose regulation,
chairs the Dutch General Practice Advisory Group and the European Association for the
especially when they are obese, should not be underestimated. In Study of Diabetes (EASD) Study Group on Primary Care Research in Diabetology, and
order to detect people with increased cardiovascular risk, a proactive,
was the first Editor in Chief of Primary Care Diabetes.
systematic opportunistic screening programme in all practices is
needed. Practice nurses could play a pivotal role in the detection of
Paul GH Janssen is a General Practitioner in Baambrugge.
From 2002 to 2007 he was a Researcher at the Julius
increased diabetes and CVD risk using a simple risk questionnaire.
Centre for Health Sciences and Primary Care at the
Intensified treatment of cardiovascular risk factors in general practice
University Medical Centrer Utrecht, where he completed
is feasible on the condition that it is delivered by specially trained and
his thesis entitled ‘Screening for type 2 diabetes in
general practice’. In 2007 he was appointed an academic
well-educated practice nurses in co-operation with the GP.
staff member in the Department of Guideline
Development and Research Policy of the Dutch College
Given the substantial number of persons with IGT remaining
of General Practitioners.
unidentified without an OGTT, and taking into account their
1. Wild S, Roglic G, Green A, et al., Diabetes Care, Care, 2008;26:160–65. 1999;22:233–40.
2004;27:1047–53. 11. Janssen PG, Gorter KJ, Stolk RP, Rutten GE, Prim Care Diabetes, 19. Sandbaek A, Griffin SJ, Rutten G, et al., The ADDITION study,
2. Borch-Johnsen K, Lauritzen T, Glümer C, Sandbaek A, 2007;1:69–74. Diabetologia, 2008;51:1127–34.
Diabet Med, 2003;20:175–81. 12. Janssen PG, Gorter KJ, Stolk RP, Rutten GE, Br J Gen Pract, 20. Gaede P, Vedel P, Parving HH, Pedersen O, Lancet,
3. American Diabetes Association, Diabetes Care, 2004;27 2009;59:43–8. 1999;353:617–22.
(Suppl. 1):S11–S14. 13. Janssen PG, Gorter KJ, Stolk RP, et al., BMC Fam Pract, 21. Gaede P, Vedel P, Larsen N, et al., N Engl J Med,
4. Alberti KG, Zimmet P, Shaw J, Diabet Med, 2007;24:451–63. 2008;9:67. 2003;348:383–93.
5. Rutten GEHM, De Grauw WJC, Nijpels G, et al., Huisarts Wet, 14. Baan CA, Poos MJJC, Bilthoven: RIVM. Available at: 22. Thoolen BJ, de Ridder DT, Bensing JM, et al., Diabetes Care,
2006;49:137–52. www.rivm.nl/vtv/object_document/o1260n17502.html 2006;29:2257–62.
6. Lauritzen T, Griffin S, Borch-Johnsen K, et al., Int J Obes Relat (accessed 14 September 2006). 23. Unwin N, Shaw J, Zimmet P, Alberti KG, Diabet Med,
Metab Disord, 2000;24:S6–S11. 15. Christensen JO, Sandbaek A, Lauritzen T, Borch-Johnsen K, 2002;19:708–23.
7. Ruige JB, de Neeling JND, Kostense PJ, et al., Diabetes Care, Diabetologia, 2004;45:1566–73. 24. De Vegt F, Dekker JM, Ruhe HG, et al., Diabetologia,
1997;20:491–6. 16. Wilson JMG, Jungner G, Principles and Practice of Screening for 1999;42:926–31.
8. Alberti KG, Zimmet PZ, Definition, Diabet Med, 1998;15:539–53. Disease, Geneva: World Health Organization, 1968. 25. DECODE Study Group, BMJ, 1998;317:371–5.
9. Janssen PG, Gorter KJ, Stolk RP, Rutten GE, Fam Pract, 17. Unwin N, Shaw J, Zimmet P, Alberti KG, Diabet Med, 26. Barrett-Connor E, Ferrara A, Diabetes Care, 1998;21:1236–9.
2007;24:555–61. 2002;19:708–23. 27. Monnier L, Colette C, Dunseath GJ, Owens DR, Diabetes Care,
10. Janssen PG, Gorter KJ, Stolk RP, Rutten GE, Scand J Prim Health 18. Coutinho M, Gerstein HC, Wang Y, Yusuf S, Diabetes Care, 2007;30:263–9.
EUROPEAN ENDOCRINOLOGY 37
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