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      Estimating the potential population impact of stepwise screening strategies for identifying and treating individuals at high risk of Type 2 diabetes: a modelling study

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          Abstract

          Background

          Diabetes risk assessment has been proposed as part of the National Health Service Health Checks programme, and HbA 1c has recently been recommended as a diagnostic test for diabetes at a threshold of 48 mmol/mol (6.5%). We estimated the potential population impact of different stepwise screening strategies to identify individuals at high risk who might be offered preventive interventions.

          Methods

          Using data from 5910 participants in the European Prospective Investigation of Cancer (EPIC)-Norfolk cohort with HbA 1c measurements, we modelled different stepwise screening strategies for identifying and treating individuals at high risk of Type 2 diabetes using different HbA 1c cut-off points with and without a stage of prestratification. For each strategy, we estimated the number needed to have a diagnostic test, the number needed to treat to prevent one new case of Type 2 diabetes, and the number of new cases that could be prevented in the population over 3 years. Relative risk reductions for estimated effects of intensive lifestyle intervention were derived from the US Diabetes Prevention Program.

          Results

          Compared with inviting all individuals in an average primary care trust for a diagnostic test, a stepwise screening approach using simple routine data such as age and anthropometric indices could prevent a slightly lower number (lower-upper estimates) of new cases of Type 2 diabetes over 3 years (224 [130–359] and 193 [109–315] cases respectively) but would only require half the population to be invited for a diagnostic blood test. A total of 162 (88–274) cases could be prevented by inviting individuals with a Cambridge risk score of ≥ 0.15, with only 40% of the total population requiring diagnostic blood tests. Using a participant completed questionnaire for risk assessment (FINDRISC) was less effective, mainly relating to the questionnaire response rate. Providing preventive interventions to those with a lower HbA 1c of 37–< 48 mmol/mol (5.5–< 6.5%) could prevent more cases but with a disproportionately higher workload, compared with using the recommended HbA 1c threshold of 42–< 48 mmol/mol (6.0–< 6.5%).

          Conclusions

          Compared with mass screening, an approach using routine data for risk stratification followed by an HbA 1c test with a threshold of 42–< 48 mmol/mol (6.0–< 6.5%) for identifying individuals suitable for preventive interventions might prevent slightly fewer cases of Type 2 diabetes but with potential cost-savings.

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          Most cited references 38

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          Validity and repeatability of a simple index derived from the short physical activity questionnaire used in the European Prospective Investigation into Cancer and Nutrition (EPIC) study.

          To assess the validity and repeatability of a simple index designed to rank participants according to their energy expenditure estimated by self-report, by comparison with objectively measured energy expenditure assessed by heart-rate monitoring with individual calibration. Energy expenditure was assessed over one year by four separate episodes of 4-day heart-rate monitoring, a method previously validated against whole-body calorimetry and doubly labelled water. Cardio-respiratory fitness was assessed by four repeated measures of sub-maximum oxygen uptake. At the end of the 12-month period, participants completed a physical activity questionnaire that assessed past-year activity. A simple four-level physical activity index was derived by combining occupational physical activity together with time participating in cycling and other physical exercise (such as keep fit, aerobics, swimming and jogging). One hundred and seventy-three randomly selected men and women aged 40 to 65 years. The repeatability of the physical activity index was high (weighted kappa=0.6, ). There were positive associations between the physical activity index from the questionnaire and the objective measures of the ratio of daytime energy expenditure to resting metabolic rate and cardio-respiratory fitness As an indirect test of validity, there was a positive association between the physical activity index and the ratio of energy intake, assessed by 7-day food diaries, to predicted basal metabolic rate. The summary index of physical activity derived from the questions used in the European Prospective Investigation into Cancer and Nutrition (EPIC) study suggest it is useful for ranking participants in terms of their physical activity in large epidemiological studies. The index is simple and easy to comprehend, which may make it suitable for situations that require a concise, global index of activity.
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            Guide to the methods of technology appraisal

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              Smoking, smoking cessation, and risk for type 2 diabetes mellitus: a cohort study.

              Cigarette smoking is an established predictor of incident type 2 diabetes mellitus, but the effects of smoking cessation on diabetes risk are unknown. To test the hypothesis that smoking cessation increases diabetes risk in the short term, possibly owing to cessation-related weight gain. Prospective cohort study. The ARIC (Atherosclerosis Risk in Communities) Study. 10,892 middle-aged adults who initially did not have diabetes in 1987 to 1989. Smoking was assessed by interview at baseline and at subsequent follow-up. Incident diabetes was ascertained by fasting glucose assays through 1998 and self-report of physician diagnosis or use of diabetes medications through 2004. During 9 years of follow-up, 1254 adults developed type 2 diabetes. Compared with adults who never smoked, the adjusted hazard ratio of incident diabetes in the highest tertile of pack-years was 1.42 (95% CI, 1.20 to 1.67). In the first 3 years of follow-up, 380 adults quit smoking. After adjustment for age, race, sex, education, adiposity, physical activity, lipid levels, blood pressure, and ARIC Study center, compared with adults who never smoked, the hazard ratios of diabetes among former smokers, new quitters, and continuing smokers were 1.22 (CI, 0.99 to 1.50), 1.73 (CI, 1.19 to 2.53), and 1.31 (CI, 1.04 to 1.65), respectively. Further adjustment for weight change and leukocyte count attenuated these risks substantially. In an analysis of long-term risk after quitting, the highest risk occurred in the first 3 years (hazard ratio, 1.91 [CI, 1.19 to 3.05]), then gradually decreased to 0 at 12 years. Residual confounding is possible even with meticulous adjustment for established diabetes risk factors. Cigarette smoking predicts incident type 2 diabetes, but smoking cessation leads to higher short-term risk. For smokers at risk for diabetes, smoking cessation should be coupled with strategies for diabetes prevention and early detection.
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                Author and article information

                Journal
                Diabet Med
                Diabet. Med
                dme
                Diabetic Medicine
                Blackwell Publishing Ltd (Oxford, UK )
                0742-3071
                1464-5491
                July 2012
                : 29
                : 7
                : 893-904
                Affiliations
                [1 ]MRC Epidemiology Unit, Institute of Metabolic Science Cambridge, UK
                [2 ]Clinical Gerontology Unit, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital Cambridge, UK
                Author notes
                Correspondence to: S. Griffin, MRC Epidemiology Unit, Institute of Metabolic Science, Box 285, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ, UK. Email: simon.griffin@ 123456mrc-epid.cam.ac.uk
                Article
                10.1111/j.1464-5491.2012.03609.x
                3814413
                22340130
                © 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK

                Re-use of this article is permitted in accordance with the Creative Commons Deed, Attribution 2.5, which does not permit commercial exploitation.

                Categories
                Original Articles
                Article: Epidemiology

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