Screening That Dare Not Speak its Name

We are about to embark on a mass screening programme to prevent diabetes: but we will not call it screening.

Every hour sees the number of diabetics in England increase by 13. Surely something must be done. An evidence base feeds a seductive narrative. Type-2 diabetes does not develop overnight; it disproportionately affects the old, the overweight, South Asians. Those about to develop diabetes have tell-tale laboratory test results: raised glycosylated haemoglobin levels (indicating persistently raised glucose), impaired glucose tolerance. These days we even have a name for this: pre-diabetes. There is good evidence that intervention to change physical activity and diet prevents about a third from developing diabetes.[1] Prevention is highly cost-effective.[2] Hey presto! The solution is obvious. We do blood tests on people at high risk of diabetes. We find those at high risk. We offer intervention. In essence this is the National Diabetes Prevention Programme.[3] Pilot projects are under way across England, including Birmingham. Before they have finished there are plans to roll the project out across the country.

As Henry Menken once said “For every complex problem there is an answer that is clear, simple, and wrong.” The scale of the problem is overwhelming. About one in ten adults is pre-diabetic. The evidence for diabetes prevention involved intensive lifestyle intervention lasting from one to six years and was delivered by health professionals. The NHS thin-gruel will be shorter and delivered by health trainers. This might work. But it would be nice to know before spending millions on the programme.

But the bigger problem is practical. While frantically trying to identify more pre-diabetics, the National Diabetes Prevention Programme simply can’t even cope with the existing burden. Most pilot projects can only offer intensive lifestyle intervention to a minority of pre-diabetics: 200 of 6,000 in Bradford; maybe up to 1500 of 13,000 in South Birmingham. Public health services face further funding restrictions just as we are identifying more pre-diabetics. One option is to offer the remaining pre-diabetic population less costly alternatives, but it is less clear that weight loss programmes prevent diabetes.[4] Even weight loss programmes have a cost. Would handing out leaflets work?

In all but name, this is a screening programme. But it won’t be called screening because that would subject the programme to the scrutiny of the National Screening Committee. One of their criteria for assessing screening programmes is revealing: “Adequate staffing and facilities for testing, diagnosis, treatment and programme management should be available prior to the commencement of the screening programme.”[5] Nobody use the “s” word.

— Tom Marshall, CLAHRC WM Co-Director

References:

  1. Orozco LJ, Buchleitner AM, Gimenez-Perez G, et al. Exercise or exercise and diet for preventing type 2 diabetes mellitus. Cochrane Database Syst Rev. 2008; 3: CD003054.
  2. Li R, Qu S, Zhang P, et al. Economic Evaluation of Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among Persons at Increased Risk: A Systematic Review for the Community Preventive Services Task Force. Ann Intern Med. 2015;163(6):452-60.
  3. NHS England. NHS Diabetes Prevention Programme (NHS DPP). 2016.
  4. Nield L, Summerbell CD, Hooper L, Whittaker V, Moore H. Dietary advice for the prevention of type 2 diabetes mellitus in adults. Cochrane Database Syst Rev. 2008; 3: CD005102.
  5. Public Health England. Criteria for appraising the viability, effectiveness and appropriateness of a screening programme. 2015.
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2 thoughts on “Screening That Dare Not Speak its Name”

  1. Emphasis has been put on obesity but as became clear at the recent conference in Solihull this is not the only symptom for diabetes risk. Stress may be another. For some years now I have been I point below the risk level for diabetes and the cut-off would seem to be rather arbitrary. I have recently brought this up with my doctor and the only solution would seem to be for a blood test though I appreciate it is far too cumbersome to do this for the whole population, which appears ultimately to be what is being asked for here.

  2. It is screening, and the screening doesn’t work. The best evaluated programme was DESMOND from Leicester. A negative trial, spun by the authors using secondary outcomes and wishful thinking as a positive one. And no-one called them out. Keep up this battle.

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