- Email: [email protected]
Reply to “Is diabetes preventable in the general population?”
Accepted Manuscript Letter to the editor: Reply to “Is diabetes preventable in the general population?”
Cathrine J Lau, Charlotta Pisinger, Lise Lotte N Husemoen, Rikke Kart Jacobsen, Allan Linneberg, Torben Jørgensen, Charlotte Glümer PII: DOI: Reference:
S0091-7435(16)30410-8 doi: 10.1016/j.ypmed.2016.12.014 YPMED 4868
To appear in:
Preventive Medicine
Received date: Revised date: Accepted date:
28 November 2016 9 December 2016 13 December 2016
Please cite this article as: Cathrine J Lau, Charlotta Pisinger, Lise Lotte N Husemoen, Rikke Kart Jacobsen, Allan Linneberg, Torben Jørgensen, Charlotte Glümer , Letter to the editor: Reply to “Is diabetes preventable in the general population?”. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ypmed(2016), doi: 10.1016/j.ypmed.2016.12.014
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Letter to the editor: Reply to “Is diabetes preventable in the general population?” (PM-16-1251)
Cathrine J Lau, senior reseacher1, Charlotta Pisinger, associate professor1,2, Lise Lotte N Husemoen1, senior researcher1, Rikke Kart Jacobsen, statistician1, Allan Linneberg, professor1,2,3, Torben Jørgensen, professor1,2,4, Charlotte Glümer, professor1,4
PT
Affiliations
Research Centre for Prevention and Health, Capital Region of Denmark, 2600 Glostrup, Denmark
2
Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
3
Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark
4
Faculty of Medicine, Aalborg University, 9229 Aalborg East, Denmark
NU
SC
RI
1
Coresponding author
MA
Cathrine J Lau, PhD, senior researcher, Research Centre for Prevention and Health, Capital Region of Denmark, Nordre Ringvej 57, DK-2600 Glostrup, Denmark.
PT E
Tel: +45 38633283. Fax: +45 38633977.
Word count
Funding
AC
Disclosures of interest
CE
Main text: 599
None
D
E-mail: [email protected].
No funding was obtained for the current manuscript.
1
Current employment as Senior Epidemiologist at Department of Epidemiology, Novo Nordisk A/S, 2860 Søborg, Denmark
ACCEPTED MANUSCRIPT
We welcome the opportunity to respond to the comments by Jørgensen and Borch-Johnsen to our article (1).
RI
PT
First of all we want to thank the authors for their appraisal of the design and conduct of the Inter99 study. A conclusion in a scientific paper is based on the presented results combined with the relevant literature, and to our knowledge, no screening studies have shown any positive effect on development of diabetes (or cardiovascular disease (CVD)) on a population level. It is, therefore, hard to see how we could have concluded differently. The authors refer to three studies, which all deal with selected individuals, showing that when you reduce obesity, and change physical activity and diet, diabetes (and CVD) can be reduced. Thus, these studies confirm that the factors in question actually are true risk factors for diabetes. We have not questioned this and we of course recommend that motivated high risk persons, who contact the health care system, are given the relevant support. But these intensive programs obviously are not feasible for the general population and therefore should be distinguished from a screening, where you want to reduce the disease burden in society.
MA
NU
SC
It is correct that only a little more than half of the invited population attended and that any effect on a population level should be driven by this half, but this is real life. We must consider, whether it is likely that those who do not want to participate would have been able to change their lifestyle radically, if we had reached them. General Practitioners (GP) see 90 % of their patients, but so far there is no evidence that health checks by GPs has an effect on morbidity or mortality on a population level (2). The authors postulate that Inter99 did not focus on physical inactivity and obesity, which is not true. We agree as discussed in the paper (1) that the intensity of the diet and physical activity intervention might have been too low to prevent diabetes, but we must face that an intervention aimed at the whole population has to be feasible. We did find a significant difference in changes in physical activity (3). We did not see an overall reduction in weight (4), but as the control group was not invited for a health check, we don’t know the weight development in this group, which could have been even bigger.
CE
PT E
D
According to the original description of Inter99 in ClinicalTrials.gov the primary outcome was “Incidence of CHD and other lifestyle related diseases after ten years”, which means that type 2 diabetes was included in the primary aim, so we – respectfully - must disagree with the authors. According to the protocol, persons were screened for diabetes, and those with screen detected diabetes and impaired glucose tolerance (IGT) were offered lifestyle counselling. As we discuss (1), this possible detection bias is important. But still we think that we should have seen a decrease in diabetes, as those with IGT and other high-risk persons were included in the high risk group and offered health counselling.
AC
There are explanations for the lack of effect on a population level. We help some, but we might harm others (2), and we will never reach everybody. We need to realize that we cannot expect people to change habits if the surroundings do not facilitate this (5). There are strong economic interests to maintain the sale of unhealthy products through advertising and lobbying (6). Society is complex, which calls for complex interventions (7) combining structural changes with relevant general information and health counselling of motivated high risk individuals for a more rational control of diabetes.
ACCEPTED MANUSCRIPT
References
Lau C. Pisinger C, Husemoen LLN, Jacobsen RK, Linneberg A, Jørgensen T, Glümer C. Effect of a general health screening and lifestyle counselling on incidence of diabetes in general population: Inter99 randomised trial. Prev Med 2016;91:172-179.
PT
Si S1, Moss JR, Sullivan TR, Newton SS, Stocks NP. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. Br J Gen Pract 2014;64(618):e47-53.
RI
Baumann S, Toft U, Aadahl M, Jørgensen T, Pisinger C. The long-term effect of screening and lifestyle counseling on changes in physical activity and diet: the Inter99 study – a randomized controlled trial. Int J Behav Nutr Phys 2015;12(33).
SC
Andersson EA, Allin KH, Sandholt CH, Borglykke A, Lau CJ, Ribel-Madsen R, Sparsø T, Justesen JM, Harder MN, Jørgensen ME, Jørgensen T, Hansen T, Pedersen O. Genetic risk score of 46 type 2 diabetes risk variants associates with changes in plasma glucose and estimates of pancreatic β-cell function of 5 years of follow-up. Diabetes 2013;62(10):3610-
NU
Schmid TL, Pratt M, Howse E. Policy as intervention: Enviromental and policy approaches to the prevention of cardiovascular disease. Am J Pub Health 1995;85(9):1207-1211.
MA
Kearns CE, Schmidt LA, Stanton A, Glantz SA. Sugar industry and coronary heart disease research. A historical analysis of internal industry documents. Jama Internal Medicin 2016;176(11):1680-1685.
AC
CE
PT E
D
Craig P, Rahm-Hallberg I, Britten N, Borglin G, Meyer G, Köpke S, et al. Researching Complex Interventions in Health: The State of the Art. BMC Health Serv Res. 2016;16 Suppl 1:101.
Cathrine J Lau, Charlotta Pisinger, Lise Lotte N Husemoen, Rikke Kart Jacobsen, Allan Linneberg, Torben Jørgensen, Charlotte Glümer PII: DOI: Reference:
S0091-7435(16)30410-8 doi: 10.1016/j.ypmed.2016.12.014 YPMED 4868
To appear in:
Preventive Medicine
Received date: Revised date: Accepted date:
28 November 2016 9 December 2016 13 December 2016
Please cite this article as: Cathrine J Lau, Charlotta Pisinger, Lise Lotte N Husemoen, Rikke Kart Jacobsen, Allan Linneberg, Torben Jørgensen, Charlotte Glümer , Letter to the editor: Reply to “Is diabetes preventable in the general population?”. The address for the corresponding author was captured as affiliation for all authors. Please check if appropriate. Ypmed(2016), doi: 10.1016/j.ypmed.2016.12.014
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Letter to the editor: Reply to “Is diabetes preventable in the general population?” (PM-16-1251)
Cathrine J Lau, senior reseacher1, Charlotta Pisinger, associate professor1,2, Lise Lotte N Husemoen1, senior researcher1, Rikke Kart Jacobsen, statistician1, Allan Linneberg, professor1,2,3, Torben Jørgensen, professor1,2,4, Charlotte Glümer, professor1,4
PT
Affiliations
Research Centre for Prevention and Health, Capital Region of Denmark, 2600 Glostrup, Denmark
2
Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
3
Department of Clinical Experimental Research, Rigshospitalet, Glostrup, Denmark
4
Faculty of Medicine, Aalborg University, 9229 Aalborg East, Denmark
NU
SC
RI
1
Coresponding author
MA
Cathrine J Lau, PhD, senior researcher, Research Centre for Prevention and Health, Capital Region of Denmark, Nordre Ringvej 57, DK-2600 Glostrup, Denmark.
PT E
Tel: +45 38633283. Fax: +45 38633977.
Word count
Funding
AC
Disclosures of interest
CE
Main text: 599
None
D
E-mail: [email protected].
No funding was obtained for the current manuscript.
1
Current employment as Senior Epidemiologist at Department of Epidemiology, Novo Nordisk A/S, 2860 Søborg, Denmark
ACCEPTED MANUSCRIPT
We welcome the opportunity to respond to the comments by Jørgensen and Borch-Johnsen to our article (1).
RI
PT
First of all we want to thank the authors for their appraisal of the design and conduct of the Inter99 study. A conclusion in a scientific paper is based on the presented results combined with the relevant literature, and to our knowledge, no screening studies have shown any positive effect on development of diabetes (or cardiovascular disease (CVD)) on a population level. It is, therefore, hard to see how we could have concluded differently. The authors refer to three studies, which all deal with selected individuals, showing that when you reduce obesity, and change physical activity and diet, diabetes (and CVD) can be reduced. Thus, these studies confirm that the factors in question actually are true risk factors for diabetes. We have not questioned this and we of course recommend that motivated high risk persons, who contact the health care system, are given the relevant support. But these intensive programs obviously are not feasible for the general population and therefore should be distinguished from a screening, where you want to reduce the disease burden in society.
MA
NU
SC
It is correct that only a little more than half of the invited population attended and that any effect on a population level should be driven by this half, but this is real life. We must consider, whether it is likely that those who do not want to participate would have been able to change their lifestyle radically, if we had reached them. General Practitioners (GP) see 90 % of their patients, but so far there is no evidence that health checks by GPs has an effect on morbidity or mortality on a population level (2). The authors postulate that Inter99 did not focus on physical inactivity and obesity, which is not true. We agree as discussed in the paper (1) that the intensity of the diet and physical activity intervention might have been too low to prevent diabetes, but we must face that an intervention aimed at the whole population has to be feasible. We did find a significant difference in changes in physical activity (3). We did not see an overall reduction in weight (4), but as the control group was not invited for a health check, we don’t know the weight development in this group, which could have been even bigger.
CE
PT E
D
According to the original description of Inter99 in ClinicalTrials.gov the primary outcome was “Incidence of CHD and other lifestyle related diseases after ten years”, which means that type 2 diabetes was included in the primary aim, so we – respectfully - must disagree with the authors. According to the protocol, persons were screened for diabetes, and those with screen detected diabetes and impaired glucose tolerance (IGT) were offered lifestyle counselling. As we discuss (1), this possible detection bias is important. But still we think that we should have seen a decrease in diabetes, as those with IGT and other high-risk persons were included in the high risk group and offered health counselling.
AC
There are explanations for the lack of effect on a population level. We help some, but we might harm others (2), and we will never reach everybody. We need to realize that we cannot expect people to change habits if the surroundings do not facilitate this (5). There are strong economic interests to maintain the sale of unhealthy products through advertising and lobbying (6). Society is complex, which calls for complex interventions (7) combining structural changes with relevant general information and health counselling of motivated high risk individuals for a more rational control of diabetes.
ACCEPTED MANUSCRIPT
References
Lau C. Pisinger C, Husemoen LLN, Jacobsen RK, Linneberg A, Jørgensen T, Glümer C. Effect of a general health screening and lifestyle counselling on incidence of diabetes in general population: Inter99 randomised trial. Prev Med 2016;91:172-179.
PT
Si S1, Moss JR, Sullivan TR, Newton SS, Stocks NP. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. Br J Gen Pract 2014;64(618):e47-53.
RI
Baumann S, Toft U, Aadahl M, Jørgensen T, Pisinger C. The long-term effect of screening and lifestyle counseling on changes in physical activity and diet: the Inter99 study – a randomized controlled trial. Int J Behav Nutr Phys 2015;12(33).
SC
Andersson EA, Allin KH, Sandholt CH, Borglykke A, Lau CJ, Ribel-Madsen R, Sparsø T, Justesen JM, Harder MN, Jørgensen ME, Jørgensen T, Hansen T, Pedersen O. Genetic risk score of 46 type 2 diabetes risk variants associates with changes in plasma glucose and estimates of pancreatic β-cell function of 5 years of follow-up. Diabetes 2013;62(10):3610-
NU
Schmid TL, Pratt M, Howse E. Policy as intervention: Enviromental and policy approaches to the prevention of cardiovascular disease. Am J Pub Health 1995;85(9):1207-1211.
MA
Kearns CE, Schmidt LA, Stanton A, Glantz SA. Sugar industry and coronary heart disease research. A historical analysis of internal industry documents. Jama Internal Medicin 2016;176(11):1680-1685.
AC
CE
PT E
D
Craig P, Rahm-Hallberg I, Britten N, Borglin G, Meyer G, Köpke S, et al. Researching Complex Interventions in Health: The State of the Art. BMC Health Serv Res. 2016;16 Suppl 1:101.