Can NICE Prevent Diabetes?
Can NICE Prevent Diabetes?
Such are the siren songs which tempt health policy makers into dangerous waters. The policy outlined by NICE, or so it seems to me, falls victim to evidence lag, good intentions and the desire for 'one size fits all' solutions. The policy is appropriate for young people at increased risk of diabetes; these have much to gain and little to lose. It probably does more good than harm in 40–74 year olds—but what about the elderly?
Old people seem to have been included in the programme almost as an afterthought, perhaps because healthy behaviours are beneficial at any age. Nonetheless, this is the point at which advocacy overtakes the evidence (Box 3). This strategy confers disease status upon two-thirds of the extreme elderly, and to what benefit? In this age group, risk assessment tools are poorly validated, there little or no evidence to support screening and intervention for diabetes and there is no evidence at all for intervening in age-related hyperglycaemia. The mortality of those who progress to diabetes over the age of 70 is only marginally elevated, and there is no good reason to believe that aggressive implementation of glucose lowering strategies will affect this other than adversely. Greater health awareness is a good thing, and selective implementation of this policy will benefit some members of an increasingly spry elderly population, but what about the down side?
Younger people can and do buffer excesses of therapeutic enthusiasm by the simple expedient of non-compliance: the elderly are more likely to have pills pushed down their throats by anxious carers. Any health information provided to older people which includes the word diabetes will almost certainly entail anxiety, increased supervision, the denial of simple pleasures and the infliction of additional medication. Side effects include nausea, diarrhoea and feeling dreadful (metformin), hypoglycaemia, not uncommonly fatal in this age group (sulfonylureas or insulin), weight gain, fluid retention and fractures (pioglitazone), pancreatitis (GLP-1 based therapies) and the oily faeces which have prompted a less elegant synonym for orlistat. For whose benefit?
In summary, this guidance has much to commend it. It sets out to mobilise our dwindling health resources towards a nasty disease with nastier consequences. The focus on prevention is welcome. The policy is well intended and thoughtfully constructed. On the utilitarian principle of the greater good for the greater number, it scores well. All it lacks, in sum, is a certain amount of common sense and quite a lot of the evidence. As David Sackett has said, 'there are simply too many examples of the disastrous inadequacy of lesser evidence as a basis for individual interventions among the well'.
Siren Songs
Such are the siren songs which tempt health policy makers into dangerous waters. The policy outlined by NICE, or so it seems to me, falls victim to evidence lag, good intentions and the desire for 'one size fits all' solutions. The policy is appropriate for young people at increased risk of diabetes; these have much to gain and little to lose. It probably does more good than harm in 40–74 year olds—but what about the elderly?
Old people seem to have been included in the programme almost as an afterthought, perhaps because healthy behaviours are beneficial at any age. Nonetheless, this is the point at which advocacy overtakes the evidence (Box 3). This strategy confers disease status upon two-thirds of the extreme elderly, and to what benefit? In this age group, risk assessment tools are poorly validated, there little or no evidence to support screening and intervention for diabetes and there is no evidence at all for intervening in age-related hyperglycaemia. The mortality of those who progress to diabetes over the age of 70 is only marginally elevated, and there is no good reason to believe that aggressive implementation of glucose lowering strategies will affect this other than adversely. Greater health awareness is a good thing, and selective implementation of this policy will benefit some members of an increasingly spry elderly population, but what about the down side?
Younger people can and do buffer excesses of therapeutic enthusiasm by the simple expedient of non-compliance: the elderly are more likely to have pills pushed down their throats by anxious carers. Any health information provided to older people which includes the word diabetes will almost certainly entail anxiety, increased supervision, the denial of simple pleasures and the infliction of additional medication. Side effects include nausea, diarrhoea and feeling dreadful (metformin), hypoglycaemia, not uncommonly fatal in this age group (sulfonylureas or insulin), weight gain, fluid retention and fractures (pioglitazone), pancreatitis (GLP-1 based therapies) and the oily faeces which have prompted a less elegant synonym for orlistat. For whose benefit?
In summary, this guidance has much to commend it. It sets out to mobilise our dwindling health resources towards a nasty disease with nastier consequences. The focus on prevention is welcome. The policy is well intended and thoughtfully constructed. On the utilitarian principle of the greater good for the greater number, it scores well. All it lacks, in sum, is a certain amount of common sense and quite a lot of the evidence. As David Sackett has said, 'there are simply too many examples of the disastrous inadequacy of lesser evidence as a basis for individual interventions among the well'.
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