Effect of screening for Type 2 diabetes on population-level self-rated health outcomes and measures of cardiovascular risk: 13-year follow-up of the Ely cohort.

AIMS: There is continuing uncertainty regarding the overall net benefits of population-based screening for Type 2 diabetes. We compared clinical measures, prescribed medication, cardiovascular morbidity and self-rated health in individuals without diabetes in a screened vs. an unscreened population. METHODS: A parallel-group, cohort study of people aged 40-65 years, free of known diabetes, identified from the population register of a general practice in Ely, Cambridgeshire (n = 4936). In 1990-1992, one third (n = 1705), selected randomly, received an invitation for screening for diabetes and cardiovascular risk factors at 5-yearly intervals (screened population). From the remainder of the sampling frame, 1705 randomly selected individuals were invited to diabetes screening 10 years later (unscreened population). Patients without known diabetes from both populations were invited for a health assessment. RESULTS: Of 3390 eligible individuals without diabetes, 1442 (43%) attended for health assessment, with no significant difference in attendance between groups. Thirteen years after the commencement of screening, self-rated functional health status and health utility were identical between the screened and unscreened populations. Clinical measures, self-reported medication and cardiovascular morbidity were similar between the two groups. CONCLUSIONS: Screening for diabetes is not associated with long-term harms at the population level. However, screening has limited long-term impact on those testing negative; benefits may largely be restricted to those whose diabetes is detected early through screening.

How much does screening bring forward the diagnosis of type 2 diabetes and reduce complications? Twelve year follow-up of the Ely cohort.

AIMS: There are continuing uncertainties about how much screening for type 2 diabetes brings forward the clinical diagnosis and the impact that earlier diagnosis has on health outcomes. We compared the duration of diabetes and health outcomes in a population invited for diabetes screening at 5-yearly intervals from 1990 (screened population) with those in a similar population not invited for screening (unscreened population). METHODS: This was a parallel-group, cohort study of people aged 40-65 years, free of known diabetes, identified from the population register of a general practice in Ely, Cambridgeshire, UK (n = 4,936). In 1990-1992, one-third (n = 1,705), selected randomly, received an invitation for screening for diabetes and cardiovascular risk factors at 5-yearly intervals (screened population). From the remainder of the sampling frame, 1,705 randomly selected individuals were invited to diabetes screening 10 years later (unscreened population). Patients with diabetes from both populations were invited for a health assessment, including biochemical, anthropometric and questionnaire measures, and testing for the presence of diabetic complications RESULTS: Of the 199 eligible individuals with diabetes diagnosed during follow-up, 152 (76%) attended for health assessment. The median duration of clinically recognised diabetes was significantly longer in cases arising in the screened (5.0 years) compared with the unscreened population (1.7 years; p = 0.006). Clinical measures, prescribed medication and functional status were similar between screened and unscreened populations. CONCLUSIONS: Diabetes screening resulted in cases being identified on average 3.3 years earlier, a difference significantly shorter than previous estimates. Earlier diagnosis did not appear to impact on health outcomes. Further evidence is needed to justify the introduction of population-based screening.

Effect of population screening for type 2 diabetes on mortality: long-term follow-up of the Ely cohort.

AIMS/HYPOTHESIS: The aim of this study was to assess the impact of invitation to screening for type 2 diabetes and related cardiovascular risk factors on population mortality. METHODS: This was a parallel-group population-based cohort study including all men and women aged 40-65 years, free of known diabetes, registered with a single practice in Ely, UK (n = 4,936). In 1990-1992, approximately one-third (n = 1,705) were randomly selected to receive an invitation to screening for diabetes (with an OGTT) and related cardiovascular risk factors. In the remaining two-thirds of the population, 1,705 individuals were randomly selected for invitation to screening in 2000-2003 and 1,526 were not invited at any point during the follow-up period. All individuals were flagged for mortality until January 2008. RESULTS: There were 345 deaths between 1990 and 1999 (median 10 years follow-up). Compared with those not invited, individuals who were invited to the 1990-1992 screening round had a non-significant 21% lower all-cause mortality (HR 0.79 [95% CI 0.63-1.00], p = 0.05) after adjustment for age, sex and deprivation. There were 291 deaths between 2000 and 2008 (median 8 years follow-up), with no significant difference in mortality between invited and non-invited participants in 2000-2003. Compared with the non-invited group, participants who attended for screening at any time point had a significantly lower mortality and those who did not attend had a significantly higher mortality. CONCLUSIONS/INTERPRETATION: Invitation to screening was associated with a non-significant reduction in mortality in the Ely cohort between 1990 and 1999, but this was not replicated in the period 2000-2008. This study contributes to the evidence concerning the potential benefits of population screening for diabetes and related cardiovascular risk factors.

Is the association between dietary fat intake and insulin resistance modified by physical activity?

The rising prevalence of type 2 diabetes, a condition associated with insulin resistance, is commonly attributed to changes in dietary patterns and physical activity levels in susceptible populations. However, few studies have described the independent effects of dietary intake and physical activity on the degree of insulin sensitivity within populations or examined the possibility of interactions between dietary factors and physical activity. This study was undertaken to describe the relationship between the quantity and pattern of dietary fat intake on fasting insulin levels (a marker of insulin sensitivity) and to investigate whether the association was modified by physical activity. A cross-sectional study of 815 nondiabetic men and women (30 to 71 years) recruited from a population-based sampling frame was undertaken. Diet was characterized using a semiquantitative food frequency questionnaire. Physical activity level (PAL), the ratio of total energy expenditure to basal metabolic rate, was estimated using individually calibrated heart rate monitoring, a method previously shown to be an objective and valid method for assessing total energy expenditure. In a linear regression model adjusted for total energy intake, total fat intake bordered on a significant association with fasting insulin (b = 0.000081; P =.058), and the polyunsaturated to saturated fat ratio (P:S ratio) of the diet was negatively associated with fasting insulin concentration (b = -0.37, P <.001). A negative association was observed between the PAL and fasting insulin (b = -0.12, P =.025). The association of the P:S ratio and PAL with fasting insulin remained significant when adjusted for each other and for total fat, total energy intake, body mass index (BMI), waist-to-hip ratio (WHR), age, sex, family history of diabetes, smoking status, and alcohol intake (P:S ratio, b = -0.24, P =.003; PAL, b = -0.13; P =.007). The association with total fat intake was no longer significant in this multivariate model (b = 6.7 x 10(-6); P =.858). There was no evidence for an interaction between total dietary fat intake and PAL (b = -0.000048; P =.243) or between the P:S ratio and PAL (b = -0.013; P =.949). These data demonstrate an independent association between the P:S ratio of the diet, the overall level of physical activity, and the fasting insulin concentration, a marker of insulin sensitivity. There was no evidence that the association between dietary fat intake and insulin resistance was modified by physical activity. The findings provide further support for efforts to promote increases in overall physical activity and modifications in the pattern of dietary fat intake in the whole population.