Revisiting Screening for Type 2 Diabetes Mellitus: To Screen or Not to Screen, That Is the Question–Reply–II

Drs Aldasouqi and Gossain advocate screening for diabetes primarily because of the increased risk of macrovascular complications associated with the metabolic syndrome. They minimize the benefits that result from proper diet and exercise because long-term adherence to this regimen is unusual. Those comments notwithstanding, persons with metabolic syndrome are exactly the ones most likely to benefit from a commitment to lifestyle change. Are Aldasouqi and Gossain suggesting that, because screening for diabetes is easy and inexpensive and because lifestyle change is difficult and time-consuming, one should opt for screening for diabetes?

One issue might be that of clinical perspective. Is type 2 diabetes mellitus (DM), a disease in and of itself, worthy of aggressive screening and treatment to avert disease-specific morbidity and mortality? Or is type 2 DM merely an indicator of genetic predisposition and lifestyle challenges? Is hyper-glycemia similar to hypertension in that it is a risk factor for adverse outcomes, such as myocardial infarction, stroke, and renal disease, or is it a specific condition that merits investments in detection and treatment? Obviously, type 2 DM includes aspects of both clinical perspectives. Nevertheless, patients with this condition are at increased risk of and eventually die of heart disease and stroke. What is the best way to prevent these killers: stopping smoking, eating healthy foods, exercising regularly, and, if indicated, using medicines to treat hyperlipidemia, hypertension, and hyperglycemia. Which of these interventions is the most effective or the most cost-effective? If the patient has stopped smoking, I am not sure the question is easily answerable.

Although somewhat controversial, Eddy and Schlessinger² developed a model of outcomes of diabetic patients termed Archimedes.^2,3 Archimedes uses object-oriented computer programming and complex differential equations to simulate pathophysiologic processes that change over time and can lead to disease. I urge all physicians who treat patients with type 2 DM to run scenarios⁴ of various interventions and to explore the impact of hyperglycemia control. Glucose control needs to be part of the treatment of patients with type 2 DM but should receive proper emphasis, not overemphasis.⁵ Screening for type 2 DM may be a misappropriation of time and money better spent elsewhere.

In conclusion, treatment of patients with metabolic syndrome and type 2 DM is likely to remain controversial, but practice recommendations should be made on the basis of well-designed and well-performed studies and validated scientific models. The allocation of limited resources to screen for hyperglycemia is debatable and may be inadvisable.