Editor's Briefing

NON-COMMUNICABLE DISEASES: TURNING THE TIDE?

Most of the research and clinical papers in this month's Journal touch on aspects of the non-cancer, non-communicable diseases, their antecedents, and consequences, that threaten to inundate healthcare systems in Western societies: obesity, diabetes, vascular disease, and multimorbidity. These are massive and growing problems for communities, health care, and economies, and much of the burden of management, and a good deal of the expectation of health improvements, falls on general practice and primary care.

In a refreshingly upbeat opening editorial Mary Pierce considers the opportunities not only for enhanced detection of diabetes but also for its prevention and cure, summarising the potential for cure by saying that ‘if a patient is prepared to lose 15–20% of their body weight and keep it off, there is a very good chance of their diabetes being cured …’. This seems to be related to the degree of weight loss rather than the duration of their diabetes. Many will not want to or be able to make such changes to their diet and lifestyle but initial responses to the Counterweight study suggest that there is a health-motivated sub-set of the population who can reverse their diabetes completely and maintain long-term norm glycaemia.

In other articles we look at the opportunities for community-based screening for diabetic retinopathy, the problems of interpreted consultations involving patients with diabetes, and also provide guidance on the use of HbA1c in the management of diabetes. Gholap and colleagues conclude that: ‘The traditional glucose-based tests for diagnosis of type 2 diabetes have shortcomings including inconvenience of fasting, limited sensitivity, and poor test reproducibility. In comparison, an HbA1c test is simple, convenient, and reliable. Use of HbA1c as the preferred diagnostic test may improve early and accurate diagnosis of type 2 diabetes in high-risk individuals.’

Dan Lasserson provides a fresh look at transient ischaemic attacks (TIAs) and stroke, and identifies a number of evidence gaps and areas of dissonance between current practice, often based on secondary care evidence, and the problems of diagnosing TIAs accurately in general practice and then doing the right thing after the diagnosis has been made. He concludes elegantly that: ‘Reducing the burden of cerebrovascular disease needs primary care, but primary care in turn needs to sharpen its detection of the patient at risk and ensure that maximal protection from evidence-based therapies is initiated as soon as possible. We also need to recognise that in our pursuit of the patient with accelerated risk of stroke, we also capture patients at risk of cardiac disease. The evidence gaps between who we detect, and when we protect, remain to be closed.’

Which leads seamlessly into multimorbidity, an increasing research pre-occupation as its consequences are gradually appreciated. Chris Salisbury provides an excellent overview as well as a call to action: ‘Introducing better care for multimorbidity will be a challenge at all levels of the healthcare system. At a national level, policy makers need to promote and incentivise continuity of care rather than speed of access, and measures to improve quality of life rather than just markers of disease control. Commissioners need to support service developments which provide horizontal integration of care for people across multiple disease domains, rather than focusing excessively on improving vertical integration between primary and secondary care within single disease domains. Researchers need to develop interventions based on sound theory and existing evidence about what is likely to work and to test them in rigorous studies. But general practices can make a start by considering how they organise their services, particularly in relation to continuity and co-ordination of care …’

In other parts of the Journal we publish new data on the differences between clinic and ambulatory blood pressure readings and the importance of checking for interarm variations in blood pressure. O'Brien and colleagues report important findings on the assessment of acutely ill children and the diagnosis of urinary tract infection. We look at under-provision of medical care for vascular disease in patients with dementia, and at the use of a granular form of flurbiprofen as an alternative management option for sore throats. And with articles on the Olympic bounce and CBT, and contributions from our excellent columnists, you should find plenty to keep your spirits up during these long February nights.