Correspondence

Geneva University Hospitals Geneva 1211,

Switzerland (DB, FC); University of Geneva, Geneva,
Switzerland (DB, FC, SC); Eduardo Mondlane
University, Maputo, Mozambique (AD); B.P. Koirala
Institute of Health Sciences, Dharan, Nepal (NJ);
Graduate Institute of International and
Development Studies, Switzerland (CS); Universit
della Svizzera italiana, Lugano, Switzerland (LSS);
and Universidad Peruana Cayetano Heredia, Lima,
Peru (JJM)
1

The Lancet Diabetes & Endocrinology. HIV and

NCDs: the need to build stronger health
systems. Lancet Diabetes Endocrinol 2016;
4: 54950.
Nou E, Lo J, Hadigan C, Grinspoon SK.
Pathophysiology and management of
cardiovascular disease in patients with HIV.
Lancet Diabetes Endocrinol 2016; 4: 598610.
Beaglehole R, Bonita R, Horton R, et al.
Priority actions for the non-communicable
disease crisis. Lancet 2011; 377: 1438-47.
WHO. Innovative care for chronic conditions:
building blocks for action. Geneva: World
Health Organization, 2002.
Epping-Jordan J, Pruitt S, Bengoa R, Wagner E.
Improving the quality of health care for
chronic conditions. Qual Saf Health Care 2004;
13: 299305.

Oral glucose tolerance

testing and
cardiovascular disease
Naveed Sattar and David Preiss
argue that HbA1c is better than oral
glucose tolerance testing (OGTT)
for diabetes screening in patients
with cardiovascular disease.1 Fasting
plasma glucose (FPG) and HbA 1c
are included as tools to diagnose
diabetes in European guidelines, 2
which recommend an OGTT if the
diagnosis cannot be established with
HbA1c and fasting glucose. OGTT is the
only method that can detect impaired
glucose tolerance.
Data from the EUROASPIRE IV
survey 3 emphasise the importance
of OGTT, using it as a reference
to assess the contribution of
fasting glucose and HbA1c to detect
diabetes. The results of EUROASPIRE
IV were criticised on the basis of
the results of the DETECT-2 trial, 4
which showed that FPG has a clear
inflection point above which the
prevalence of retinopathy increases,
suggesting there was a relatively
weak association between OGTT and
732

prevalent retinopathy compared with

results of FPG or HbA 1c. However,
this is a circular argument because
the original definition of diabetes
(FPG 7 mmol/L) was based on
the inflection point for the risk of
retinopathy.5 In EUROASPIRE IV, 19%
of patients with diabetes were not
identified without OGTT and 83%
were not identied by HbA1c alone.
Sattar and Preiss 1 questioned
the use of OGTT because its lack
of reproducibility compared with
FPG. Although this is true, much
variability occurs within the normal
glucose range. One has to consider the
repeatability of the 2 h plasma glucose
at the level indicating diabetes,
which is high.6 An overall comparison
of the coefficient of variance in a
random population sample between
FPG, 2 h plasma glucose, and HbA1c
is meaningless. Furthermore, the
point-of-care method for glucose
measurements in EUROASPIRE IV was
also criticised by Sattar and Preiss,
without consideration of the problems
association with laboratory testing
of glucose and HbA1c. Haemolysis,
mishandling of samples, and
transportation delays can aect FPG,
and anaemia, haemoglobinopathies,
polycytaemia, and smoking can
aect HbA1c. The Hemocue equipment
that was used to test glucose in
EUROASPIRE IV has been carefully
tested against laboratory techniques.
An advantage of using OGTT for
diabetes screening is that impaired
glucose tolerance can be diagnosed.
Accumulating evidence supports
the notion that impaired glucose
tolerance is an indicator of poor
prognosis.7 Sattar and Preiss argue
that even if there was evidence to
suggest that diagnosis via OGTT
resulted in a reclassication of risk of
subsequent cardiovascular disease,
it is necessary to show that this
reclassification is more accurate or
cost-effective than using HbA1c. We
take a different view. If impaired
glucose tolerance or diabetes is
detected, guideline-recommended

management should be initiated.3 To

ignore such important information is
a matter of inertia by the responsible
physician, by not caring for
undiagnosed individuals. Our view is
supported by recommendations from
the American Diabetes Association
(ADA), which does not, in its 2016
guideline, 8 give priority to HbA 1c,
instead recommending use of
anOGTT, stating that advantages
of HbA1c might be oset by its the
lower sensitivity of HbA 1c at the
designated cut point, greater cost,
limited availability of HbA1c testing
in certain regions of the developing
world, and the imperfect correlation
between HbA1cand average glucose
in certain individuals. The ADA also
notes that results of several studies
confirmed that 2 h plasma glucose
value diagnoses more people with
diabetes than does FPG and HbA1c.
We agree with Sattar and Preiss
about the need for feasible and costeective screening methods, but we
should not mix or simplify screening
tools needed by high-risk people with
those that are sucient for use in the
general population. In the general
population, a simple questionnaire
such as FINDRISC is the best starting
tool, and further diagnostic tests can
subsequently be used for individuals
at the highest risk for glucose
perturbations. Within the framework
of EUROASPIRE IV, we are developing
an algorithm that eliminates as many
OGTTs as possible and shortens the
time for those needed without losing
diagnostic accuracy. We believe that
such attempts could simplify future
screening, bringing improved care of
patients into practice in a better way
than by using insensitive methods
just because they are seemingly
simple.
We declare no competing interests.

*Lars Rydn, Gyberg Viveca,

Oliver Schnell, Tuomilehto Jaakko,
on behalf of the EUROASPIRE IV
investigators
lars.ryden@ki.se

www.thelancet.com/diabetes-endocrinology Vol 4 September 2016

Correspondence

Cardiology Unit, Department of Medicine,

Karolinska University Hospital Solna,
171 76 Stockholm, Sweden (LR, VG); Centre for
Vascular Prevention, Danube-University Krems,
Krems, Austria (JT); and Forschergruppe Diabetes eV
Helmholtz Center, Munich, Germany (OS)
1

Sattar N, Preiss D. Screening for diabetes in

patients with cardiovascular disease: HbA1c
trumps oral glucose tolerance testing.
Lancet Diabetes Endocrinol 2016; 4: 56062.
Rydn L, Grant PJ, Anker SD, et al.
ESC Guidelines on diabetes, pre-diabetes, and
cardiovascular diseases developed in
collaboration with the EASD: the Task Force on
diabetes, pre-diabetes, and cardiovascular
diseases of the European Society of Cardiology
(ESC) and developed in collaboration with the
European Association for the Study of Diabetes
(EASD). Eur Heart J 2013; 34: 303587.
Gyberg V, De Bacquer D, Kotseva K, et al.
Screening for dysglycaemia in patients with
coronary artery disease as reected by fasting
glucose, oral glucose tolerance test, and
HbA1c: a report from EUROASPIRE IVa
survey from the European Society of
Cardiology. Eur Heart J 2015; 36: 117177.
Colagiuri S, Lee CM, Wong TY, et al. Glycemic
thresholds for diabetes-specic retinopathy:
implications for diagnostic criteria for
diabetes. Diabetes Care 2011; 34: 14550.
The Expert Committee on the Diagnosis and
Classication of Diabetes Mellitus. Report of
the Expert Committee on the Diagnosis and
Classication of Diabetes Mellitus.
Diabetes Care 1997; 20: 118397.
Wallander M, Malmberg K, Norhammar A, et al.
Oral glucose tolerance test: a reliable tool for
early detection of glucose abnormalities in
patients with acute myocardial infarction.
A report on repeated oral glucose tolerance
tests from the GAMI study. Diabetes Care 2008;
31: 3638.
George A, Bhatia R T, Buchanan G L, et al.
Impaired glucose tolerance or newly diagnosed
diabetes mellitus diagnosed during admission
adversely aects prognosis after myocardial
infarction: an observational study. PLoS One
2015; 10: e0142045.
American Diabetes Association. 2.
Classication and diagnosis of diabetes.
Diabetes Care 2016; 39 (suppl 1): S1322.

Young people have a

new vision for essential
medicines
The struggle to secure equitable
access to affordable, quality
medicines transcends national
borders and affects patients of all
ages. Young people are inheriting
an inequitable and dysfunctional
system that often fails to deliver lifesaving drugs. These systemic deficits
range from the present research and
development system that is unable

to meet population health needs,

to stringent intellectual property
protections restricting access and
innovation, and to weak health
systems that render medicine
service delivery and use inadequate.
Being less bound by the interests of
existing institutions, young people
have a unique role in analysing
and advocating for transformative
policies to ensure access to
medicines. They should be partners
in shaping and implementing a
sustainable system that serves
everyone.
Well designed youth policies and
strategies give young people the
means to collaborate in shaping
their own future within healthy
and resilient societies. The National
Strategy for Young Australians, for
example, recognises the potential of
young people to address the problems
of climate change, terrorism, ageing
societies, and health infrastructure.1
Indeed, young people can contribute
to addressing many more systemic
social issues. The reorientation
of sectoral policies and strategies
to engage the next generation
in advancing access to services
and drugs for non-communicable
diseases, along with other challenges
in the sustainable development
agenda, is long overdue. Young
people should be equipped with the
critical thinking skills to overcome
barriers to equitable access,
aordability, availability, and quality
of pharmaceutical products.
For young researchers, many
institutions offer workshops
and universities run courses on
intellectual property considerations
and technology transfer, with a
patentable discovery as an aim and
commercial licensing as the only
option. 2 Greater knowledge and
awareness of social responsibility
licensing and research and
development models, including the
concept of delinkage, should also be
readily accessible. Universities Allied
for Essential Medicines 3 and the

www.thelancet.com/diabetes-endocrinology Vol 4 September 2016

Young Professionals Chronic Disease

Network have used a decentralised
approach to education by providing
such information, but formal
incorporation of this content into
academic institutions could reap
substantial benets.
The UN Major Group for Children
and Youth (MGCY), mandated by
UN resolutions for civil society
engagement in high-level decision
making,4 was virtually absent in the
recent UN Secretary Generals HighLevel Panel on Access to Medicines
(HLPAM). Awareness needs to
be raised among young people
about the process in HLPAM and
how it is linked to the Sustainable
Development Goals. There should
be opportunities for engagement at
local or regional levels to ensure that
the global policy discourse translates
into realisation of access locally.
An opportunity will arise at the
proposed Youth Gateway Initiative,5
which is to be co-convened by the
UNs Office of the Secretary Generals
Envoy on Youth and MGCY.
The Lancet Youth Commission
on Essential Medicine Policies,
was formed in March, 2015, as
an independent commission
complementing the work of the
Lancet Commission on Essential
Medicine Policies. As a global team
of young professionals from diverse
backgrounds, we will be releasing
a report in the coming months
that seeks to provide evidencebased policy recommendations
and raise awareness, not only to
describe what is known, but also to
elaborate on what principles and
long-term solutions are needed to
achieve equitable access. We seek
accountability from those who wield
power to make decisions that will
aect us all.
Next year will mark the 40-year
anniversary of the revolutionary
WHO Essential Medicine List. 6
Noting that young people comprise
nearly a quarter of the worlds
population, yet are underrepresented

For the Young Professionals

Chronic Disease Network see
http://ypchronic.org/

For The Lancet Youth

Commission on Essential
Medicine Policies see
http://www.ycemp.com

For The Lancet Commission on

Essential Medicine Policies see
http://www.bu.edu/lancetcommission-essentialmedicines-policies/

Published Online
July 22, 2016
http://dx.doi.org/10.1016/
S2213-8587(16)30153-X
This online publication has
been corrected.
The corrected version rst
appeared at thelancet.com/
diabetes-endocrinology on
August 16, 2016

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