Correspondence
of non-communicable diseases will
also be impaired, leading to increased
complication and hospitalisation rates
and adding to the rise of catastrophic
health expenditures.
Our research shows the remarkable
capacity of UNRWA—through flexible
staff deployment, innovation in models
of service delivery, and introduction
of e-health—to demonstrate resilient
functioning in the face of threats
to its operations. However, the
current funding crisis could severely
compromise its capacity to support
the health and dignity of Palestinians.
Our analysis reinforces the moral
and technical rationale for the call
to the international community to
#FundUNRWA.
This work is informed by ongoing research funded
by Elrha’s Research for Health in Humanitarian
Crises (R2HC) Programme. The R2HC programme
aims to improve health outcomes by
strengthening the evidence base for public health
interventions in humanitarian crises. The R2HC
programme is funded equally by the Wellcome
Trust and the UK Department for International
Development, with Elrha overseeing the
programme’s execution and management. AA is
Deputy Chief Scientific Adviser to the UK
Department for International Development. We
declare no other competing interests.
Alastair Ager, Mohamad Alameddine,
Sophie Witter, Fouad M Fouad,
*Karin Diaconu, Zeina Jamal,
Graham Lough
kdiaconu@qmu.ac.uk
Institute for Global Health & Development, Queen
Margaret University, Edinburgh EH21 6UU, UK
(AA, SW, KD, GL); and Faculty of Health Science,
American University of Beirut, Beirut, Lebanon
(MA, FMF, ZJ)
1 Elrha. Systems resilience in UNRWA health
provision to Palestine refugees displaced by
Syria crisis. http://www.elrha.org/map-
location/systems-resilience-unrwa-health-
provision-palestine-refugees-displaced-syria-
crisis/ (accessed Feb 8, 2018).
2 Seita A, Goldsmith A, Hababeh M, Shahin Y.
Amid US funding cuts, UNRWA appeals for
health and dignity of Palestinian refugees.
Lancet 2018; published online Jan 22.
DOI:10.1016/S0140-6736(18)30113-2.
3 The UN Relief and Works Agency. Syria
regional crisis. Emergency appeal 2018.
https://www.unrwa.org/sites/default/files/
content/resources/2018_syria_ea_final_web.
pdf (accessed Feb 5, 2018).
4 The UN Relief and Works Agency. Health
Department annual report 2016.
May 24, 2017. https://www.unrwa.org/
resources/reports/health-department-
annual-report-2016 (accessed Feb 10, 2018).
www.thelancet.com Vol 391 March 31, 2018 1261
Type 2 diabetes
We read with great interest the
Seminar (Feb 9, 2017, p 2239) 1 on
type 2 diabetes by Sudesna Chatterjee
and colleagues. However, we were
surprised by the articles selected
and believe that detailed selection
criteria with the level of evidence of
reported studies would have been
useful to the reader. According to
the research method described, we
would expect other papers to be
cited, including meta-analyses of
randomised con­trolled trials that could
have balanced the authors’ outlook.2–6
For example, intensive glycaemic
control probably has some beneficial
effect on diabetic complications, such
as non-fatal myocardial infarctions3–5
or retinopathy assessed with the
Early Treatment Diabetic Retinopathy
Study scale. 5 However, there is no
evidence that glycaemic control
prevents or slows down progression
of neuropathy 3,4 or severe renal
failure. 3–5 There is also good evi­
dence that stroke and mortality are
not reduced.3–5 Intensive glycaemic
control might even increase the risk of
heart failure.4
Another point that requires further
explanation is the role of metformin.
Although it is still the first-line
treatment for type 2 diabetes, the
level of evidence on clinically relevant
endpoints (morbidity and mortality)
is low. Metformin has not shown
any efficacy on these endpoints in
systematic reviews.2,6 The same is true
for sulfonylureas and insulin, which
also have serious adverse effects, such
as severe hypoglycaemia. 2 Finally,
there is no evidence that dipeptidyl
peptidase-IV inhibitors prevent
diabetic complications.2
Intensive glycaemic control does
not appear to be an appropriate
strategy for type 2 diabetes and
wrongly focusing on HbA1c should not
overshadow other treatments (such
as statins) with a higher level of evi­
dence for prevention of macrovascular
complications in particular.
We declare no competing interests.
Remy Boussageon, Matthieu Roustit,
Francois Gueyffier, Benoit V Tudrej,
*Michaela B Rehman
michaela.rehman@gmail.com
Department of General Practice, Faculty of Medicine,
Université de Poitiers, Poitiers, France (RB, BVT);
Université Grenoble-Alpes, Grenoble, France (MR);
UMR 5558, Laboratoire de Biométrie et Biologie
Evolutive, Claude-Bernard Lyon 1 University, CNRS,
Lyon, France (FG); and Cardiology Department, CHU
de Poitiers, Poitiers 86000, France (MBR)
1 Chatterjee S, Khunti K, Davies MJ.
Type 2 diabetes. Lancet 2017; 389: 2239–51.
2 Palmer SC, Mavridis D, Nicolucci A, et al.
Comparison of clinical outcomes and adverse
events associated with glucose-lowering drugs
in patients with type 2 diabetes:
a meta-analysis. JAMA 2016; 316: 313–24.
3 Rodríguez-Gutiérrez R, Montori VM.
Glycemic control for patients with type 2
diabetes mellitus: our evolving faith in the face
of evidence. Circ Cardiovasc Qual Outcomes
2016; 9: 504–12.
4 Boussageon R, Bejan-Angoulvant T,
Saadatian-Elahi M, et al. Effect of intensive
glucose lowering treatment on all cause
mortality, cardiovascular death, and
microvascular events in type 2 diabetes:
meta-analysis of randomised controlled trials.
BMJ 2011; 343: d4169.
5 Hemmingsen B, Lund SS, Gluud C, et al. Intensive
glycaemic control for patients with type 2
diabetes: systematic review with meta-analysis
and trial sequential analysis of randomised
clinical trials. BMJ 2011; 343: d6898.
6 Boussageon R, Supper I, Bejan-Angoulvant T,
et al. Reappraisal of metformin efficacy in the
treatment of type 2 diabetes: a meta-analysis
of randomised controlled trials. PLoS Med 2012;
9: e1001204
In the summary of their Seminar,1
Sudesna Chatterjee and colleagues
state that the incidence of type 2
diabetes “continues to rise globally”.
There is no evidence to support this
claim and most recent literature
suggests that, in developed countries,
incidence peaked sometime in the
iStock/wragg
last decade and then levelled off or
slightly decreased.2–5
Incidence is more difficult to esti­
mate than prevalence because it
is more dependent on timely and
accurate recording of the disease. A
2014 survey2 of worldwide trends in
diabetes incidence and prevalence
concluded that, although reports
of incidence are fairly sparse, “evi­
dence from developing countries
demonstrates increasing incidence