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We read with interest both the original CMAJ article (1) and the response (2) regarding gestational diabetes mellitus (GDM) screening in BC. In the response (2), there is a strong argument put forth to justify implementation of more specific, less sensitive, 2-step screening criteria for GDM. The argument notes that the more specific 2-step criteria avoid: i) the potential patient harm and ii) the expected financial waste that accompany over-diagnosis and consequent over-treatment.
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We agree with this argument and wish to add to it additional considerations that apply to any screening program. The considerations are pertinent now, as opposed to 1968, when Wilson, Jungner et al (3) developed the principles for instituting a screening program. And these criteria have not been duly considered in a more recent update (4) to the Wilson, Jungner criteria that: i) does not reference the meta-crisis caused by human activity exceeding multiple planetary boundaries (5) and ii) posits adequate resources as a criterion for a screening program in a world that uses its resources at a pace that would require 2 – 3 earth’s to sustain. (5)
1. Is there an optimal threshold for identifying patients?
In the current meta-crisis, the optimal threshold for a screening test is that which maximize the ratio of disability adjusted life years (DALY) prevented to the energy and resource use (ERU) of the screening/treatment system: DALY/ERU. ERU would be measured as a weighted functio...Competing Interests: None declared.References
- Nethery E, Law MR, Kotaska A, Janssen PA, Hutcheon JA. The effect of changing screening practices and demographics on the incidence of gestational diabetes in British Columbia, 2005–2019. CMAJ. 2023 Mar 20;195(11):E396-403.
- Bell KJ, Glasziou PP, Doust JA. A call to reconsider the new diagnostic criteria for Gestational Diabetes Mellitus.
- Wilson JM, Jungner G, World Health Organization. Principles and practice of screening for disease.
- Dobrow MJ, Hagens V, Chafe R, Sullivan T, Rabeneck L. Consolidated principles for screening based on a systematic review and consensus process. Cmaj. 2018 Apr 9;190(14):E422-9.
- Hickel J, O’Neill DW, Fanning AL, Zoomkawala H. National responsibility for ecological breakdown: a fair-shares assessment of resource use, 1970–2017. The Lancet Planetary Health. 2022 Apr 1;6(4):e342-9.