USPSTF: Insufficient evidence to recommend screening kids, teens for prediabetes, diabetes

Dana Dabelea, MD, PhD

Youth-onset type 2 diabetes is a relatively new pediatric condition, which really did not exist until the 1990s. Decades ago, type 2 diabetes used to be called “adult-onset diabetes” (while type 1 diabetes was called “juvenile diabetes”), but we are now seeing type 2 diabetes in children, and it is actually increasing rapidly, especially in indigenous and youth of color.

Since it is such a new condition, evidence on benefits or harms of screening is accumulating, but right now it is insufficient. However, we do have evidence that youth-onset type 2 diabetes is a more aggressive disease than both adult-onset type 2 diabetes and youth onset type 1 diabetes. So, creating the evidence base for USPSTF recommendations is crucial.

One of the most important areas for immediate research include knowing how the risk factors for youth-onset type 2 diabetes operate. In other words, we need to understand better the pathophysiology of youth-onset type 2 diabetes, and to what extent that is different from adult-onset type 2 diabetes. We also do not know how to predict who is at greatest risk, so research is needed to develop optimal prediction models. We have some approved treatments, but right now they do not seem to halt the disease progression and development of chronic complications, so more work is needed to develop optimal therapies that address key disease pathways. Finally, while we know that childhood obesity is a key risk factor, we still do not have definitive evidence that preventing or treating obesity will prevent youth-onset type 2 diabetes, so that is also a crucial area for immediate research.

Until evidence that the USPSTF deems reviewable can be found, primary care physicians should follow the ADA guidelines. This group recommends screening for youth-onset type 2 diabetes those youth who have overweight/obesity and one or more additional risk factors (eg, family history of diabetes, maternal gestational diabetes, metabolic syndrome, or are of “non-white” race or ethnicity). Screening should start after onset of puberty or at age 10 years, using HbA1c, fasting glucose or oral glucose tolerance tests every 3 years if tests are normal, or more frequently if BMI increases. To those at high risk, PCPs should offer developmentally and culturally competent lifestyle programs, targeting 7% to 10% decreases in excess weight.

Arch G. Mainous III, PhD

The USPSTF is correct in its assessment that there is insufficient evidence to justify screening for type 2 diabetes in children and adolescents. Admittedly, there have been reports for several years of type 2 diabetes presenting in adolescents. However, the overall prevalence would still solidly classify this as a rare disease by the NIH. This would be a condition that affects fewer than 200,000 people. The CDC estimate of type 2 diabetes prevalence in children and adolescents younger than age 20 is 23,000. Remember, the United States’ total population is about 320 million. Consequently, any screening would have to be strategically targeted because a general screening among children and adolescents for type 2 diabetes would be a substantial amount of costs and activity for negative tests.

Further, the USPSTF looks for trial results of treatment once individuals are identified. I believe that this is an area with very limited evidence. In addition to screening for type 2 diabetes, it would probably be particularly useful to identify children and adolescents with prediabetes so that we could try and prevent the development of diabetes. This would be critically important to prevent type 2 diabetes in children. Unfortunately, our knowledge base is quite limited in this area.

At this point, the best strategy for PCPs is to monitor the BMI and physical activity of their adolescent patients, since a sedentary lifestyle and obesity will play a role in the development of diabetes. However, we need to go beyond just telling all parents and children to exercise and eat right. It might be prudent to propose that those who seem at particular risk should have a more intense regimen. PCPs should have at-risk patients focus on lifestyle interventions, which should pay dividends.

Scott Clements, MD

Type 1 and type 2 diabetes are both increasing at alarming rates across the world. Type 2 diabetes has typically only been a problem in adults. With the obesity epidemic, more and more teenagers are developing type 2 diabetes, particularly those who are Black, Latinx and Native American. But while there is a large increase compared to rates in the past, statistically, this is still a small percentage compared to the number of children in the country. If you consider there are roughly 73,000,000 children in the U.S, and there are roughly 23,000 children with type 2 diabetes, this comes to a rough estimate of 0.03% of children having type 2 diabetes. This means you would need to screen about 3,000 children to find one case of type 2 diabetes. Universal screening for type 2 diabetes would be expensive and time-consuming, and most primary care providers would not see even one case of type 2 diabetes in an entire year.

A more targeted approach to screening would likely be more effective. Teenagers who are obese, have already started puberty, and have acanthosis nigricans, a dark ring around the back of the neck, are much more likely to have type 2 diabetes than other children. Primary care providers should focus their screening efforts on teenagers with these findings, particularly if there is a family history of type 2 diabetes.

When a teenager’s HbA1c level is in the range for type 2 diabetes (greater than 6.5%) they should be referred to a pediatric endocrinologist or a diabetes specialty clinic for management of their diabetes. There are a lot of new medications and technologies for treating type 2 diabetes, so it is better to see a diabetes specialist. When a teenager’s HbA1c level is in the prediabetes range (5.7% to 6.4%), the only treatment is lifestyle modifications such as healthy eating, increased physical activity and weight loss. Therefore, primary care providers should encourage a healthy lifestyle and they should identify community resources that can be helpful for the families they take care of. On that last point, many communities have healthy living classes, support for obtaining healthy foods and weight management clinics.