Screening updates for prediabetes, diabetes may increase detection
Click Here to Manage Email Alerts
Implementing new guidelines would increase screening eligibility and detection of diabetes and prediabetes, according to an analysis published in JAMA.
Screening, prevention and treatment of diabetes in younger patients is “suboptimal” in the United States, the authors of the analysis wrote. To facilitate earlier detection and treatment, the U.S. Preventive Services Task Force and American Diabetes Association (ADA) recently lowered the recommended age to start diabetes screening to 35 years.
“The new guidelines partially address the front end of this chain [of diabetes prevention], but we know from existing research that there are lots of gaps in this process,” Michael Fang, PhD, MHS, an assistant scientist in the division of cardiovascular and clinical epidemiology at Johns Hopkins Bloomberg School of Public Health, told Healio. “For example, studies show that only about 5% of patients with prediabetes in the U.S. are actually referred to prevention programs by their provider.”
Fang and colleagues analyzed 2015 to 2020 data from the National Health and Nutrition Examination Survey on adults aged 20 years and older without a history of prediabetes or diabetes. These individuals were fasting, not pregnant and had recorded measurements of their HbA1c, fasting plasma glucose (FPG), weight and height. The mean age of the 4,480 participants included in the analysis was 45.6 years; 51.2% were women.
Fang and colleagues defined prediabetes as an FPG level of 100 to 125 mg/dL, or an HbA1c of 5.7% to 6.4%. Undiagnosed diabetes was considered at an FPG level of 126mg/dL or greater, or HbA1c of 6.5% or greater. The researchers estimated the proportion of U.S. adults eligible for screening based on the USPSTF 2015 guidelines (aged 40 to 70 years with BMI of 25 kg/m² or greater), USPSTF 2021 guidelines (aged 35 to 70 years with BMI of 25 kg/m² or greater), ADA 2003 guidelines (aged 45 years or older or a BMI of 25 kg/m² or greater and one or more risk factors) and ADA 2022 guidelines (aged 35 years or older or a BMI of 25 kg/m² or greater and one or more risk factors).
It is yet unknown whether clinicians and the health care system will be able to reach and test an expanded patient population for diabetes and prediabetes, according to Fang.
“Our paper assumed perfect implementation of the guidelines,” he said. “We will have to wait and see how things play out in the ‘real world.’”
Implementing the USPSTF 2021 and ADA 2022 guidelines would increase screening eligibility by about 6 to 7 percentage points, leading to a 4 to 6 percentage-point increase in prediabetes detection and a 2 to 9 percentage-point increase in undiagnosed diabetes detection, Selvin and colleagues approximated.
The ADA 2022 guideline considers a broader set of risk factors than the USPSTF 2021 guideline, according to the researchers. As a result, the ADA 2022 guideline can identify a larger portion of persons with prediabetes or diabetes. This would require screening about twice as many people, upwards of 80% of asymptomatic adults, if implemented, which may be “cost prohibitive” and put a greater burden on physicians overall, the researchers wrote.
Yet, the new guidelines will expand screening eligibility to millions of young adults in the U.S., according to Fang.
“Given the high prevalence of prediabetes and diabetes in the U.S., I am in favor of a more inclusive screening strategy,” he said. “With that being said, the ADA 2022 criteria may be too broad and complex.”
With regard to the adoption of the new guidelines, Fang said it will “vary dramatically by setting.”
“In environments where resources are more limited, implementing guidelines may take more time,” he added.
Perspective
Back to Top
Rajesh K. Garg, MD
This study included a representative sample of the U.S. adult population and looked at their eligibility for screening for diabetes and prediabetes based on old and new criteria proposed by the USPSTF and ADA. The new criteria would increase the number of adults eligible for screening by 6 to 7 percentage points, and authors think that it would be cost prohibitory. I think the proportion of eligible population based on the old ADA criteria (76.7%) was already very high, and an increase to 82.9% is not a big jump. However, the bigger question is the effectiveness of management strategies for prediabetes. The clinical trial data that showed a delay in progression from prediabetes to diabetes have been difficult to implement in real life. Moreover, the utility of any treatment for prediabetes in older age groups is questionable. Therefore, while we find effective treatment strategies to prevent diabetes and learn more about the long-term benefits of treatment of prediabetes, screening may be limited to age group 35 to 65 years, with treatment reserved for those with HbA1c greater than 6%. This will limit the number of eligible adults for screening and treatment to a reasonable number.
Collapse
Click Here to Manage Email Alerts