Diabetes screening based on race, ethnicity may lead to more equitable care
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Black, Hispanic and Asian Americans may be at risk for developing diabetes at lower weights and younger ages than white Americans, according to a study in Annals of Internal Medicine.
Researchers said the findings highlight the need to update screening recommendations based on race and ethnicity.
Diabetes is a significant issue in the United States, as it affects more than 34 million adults and generates $330 billion in annual health care expenses, according to a press release about the study. One well-known risk factor is excess body weight, so the U.S. Preventive Services Task Force recommends diabetes screening at age 35 years for all adults who have a BMI of 25 kg/m2 or higher.
But a “more equitable approach” would be to offer screening starting in the early 20s or at a BMI of 20 kg/m2 for Asian Americans and about 18.5 kg/m2 in Hispanic and Black Americans, first author Rahul Aggarwal, MD, an internal medicine resident at the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center, said in the press release.
The ease of a single screening threshold for all Americans is “alluring” but “deeply inequitable,” senior author Dhruv Kazi, MD, MSc, MS, an associate director of the Smith Center and associate professor of medicine at Harvard Medical School, said in the release.
“Our findings suggest that Asian, Hispanic and Black Americans may need to get screened at lower BMI or younger ages than white Americans. If the current thresholds are universally applied, without accounting for differential risk in racial/ethnic groups, clinicians may underdiagnose diabetes in Asian, Hispanic and Black Americans. On the other hand, applying a more tailored approach may ... reduce rates of undiagnosed diabetes and produce population-wide improvements in diabetes care,” Kazi said.
Aggarwal, Kazi and colleagues used statistical modeling and CDC data on diabetes prevalence to estimate the age and BMI levels at which the prevalence of diabetes in historically underrepresented ethnic populations in the U.S. is equivalent to white Americans.
Among adults aged 35 years with a BMI of 25 kg/m2, the researchers reported that the prevalence of diabetes was 3.8% (95% CI, 2.8-5.1) among Asian Americans, 3.5% (95% CI, 2.7-4.7) among Black Americans, and 3% (95% CI, 2.1-4.2) among Hispanic Americans. This was significantly higher than the prevalence among white Americans — 1.4% (95% CI, 1-2), according to Aggarwal, Kazi and colleagues.
“When estimating equivalent screening thresholds, our analysis accounted for imprecision in diabetes prevalence estimates for both white and racial/ethnic minority populations,” the researchers wrote. “With this approach, the estimated BMI thresholds for diabetes screening were 20 kg/m2 for Asian Americans, less than 18.5 kg/m2 for Black Americans, and 18.5 kg/m2 for Hispanic Americans.”
Aggarwal noted in the press release that late diagnoses and inadequate treatment of diabetes “can produce catastrophic consequences,” and can jeopardize one’s heart, kidney, eyes and limbs.
“But it doesn’t affect all of us equally — there are striking disparities that are largely the legacy of structural racism. Fixing the health disparities for Americans with diabetes will require a range of strategic investments in health care and efforts to reduce structural inequities,” he said. “Making screening more equitable is a place to start, as it ensures that individuals with diabetes can receive preventive care and treatment in a timely manner and avert the most catastrophic consequences of diabetes.”
In a related editorial, Quyen Ngo-Metzger, MD, MPH, a professor in the department of health systems science at Kaiser Permanente Bernard J. Tyson School of Medicine in Pasadena, California, cited previous research highlighting the racial and ethnic disparities in the quality of diabetes care.
“Black, Hispanic and Asian Americans with diabetes were all less likely than white Americans to receive hemoglobin A1c testing and eye examinations,” she wrote. “The USPSTF already recommends risk-based preventive services for other conditions, including cancer, cardiovascular disease and infectious disease. To address the current inequity in diabetes screening, the USPSTF should apply the same consideration to its diabetes screening recommendation.”
References:
- Aggarwal R, et al. Ann Intern Med. 2022;doi:10.7326/M20-8079.
- Screening some sooner may reduce racial and ethnic disparities in diabetes diagnosis, researchers show. https://www.eurekalert.org/news-releases/951828. Published May 9, 2022. Accessed May 31, 2022.
Perspective
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This study emphasizes the importance of taking race and ethnicity into consideration in order to reduce health inequities, which is extremely important. Using race and ethnicity-specific criteria for screening for diabetes can avoid delays in diagnosis, complications from undiagnosed diabetes, and the subsequent perpetuation of inequitable health outcomes, as was previously reported.
As a nation, we must end practices that disproportionately result in poor health outcomes for specific racial and ethnic communities. For example, removing race-based eGFR cutoffs to determine kidney function can reduce the delay in diagnosis of kidney disease in the African American community.
Similarly, using lower BMI cutoffs for diabetes screening depending on patients’ race/ethnicity, as suggested in this study, can reduce the delay in diagnosis of diabetes among patients of certain racial/ethnic backgrounds.
Even though studies like this show the importance of screening patients of certain racial and ethnic backgrounds for diabetes at a lower BMI, that does not mean that insurance carriers will cover these screenings at an earlier time, since the current diabetes screening guidelines updated by the U.S. Preventive Services Task Force in 2021 recommend screening for diabetes when patients are considered overweight using the standard U.S. BMI cutoff of 25 kg/m2, rather than international BMI definitions for being overweight, which vary based on race and ethnicity.
As we raise awareness of the need to take race and ethnicity into account when screening for diabetes to prevent delays in diagnosis, in order to further prevent the perpetuation of racial and ethnic health inequities, we must also advocate for updated guidelines, clinical criteria and policies that ensure patients receive the screenings they need without increased personal financial burden in order to achieve more equitable health outcomes.
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