Albert L. Siu, MD, MSPH; on behalf of the U.S. Preventive Services Task Force *
Disclaimer: Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
Financial Support: The USPSTF is an independent, voluntary body. The U.S. Congress mandates that the Agency for Healthcare Research and Quality support the operations of the USPSTF.
Disclosures: Authors followed the policy regarding conflicts of interest described at www.uspreventiveservicestaskforce.org/Page/Name/methods-and-processes. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2345.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Requests for Single Reprints: Reprints are available from the USPSTF Web site (www.uspreventiveservicestaskforce.org).
Update of the 2008 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for diabetes in asymptomatic adults.
The USPSTF reviewed the evidence on screening for impaired fasting glucose, impaired glucose tolerance, and type 2 diabetes in asymptomatic, nonpregnant adults who are at average or high risk for diabetes and its complications.
This recommendation applies to adults aged 40 to 70 years seen in primary care settings who do not have symptoms of diabetes and are overweight or obese.
The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. (B recommendation)
Screening for abnormal blood glucose and type 2 diabetes mellitus: clinical summary.
IFG = impaired fasting glucose; IGT = impaired glucose tolerance.
Appendix Table 1. What the USPSTF Grades Mean and Suggestions for Practice
Appendix Table 2. USPSTF Levels of Certainty Regarding Net Benefit
Table. Test Values for Normal Glucose Metabolism, IFG or IGT, and Type 2 Diabetes*
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Morton H Linder, MD FACP
October 28, 2015
In your new article about screening for diabetes mellitus, why in the world do you even mention "fasting blood glucose"? An FBS misses 50% of new diabetics,and is a terrible screening test. This has been known for 50 years or more . A 2-hour post-prandial blood glucose test is much more valuable. Thank you.
Ebrahim Barkoudah, MD, MPH, FACP 1 3, Larry A Weinrauch, MD 2 3
1 Department of Medicine Brigham and Women’s Hospital; 2 E P Joslin Research Laboratory, Department of Global Health and Population; and 3 Harvard Medical School, Boston, all in MA
November 20, 2015
The Benefits of Screening and Treating Abnormal Blood Glucose in the Population
TO THE EDITOR: We read with interest the US Preventive Services Task Force recommendations for screening of asymptomatic adults, in primary care settings. While the focus on hard events in clinical trials is understandable and appropriate, discounting morbid events in the production of guidelines is not fully examined. Focusing on all-cause mortality in patients at low risk of events and for short observation time is insufficient to draw conclusions, when mortality rates are low.1 Therefore, a finding of clinical equipoise may represent a statistical error, as the studies are underpowered to define a difference between strategies. Trials may demonstrate equipoise with respect to predefined cardiovascular morbid events yet disregard major differences in heart failure hospitalizations, visual handicap, workplace disability, and loss of productivity due to illness. Yet each of these outcomes may be diminished by early recognition of populations at risk. To balance this potential benefit against a risk for “anxiety” is inequitable for our patients and community. Accepting only randomized control trials in specific populations or studies in specific populations to generate guidelines for populations not represented in those studies is not sufficient. This is especially true as moderate benefits have been supported by trials in the United States 2, in Canada 3 and in Europe 4; that might indicate a much larger effect when it comes to the population. With respect to the development of task force guidelines, one must also remember that the suggestion of an absence of evidence of benefit may itself create harm when founded upon an underpowered database. The creation of a cohort of individuals whose type 2 diabetes (T2DM) is only discovered after the development of morbid/mortal events, polyuria or polydipsia makes neither clinical nor global/population sense. The Center for Disease Control has estimated that approximately 8 million people in United States have undiagnosed diabetes; at least half of this cohort is under age 45. The unadjusted prevalence of diabetes in the US for those older than 18 years has increased by more than 150% over the last 4 decades. Adjustment for age does not change observed prevalence; thus the increase is not related to population age change. 5 6 Understanding that the risk of myocardial infarction in diabetic patients before age 45 is an alarming and 14-fold greater than that of the non-diabetic population.7 This lead us to conclude that failing to diagnose those younger until overt diabetes is clinically evident, after their initial cardiovascular event will have unfortunate consequences. We consider that waiting for symptoms to develop causes harm and is not the best population management approach. We find the evidence provided against screening is underwhelming, biased and advances neither population nor community care. We believe that it is the time to screen the US adult population for T2DM at-large and that is imprudent not to do so. 1. Barkoudah E, Skali H, Uno H, Solomon SD, Pfeffer MA. Mortality rates in trials of subjects with type 2 diabetes. J Am Heart Assoc. 2012;1(1):8-15. 2. Kahn R, Alperin P, Eddy D, Borch-Johnsen K, Buse J, Feigelman J, Gregg E, Holman RR, Kirkman MS, Stern M, Tuomilehto J, Wareham NJ. Age at initiation and frequency of screening to detect type 2 diabetes: a cost-effectiveness analysis. Lancet. 2010; 375(9723):1365-74. 3. Mortaz S, Wessman C, Duncan R, Gray R, Badawi A. Impact of screening and early detection of impaired fasting glucose tolerance and type 2 diabetes in Canada: a Markov model simulation. Clinicoecon Outcomes Res. 2012;4:91-7. 4. Herman WH, Ye W, Griffin SJ, Simmons RK, Davies MJ, Khunti K, Rutten GE, Sandbaek A, Lauritzen T, Borch-Johnsen K, Brown MB, Wareham NJ. Early Detection and Treatment of Type 2 Diabetes Reduce Cardiovascular Morbidity and Mortality: A Simulation of the Results of the Anglo-Danish-Dutch Study of Intensive Treatment in People With Screen-Detected Diabetes in Primary Care (ADDITION-Europe). Diabetes Care. 2015;38(8):1449-55.5. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014. National diabetes statistics report: estimates of diabetes and its burden in the United States, 2014. Accessed at http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf on 17 Nov 2015.6. Centers for Disease Control and Prevention. Diabetes Public Health Resource. Accessed at http://www.cdc.gov/diabetes/statistics/prevalence_national.htm on 17 Nov 20157. Hillier TA, Pedula KL. Complications in young adults with early-onset type 2 diabetes: losing the relative protection of youth. Diabetes Care. 2003; 26(11):2999-3005.
1Mary Pat Raimondi, MS, RD, 2Robert Ratner, MD, 3Todd Hobbs, MD, 4Henry Rodriguez, MD
1Academy of Nutrition and Dietetics, Washington, DC; 2American Diabetes Association, Alexandria, VA; 3Novo Nordisk Inc., Plainsboro, NJ; 4University of South Florida, Tampa, FL
November 23, 2015
Conflict of Interest:
MPR, RR, and HR have no disclosures; TH is an employee of Novo Nordisk, Inc.
Comment on: Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: U.S. Preventive Services Task Force Recommendation Statement
To the Editor:
The final U.S. Preventive Services Task Force (USPSTF) diabetes screening guideline, published on October 26, 2015, (1) improves upon the 2008 guideline it replaces, as more of the 8.1 million Americans living with undiagnosed diabetes and the 86 million with prediabetes (2) are targeted for screening. Also, this “B” level guideline recommends intensive lifestyle change programs for adults identified with abnormal blood glucose, a tremendous step forward in helping people with prediabetes prevent progression to type 2 diabetes and those with diabetes prevent complications. That’s the good news.
Unfortunately, the final guideline will fail to identify significant numbers of Americans with undiagnosed diabetes or prediabetes – and denies them important benefits of preventive interventions or early disease detection and treatment. That’s a significant step backwards.
Compared with the 2014 draft, the final guideline changed the population targeted for screening from all adults with widely accepted risk factors for diabetes to a narrower population of adults aged 40 to 70 years who are overweight or obese. (1) Absent are several critical factors placing patients at high risk for diabetes. Rates of undiagnosed diabetes are significantly higher in Asian Americans (61%+), Hispanic Americans (50%+), and Black Americans (33%+) compared with non-Hispanic whites. (3) The focus on weight alone is particularly problematic for Asian Americans, who are at risk for diabetes at a lower body mass index than USPSTF identifies for screening. (4)
Additionally, women with a history of gestational diabetes are at the highest risk, with 50% developing type 2 diabetes within five years. (5) For many new mothers with GDM, beginning screening at age 40 is too little, too late.
Most fundamentally, the final guideline portrays diabetes solely as a risk factor for cardiovascular disease, (1) completely ignoring the importance of screening to detect type 2 diabetes and treat it appropriately in order to reduce retinopathy, nephropathy and neuropathy – the complications most amenable to prevention through glucose control.
Despite these shortcomings, the new guideline will encourage screening at no cost for many more at-risk patients, as well as expand access to intensive behavioral counseling for those with abnormal glucose levels. Moving forward, we encourage primary care providers to review all risk factors identified by the American Diabetes Association in considering patients for screening. Our organizations stand ready to support the primary care community in its efforts to tackle the enormous and growing challenges posed by diabetes. Our patients deserve nothing less.
1. Siu A, on behalf of the U.S. Preventive Services Task Force. Screening for abnormal blood glucose and type 2 diabetes mellitus: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015; doi:10.7326/M15-2345.
2. Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion. National Diabetes Statistics Report, 2014. Atlanta: Centers for Disease Control and Prevention; 2014. Accessed at www.cdc.gov/diabetes/pubs/statsreport14 /national-diabetes-report-web.pdf on 16 November 2015.
3. Menke A, Casagrande S, Geiss L, Cowie C. Prevalence of and trends in diabetes among adults in the United States, 1988-2012. JAMA. 2015; 314(10):1021-1029.
4. Hsu WC, Araneta MR, Kanaya AM, Chiang JL, Fujimoto W. BMI cut points to identify at-risk Asian Americans for type 2 diabetes screening. Diabetes Care. 2015; 38:150–158.
5. Kim C, Newton K, Knopp R. Gestational diabetes and the incidence of type 2 diabetes. Diabetes Care. 2002; 25(10):1862-1868.
Siu AL, on behalf of the U.S. Preventive Services Task Force. Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2015;163:861–868. doi: 10.7326/M15-2345
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Published: Ann Intern Med. 2015;163(11):861-868.
Published at www.annals.org on 27 October 2015
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Guidelines.
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