USPSTF: Screen Everyone 45 and Older for Abnormal Glucose

Miriam E. Tucker

October 06, 2014

Adults aged 45 and older and those who are younger with risk factors should be screened for abnormal blood glucose and type 2 diabetes, according to new draft guidelines from the US Preventive Services Task Force (USPSTF).

The draft recommendation statement and draft evidence review are now open for public comment through November 3 here. The USPSTF, an independent panel of experts under the auspices of the US Agency for Healthcare Research and Quality, makes evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications.

The new statement is an update to the 2008 USPSTF diabetes screening guideline, which targeted individuals with high blood pressure. Now, the new focus is on identifying people with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT), task force member Michael P. Pignone, MD, professor, department of medicine, and chief, division of general internal medicine, at the University of North Carolina, Chapel Hill, told Medscape Medical News.

"It's been through an evolution in the evidence. There have been studies that have come out subsequent to the 2008 recommendation that, in the task force's opinion, really compelled screening to identify people who have abnormal blood glucose that might not fall into the diabetes range but that would be amenable to intensive lifestyle intervention."

According to the document, 2012 national data suggest that approximately 86 million Americans have impaired glucose tolerance or impaired fasting glucose, and about 8 million have undiagnosed diabetes. In 2012, about 9% of the US population had diabetes, up from 5% in 1995.

"There are a lot of people who have this abnormal glucose that falls short of diabetes, so we really need to work on making sure we have appropriate interventions available for them.…Part of the task force's intent is to get physicians to think about lifestyle intervention more, and it's also a call to make effective lifestyle programs more available," Dr. Pignone told Medscape Medical News.

Lifestyle Change Advocated for People at Risk, but No Medication

The recommendation calls for screening everyone beginning at age 45 years, as well as younger adults with risk factors including overweight or obesity, a first-degree relative with diabetes, women with a history of gestational diabetes or polycystic ovarian syndrome, and certain racial/ethnic minority groups, including African Americans, American Indians/Alaskan Natives, Asian Americans, Hispanics/Latinos, and Native Hawaiians/Pacific Islanders.

Acceptable screening tests include HbA1c, fasting plasma glucose, or an oral glucose tolerance test. For each, the document provides cutoff values for normoglycemia, impaired fasting glucose, impaired glucose tolerance, and diabetes.

The task force suggests screening low-risk individuals every 3 years and annual screenings for those at greater risk or who have had previous abnormal values, although data supporting interval recommendations are limited.

Also included are references to previous USPSTF recommendations for screening and interventions for overweight/obesity, physical inactivity, abnormal lipid levels, hypertension, and smoking.

Diet and physical-activity promotion programs for those at increased risk for type 2 diabetes had also been previously recommended.

Dr. Pignone told Medscape Medical News that the task force considered whether or not to recommend any medications for people identified with IGT or IFG but did not find sufficient evidence that the benefit would outweigh potential risk. In contrast, "there's good evidence for the effectiveness of lifestyle intervention."

Consistent Message: Follow-up Is Most Important

The new proposed USPSTF recommendations are generally in line with diabetes screening recommendations previously made by other groups, including the American Diabetes Association (ADA), the American Association of Clinical Endocrinologists, the American Academy of Family Physicians, Diabetes Australia, Diabetes UK, and the Canadian Task Force on Preventive Health Care.

However, there is a difference in emphasis with the ADA's recommendation, which focuses on obesity: "Testing to detect type 2 diabetes and prediabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI >25 kg/m2) and who have 1 or more additional risk factors for diabetes. In those without these risk factors, testing should begin at age 45 years" (Diabetes Care. 2014;37:S14-S80).

Dr. Pignone told Medscape Medical News, "Obesity is one of the risk factors we listed and probably the most common and most important in younger people, but [so is] family history.

"We also wanted to highlight that in some racial/ethnic groups diabetes tends to develop at lower BMI and waist/height ratios, so we didn't want to focus solely on obesity. But clearly that's one of the important risk factors."

In general, he said, the proposed USPSTF guidelines and those of other organizations are generally in agreement and the more major issue is how to follow up with those who screen positively.

"There will be a more consistent message with the convergence between the recommendations. But it's not a small problem. The cost of screening itself is quite inexpensive, but we have to think of the full spectrum of care that's required. Apart from cost, it's going to be hard to deliver good lifestyle-intervention programs to the large number of US adults who might benefit from them."

He said that the task force will welcome comments for the next 30 days. "We look forward to hearing from people because this is an important issue. We'll take their comments into strong consideration."

Dr. Pignone has reported no relevant financial relationships.

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