In a new clinical guideline published in October 2015, the United States Preventive Services Task Force (USPSTF) recommended screening for diabetes in overweight and obese adults aged 40 to 70 years as part of cardiovascular (CV) risk assessment. Some clinicians, however, feel that this recommendation is too limited.1
“Our fear is that without strong screening guidelines, the number of people diagnosed with diabetes will continue to grow unabated,” Robert Lash, MD, chair of the Endocrine Society’s Clinical Affairs Core Committee, told Endocrinology Advisor. “About 8 million people don’t even know they have the condition, and they could be doing serious harm to their health if it isn’t diagnosed.”
Other clinicians appear to share Dr Lash’s concerns, with statements from several associations noting that many endocrinology professionals were disappointed when the USPSTF released the new screening recommendations for abnormal glucose and type 2 diabetes in asymptomatic adults.
It is estimated that approximately 29 million Americans aged 20 years and older have diabetes, and another 86 million have prediabetes, according to the 2014 National Diabetes Statistics Report published by the Centers for Disease Control and Prevention.2 Given the serious complications associated with the disease, and because symptoms often do not appear until later in the course of its progression, early prevention and detection efforts are imperative.
“The Task Force conducted a systematic review of the available evidence and evaluated the benefits and harms of this preventive service,” Michael Pignone, MD, a USPSTF member and professor of medicine at the University of North Carolina in Chapel Hill, told Endocrinology Advisor. “We concluded that there is a moderate net benefit” to screening among this patient population.
Nevertheless, several professional organizations believe the guidelines miss the mark in several ways.
“The Endocrine Society and other members of the diabetes community share the concern that the final diabetes screening guideline is too narrow,” said Dr Lash, who is also a professor of internal medicine in the division of metabolism, endocrinology and diabetes at the University of Michigan. “The USPSTF’s 2014 draft guideline encompassed a broader range of diabetes risk factors in defining which adults would be candidates for screening.”
The Diabetes Advocacy Alliance (DAA), which includes organizations like the Endocrine Society, the American Diabetes Association (ADA), and the American Association of Clinical Endocrinologists, issued a statement of support for the draft version when it was released in 2014.3 Upon release of the final version, however, they issued a statement expressing that they were surprised and “deeply disappointed” with the changes.4
The recent DAA statement acknowledged that the new guideline is an improvement in some ways over the 2008 version but said the new one minimizes key factors like race, ethnicity, family history, and gestational diabetes. Although the USPSTF guideline does suggest that healthcare providers consider earlier screening in patients with one or more of these characteristics, it is included under a section called “Clinical Considerations” rather than as part of the recommendation summary.
“Given the significant challenge of health disparities in America, it is unconscionable that the USPSTF excluded race and ethnicity from its definition of the population to be screened for diabetes,” DAA co-chair Tricia Brooks of Novo Nordisk Inc, said in the statement.4
A paper published in Clinical Diabetes in 2012, for instance, noted that racial and ethnic minorities have higher rates of diabetes than white patients, with African Americans, Hispanics, and Native Americans having a 50% to 100% higher disease-related burden and mortality than white Americans.5
In addition to race/ethnicity, the age range outlined in the new guideline also poses a problem, according to Robert Ratner, MD, chief scientific and medical officer of the American Diabetes Association.
“In addition to the at-risk, minority populations that are not addressed in the new guidelines, the age bracket covered for screening does not encompass all who are at risk,” Dr Ratner said in a statement from the ADA.6 “Diabetes screening should not be limited to ages 40 to 70. This grossly ignores the evidence of the National Institutes of Health’s Diabetes Prevention Program (DPP) that found individuals at high risk as young as age 25 are able to reduce their risk for type 2 diabetes. Moreover, there was no upper age limit in the DPP trial, and seniors had an even higher success rate with lifestyle intervention.”
Furthermore, the age range may be particularly harmful for women with gestational diabetes.
“Also of note, women with a history of gestational diabetes are at the highest risk of developing type 2 diabetes, with 50% developing type 2 diabetes within 5 years. Beginning screening at age 40 is too little too late for many of these women with a history of gestational diabetes. They may have had diabetes for 5 to 10 years by then,” Dr Ratner added.6
In the DAA statement, Brooks also expressed concern that the guideline could negatively impact insurance reimbursement for patients who do not meet the specified characteristics, since the Affordable Care Act makes reimbursement contingent on USPSTF recommendations.
Another point of contention is the guideline’s emphasis on diabetes screening as part of assessment for CV disease, which could minimize the perceived importance of screening for diabetes itself, according to the DAA statement.
“Diabetes is an important condition in its own right, and we know that undiagnosed cases can lead to a range of health problems, including blindness, kidney disease, and amputations,” said Dr Lash.