Clinicians should screen asymptomatic obese and overweight adults, ages 40 to 70, for type 2 diabetes, and refer patients with abnormal glucose to intensive behavioral counseling, the U.S. Preventive Services Task Force (USPSTF) recommended.
In an update to the 2008 guidelines, and based on a review of scientific literature, the USPSTF found sufficient evidence to support the use of glucose screening in this population to detect opportunities for dietary and exercise intervention to prevent cardiovascular disease and type 2 diabetes, Albert L. Siu, MD, MSPH, of Mount Sinai Hospital in New York City, wrote on behalf of the USPSTF in Annals of Internal Medicine.
The USPSTF states that this recommendation was not intended to negate tailoring medicine to individual patients, but rather serves as a summation of the evidence supporting the use of proactive screening and referral for behavioral intervention in this population.
“I happen to be a preventive medicine specialist. If your blood sugar is abnormal, it’s not costly or invasive do do another test,” Hull told MedPage Today in a phone interview. “People get more upset if you tell them they shouldn’t have a test that they think they need, and it’s inexpensive, so I don’t think anybody is going to push back.”
Hull, who was not involved in developing the USPSTF guidelines, said that the key to the behavioral interventions is the approach. “I also think it’s important to work with communities, and community and public health agencies, to work with people where they live, not just in the clinic. That’s what we do.”
The specifics of the screening recommendations, classified as Grade B, note additional risk factors for patients with a high percentage of abdominal fat, high cholesterol, high blood pressure, physical inactivity, and smoking.
For patients who show normal glucose levels, re-screening every 3 years was recommended. However, the USPSTF did say that the evidence on optimal screening intervals after initial normal results was limited.
In the event of abnormal test results, the USPSTF recommendation for behavioral intervention in the form of combined dietary and physical activity counseling suggested multiple contacts over extended periods; and that there was insufficient evidence to support the use of medication over behavioral interventions.
“The recommendations are warranted and long overdue,” wrote Neda Laiteerapong, MD, assistant professor of medicine at the University of Chicago, wrote in an email to MedPage Today.
“I think many primary care physicians are doing this already. But I think it’s very likely that some physicians are still relying on the 2008 guidelines to screen based on blood pressure levels. So the updated guidelines were very necessary,” added Laiteerapong, who was not involved in the the guidelines.
“Importantly, a major reason the guidelines have changed is because new trials that have demonstrated the benefits of intensive behavioral counseling to combat diabetes and other cardiovascular outcomes,” Laiteerapong added. “However, the systems to routinely get intensive behavioral counseling are not yet in place in many healthcare settings.”
There are a large number of adults who are recommended to have screening at a younger age for diabetes based on their race or ethnicity, family history, or clinical history, Laiteerapong said. “The American Diabetes Association has recommended this for years, and it is excellent that the USPSTF is now including these populations in their recommendations.”
“Diabetes is on the rise and it’s directly related with the increase in obesity. [Though] there’s been some leveling off with the rate of rise, the absolute rate of the population that is overweight or obese hasn’t been decreasing,” Don Bradley, MD, an associate consulting professor in the department of community and family medicine at Duke University, said in a phone interview with MedPage Today. “We have yet to see the peak in type 2 diabetes. We’re seeing an increasing prevalence of type 2 diabetes in kids, and we’re still going to see a continued increase.”
According to Bradley, the real question is what impact will these recommendations make. “Will knowing if someone is glucose intolerant make a difference? The USPSTF isn’t overly enthusiastic about meds, but to the extent that this is a motivator to get folks to do what they ought to be doing anyway.”
Bradley, who served on the Institute of Medicine (IOM) roundtable on obesity solutions, said counseling and integration with community efforts and environment and other social determinants will be critical to move the dial.
“The 15 minutes are probably 7 minutes that you get to see the doctor, and the few minutes that you see the nutritionist are important, but if you go home and you can’t buy food, or there isn’t a safe place to walk, or there’s no place to exercise at work…[there’s] a need to think more broadly, intensive behavioral counseling can only go so far if they [patients] know what to do, but they go home and can’t make [the changes] happen.”
Michael Pignone, MD, MPH, a member of the USPSTF committee, said in an email to MedPage Today that the hope is that the updated recommendation will “improve the consistency of appropriate screening.”
“Diabetes has been increasing in prevalence in the United States in the past 15 years. Almost 40% of adults have abnormal blood sugar levels that put them at increased risk for developing diabetes or cardiovascular disease,” Michael Pignone, MD, of the University of North Carolina at Chapel Hill, wrote in an email to MedPage Today. “The good news is that the task force found screening adults ages 40 to 70 who are overweight or obese can identify individuals with abnormal blood glucose levels before it progresses to diabetes and that offering or referring them to intensive lifestyle interventions can help prevent or daily complications from the disease.”
“The best way to do this is an intensive counseling program that supports improved nutrition, healthy eating behaviors, and increased physical activity. Currently, physician practice with respect to screening for abnormal blood sugar is variable,” he added.
For more information about AACE’s guidelines on glucose screening, see here.