Prediabetes screening: ‘Target of reducing disparities should be geared towards advocacy’

On Aug. 24, the United States Preventive Services Task Force (USPSTF) published the newly updated recommendations regarding screening for prediabetes and type-2 diabetes mellitus.^1,2 The recommendation has been graded B, which translates to at least fair evidence to suggest that screening for prediabetes improves health outcomes and benefits outweigh harms. This recommendation applies to nonpregnant adults aged 35 to 70 years seen in primary care settings who are overweight and obese (body mass index [BMI] ≥25kg/m2) without symptoms of diabetes.¹

Secondly, it also emphasizes that clinicians should consider screening at an earlier age in individuals from groups with disproportionately high incidence and prevalence of diabetes mellitus, including American Indian/ Alaska native, Asian American, Black, Hispanic/Latino or native Hawaiian/ Pacific Islander persons.^3,4 Screening should follow the American Diabetes Association guidelines.⁵

These new recommendations are an update of the 2015 USPSTF guidance that recommended screening for abnormal blood glucose levels as part of cardiovascular risk assessment in adults aged 40–70 years who are overweight or obese. Evidence to support these new guidelines comes from the effects of interventions for those newly or recently diagnosed with type-2 diabetes or prediabetes—including overall mortality and cardiovascular-related mortality at 10 and 20 years after diagnosis.²

Among the harms reported in these studies supporting earlier screening were short-term increases in anxiety among persons screened and hypoglycemia events requiring intervention (approximately 1%). The value of these guidelines is significant to our diabetic patient population since an excess of 30% of vascular patients have diabetes.⁶

These new guidelines will positively aid us in the earlier detection of diabetes and, as a result, prolong the appearance of secondary consequences in the vasculature, including large and small vessel disease—very typical in our peripheral arterial disease (PAD) patient population—and acute-on-chronic kidney disease patients.⁷ Several criticisms of the guidelines are that the racial/ethnic disparities noted are purely dependent on social—not biological—factors.⁸ Secondly, the benefits noted occur an extremely long time after detection of diabetes and, at times, beyond the study period.

In terms of the data available concerning racial/ethnic disparities, Peek et al⁸ published a comprehensive systematic review—and it is of utmost importance to highlight that the incidence and prevalence is reported at 7% in Americans. However, the prevalence among Hispanics and African Americans is 9% and 11%, respectively.

Furthermore, racial/ethnic minorities carry a two-to-four times greater rate of renal disease, blindness, amputations, and amputation-related mortality. These disproportionately higher rates of complications may be a product of poor control of diabetes, as well as associated cardiovascular risk factors. While the reasons for disparities in prevalence and outcomes are multifactorial, there is evidence to suggest that lower quality of care may be an important contributor to the disparities.^9,10 Whites are more likely than Hispanics to receive annual HbA1c and cholesterol testing along with hypertensive medications, despite having equal access to healthcare, as measured by insurance coverage, particular place for medical care and frequency of physician visits.¹¹ Similar studies have found racial differences in the quality of care for comorbid conditions, and this includes both testing and treatment for hypertension and dyslipidemia among Hispanics and African Americans when compared to non-Hispanic whites.^12,13

Although the intent of the USPSTF is based on earlier detection for minority groups, the target of reducing disparities should be geared towards advocacy¹⁴ and equal access to healthcare systems so that post-diagnosis management in these groups is improved, thus eliminating disparities in mortality and cardiovascular-related mortality.

REFERENCES

1. Force USPST, Davidson K.W., Barry M.J., et al. Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;326(8):736–743
2. www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes
3. www.cdc.gov/diabetes/library/spotlights/diabetes-asian-americans.html
4. Lee JW, Brancati FL, Yeh HC. Trends in the prevalence of type-2 diabetes in Asians versus whites: results from the United States National Health Interview Survey, 1997– 2008. Diabetes Care. 2011;34(2):353-357
5. American Diabetes A. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2020. Diabetes Care. 2020;43(Suppl 1):S14-S31
6. Thiruvoipati T., Kielhorn CE, Armstrong EJ. Peripheral artery disease in patients with diabetes: Epidemiology, mechanisms and outcomes. World J Diabetes. 2015;6(7):961–969
7. Squadrito G, Cucinotta D. The late complications of diabetes mellitus. Ann Ital Med Int. 1991;6(1 Pt 2):126–136
8. Peek ME, Cargill A, Huang ES. Diabetes health disparities: a systematic review of health care interventions. Med Care Res Rev. 2007;64(5 Suppl):101S-156S
9. Harris MI. Racial and ethnic differences in health insurance coverage for adults with diabetes. Diabetes Care. 1999;22(10):1679–1682
10. Harris MI, Eastman RC, Cowie CC, Flegal KM, Eberhardt MS. Racial and ethnic differences in glycemic control of adults with type-2 diabetes. Diabetes Care. 1999;22(3):403–408
11. Hosler AS, Melnik TA. Population-based assessment of diabetes care and self-management among Puerto Rican adults in New York City. Diabetes Educ. 2005;31(3):418–426
12. Arday DR, Fleming BB, Keller DK, et al. Variation in diabetes care among states: Do patient characteristics matter? Diabetes Care. 2002;25(12):2230–2237
13. Hertz RP, Unger AN, Ferrario CM. Diabetes, hypertension, and dyslipidemia in Mexican Americans and non-Hispanic whites. Am J Prev Med. 2006;30(2):103–110
14. Kraft AN, Thatcher EJ, Zenk SN. Neighborhood Food Environment and Health Outcomes in U.S. Low- Socioeconomic Status, Racial/ Ethnic Minority, and Rural Populations: A Systematic Review. J Health Care Poor Underserved. 2020;31(3):1078–1114

Young Erben, MD, is an associate professor of surgery at the Mayo Clinic in Jacksonville, Florida.