Adapted from JAMA Editorial August 24/31 2021 by Edward W Gregg and Tannaz Moin
The point for screening for diabetes is that early treatment will prevent complications.
In this article, the US Preventative Services Task Force (USPSTF) discusses its Recommendation Statement and its Evidence Review on screening for pre-diabetes and type two diabetes. They now recommend that adults aged 35 – 70 who are overweight or obese should now be screened and that those with pre-diabetes are referred for effective prevention interventions. Previously the age to start screening was 40 and they have also suggested that the drug metformin is used as a preventative intervention.
A recent study by Wang et al shows that 14% of the US population have diabetes and that there have been no consistent improvements in glycaemic control and risk factor management for 10 years. There has been also no improvement in diabetes care and outcomes.
The USPSTF actually found that there was little direct evidence that screening improves health outcomes for people diagnosed with diabetes. The rationale from screening relies largely on the 25 year old UK Prospective Diabetes Study Group which showed that glycaemic and blood pressure control in new diabetics reduced micro and macro vascular complications, myocardial infarction, diabetes mortality and all cause mortality. This was without the advantages of new drugs and monitoring techniques to boot.
More than 40% of the adult population will now be eligible for screening and a third of these are expected to be referred to an intervention programme. Young adults have had the biggest relative increase in diabetes prevalence, yet they get proportionately the lowest degree of preventative service and risk factor control and not surprisingly this has resulted in an increase in diabetes related complications.
An estimated 24.3% of young adults aged 18-44 have pre-diabetes. Only 44% of these reported being tested in the previous 3 years and they were less likely to be referred and to take up prevention services. Young adults also have more problem affording food, housing and medication. The new screening recommendations are an opportunity to improve this dire situation. Without effective intervention the burden of future diabetes complications will be immense.
Sorting this problem out calls for new ideas, new science and perhaps new frameworks. Metformin has shown to be cost saving, and most effective for pre-diabetes among younger, more obese patients and those with gestational diabetes but it tends not to be prescribed to these groups. More personalised prevention programmes may help. We must address the barriers to accessing effective risk factor management and this must be done throughout the lifespan of the affected group.