The USA want screening for diabetes and pre-diabetes to start at age 35

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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.

Type 2 diabetes produces more severe complications than type 1

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Adapted from BMJ 11 March 2017

In an observational study reported in JAMA 1,746 type one patients were compared with 272 type two patients. All had developed their diabetes before the age of 20. My comment: It is not clear whether the duration of diabetes was adjusted for, as the onset of type one diabetes tends to cluster around puberty, although it can occur as early as soon after birth, and the onset of type two diabetes tends to arise in later teenage years. Thus if average 30 year olds were compared head to head in the study, for instance, one would expect the type 1 patients to have more complications purely based on having had the condition much longer on average than the type 2s.

Nevertheless, the prevalence of diabetic kidney disease, retinopathy and peripheral neuropathy was significantly greater in the type two group compared to the type one group, even after they adjusted for differences in glycated haemoglobin, body mass index, waist to height ratio, and mean arterial blood pressure.

This study provides information that early age of onset of type 2 diabetes is a real problem, as once established, it does a lot of damage, that is difficult to control with standard therapies.