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Current Screening Criteria Misses 50% of Those with Diabetes and Prediabetes

Jun 9, 2018

Do USPSTF screening criteria need revision? Use of expanded criteria thought best way to detect widest population with abnormal blood glucose levels.

The current US Preventive Services Task Force (USPSTF) screening criteria only use age and weight alone to screen for diabetes.


Using expanded criteria on the basis of other high-risk factors (gestational diabetes, polycystic ovarian syndrome, racial/ethnic minority, and/or family history of diabetes) may improve detection of abnormal blood glucose levels.

This study is the first nationally representative evaluation of how using expanded screening criteria could improve diabetes detection. First author Matthew O’Brien, MD, assistant professor of medicine at Northwestern University Feinberg School of Medicine, Chicago, Illinois, said in a press release. “By demonstrating how well these expanded criteria work in identifying patients with prediabetes and diabetes, we’re proposing a better path for the USPSTF to strengthen its screening guidelines.”

The 2015 USPSTF recommendations call for prediabetes and diabetes screening in adults ages 40 to 70 years who are overweight or obese (referred to as limited criteria). The USPSTF also suggests, but does not formerly recommend, earlier screening in people with certain diabetes risk factors, including a history of gestational diabetes, polycystic ovarian syndrome, membership of an ethnic/racial minority, or a family history of diabetes (expanded criteria).

Early screening is important because it can enable earlier pharmacotherapy and lifestyle modification, potentially warding off more serious complications of diabetes. The earlier patients are diagnosed with these conditions, the sooner they can begin to combat them, most of the time with just lifestyle changes.

To compare the limited USPSTF screening criteria to expanded criteria, they conducted a cross-sectional study using data from a nationally representative sample of participants in the 2011 to 2014 National Health and Nutrition Examination Surveys study. The study included 3,643 adults who had never been diagnosed with diabetes. The study defined abnormal blood glucose as an A1c ≥5.7%, fasting blood glucose ≥100 mg/dL, and/or 2-hour blood glucose ≥140 mg/dL.

Overall, the researchers found that 49.7% of the study population had undiagnosed abnormal blood glucose. By ethnicity/race, the prevalence was 48.6% among non-Hispanic whites, 54.0% among blacks, 50.9% among Hispanic/Latinos, and 51.2% among Asians. Extrapolating from Census data, the researchers estimate that 105.1 million Americans have undiagnosed dysglycemia.

So, if they had restricted their analysis to only those who met the limited criteria, they would only identify 47.3% of those who truly have abnormal blood glucose. The expanded criteria performed better in identifying true cases of abnormal blood glucose and identified 76.8% of people who were truly positive. In contrast, the expanded criteria would only weed out 33.8% of people who truly did not have abnormal blood glucose.

The results mean that using the expanded criteria will miss fewer cases of abnormal blood glucose, but would result in further testing for more individuals, many of whom will have normal results.

Because the Affordable Care Act requires health plans to fully cover services recommended by the USPSTF, the results raise the question of whether insurance should cover blood glucose screening in people who meet the expanded criteria. This is also a problem for people of low socioeconomic status who are at high-risk of developing diabetes and may be unable to pay for a screening test. The results also showed that using the limited criteria would miss other high-risk groups. These include women with polycystic ovarian syndrome and/or a history of gestational diabetes, and younger age groups who are increasingly at risk.

Importantly, racial/ethnic minorities have higher rates of abnormal blood glucose and are at higher risk for diabetes complications than whites. African Americans develop abnormal blood glucose levels at younger ages, and Asians do so at lower body weights.

In general, the expanded criteria showed better performance for racial/ethnic minorities. In contrast, the limited criteria showed a trend for lower detection of truly abnormal blood glucose levels in all minority groups, especially Asians. Using the limited criteria, 70% of Asians with prediabetes or diabetes would go undiagnosed.

It has been shown in many studies that diagnosing diabetes and prediabetes as early as possible will improve the quality of life, especially into the patient’s senior years.

AACE/ACE and ADA recommend more encompassing indicators for the diagnosis of diabetes and prediabetes. AACE recommends that individuals who meet any of the clinical risk criteria should be screened for prediabetes or type 2 diabetes (T2D).

Using the AACE recommendations for screening includes more encompassing indicators for screening. Plus, to make it less confusing we should agree on just one set of criteria for the diagnosing of diabetes and prediabetes

Practice Pearls:

  • The current USPSTF screening criteria only use age and weight alone.
  • The USPSTF criteria will miss more than 50% of those with diabetes or prediabetes.
  • Using criteria from the different organizations is very confusing and we should use the criteria that can find the most patients with diabetes and prediabetes and start lifestyle changes immediately.

J Gen Intern Med. Published online April 13, 2018. Abstract Journal of General Internal Medicine