Prediabetes and Diabetes Screening Eligibility and Detection in US Adults After Changes to US Preventive Services Task Force and American Diabetes Association Recommendations | Cardiology | JAMA | JAM
Prediabetes and type 2 diabetes have reached epidemic levels and are associated with major morbidity and mortality. The US Preventive Services Task Force (USPSTF) and the American Diabetes Association (ADA) recently recommended lowering the starting age for diabetes screening to 35 years to facilitate earlier detection and treatment.1,2 We estimated the proportion of asymptomatic US adults eligible for screening based on new vs current USPSTF and ADA screening guidelines, overall and among those with prediabetes or undiagnosed diabetes.
Methods
We analyzed data from the 2015-2020 National Health and Nutrition Examination Survey (NHANES), a nationally representative, cross-sectional survey of the noninstitutionalized US population. NHANES consisted of in-person interviews and physical examinations that included laboratory testing.
We included adults (aged ≥20 years) without a history of diagnosed prediabetes or diabetes who were fasting, were not pregnant, and had hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), weight, and height measured during the examination.
We defined prediabetes as an FPG level of 100 to 125 mg/dL or HbA1c of 5.7% to 6.4% and undiagnosed diabetes as an FPG level of 126 mg/dL or greater or HbA1c of 6.5% or greater. In sensitivity analyses, we considered a “confirmatory” definition of undiagnosed diabetes (FPG ≥126 mg/dL and HbA1c ≥6.5%). We calculated body mass index (BMI) as weight in kilograms divided by height in meters squared using measured weight and height.
We selected screening guidelines based on the first year new recommendations were introduced. We defined screening eligibility as (1) aged 40 to 70 years with a BMI of 25 or greater (USPSTF, 2015); (2) aged 35 to 70 years with a BMI of 25 or greater (USPSTF, 2021); (3) aged 45 years or older or a BMI of 25 or greater and 1 or more risk factors (ADA, 2003); or (4) aged 35 years or older or a BMI of 25 or greater and 1 or more risk factors (ADA, 2022) (eAppendix in the Supplement).1-3
We estimated the proportion of US adults eligible for screening based on the USPSTF 2015, USPSTF 2021, ADA 2003, and ADA 2022 guidelines, overall and among those with prediabetes or undiagnosed diabetes. All analyses were conducted using Stata version 17.0 (StataCorp) and used survey weights to generate estimates representative of the US adult population. NHANES study protocols were approved by the National Center for Health Statistics institutional review board, and all participants provided written informed consent.
Results
Among 4836 eligible adult participants, 4480 (92.6%) had HbA1c, FPG, and BMI data available and were included in the study (mean age, 45.6 years; 51.2% women). The weighted proportion eligible for screening increased from 36.3% (95% CI, 34.1%-38.5%) to 43.0% (95% CI, 40.5%-45.6%) comparing USPSTF 2015 with USPSTF 2021 guidelines and from 76.7% (95% CI, 73.8%-79.3%) to 82.9% (95% CI, 80.1%-85.3%) comparing ADA 2003 with ADA 2022 guidelines (Table). Screening eligibility rose among those with prediabetes comparing USPSTF 2015 with USPSTF 2021 guidelines (from 50.1% to 56.2%) and ADA 2003 with ADA 2022 guidelines (from 89.4% to 93.7%). Among adults with undiagnosed diabetes, screening eligibility increased comparing USPSTF 2015 with USPSTF 2021 guidelines (from 58.7% to 67.8%) but not comparing ADA 2003 with ADA 2022 guidelines (from 97.6% to 99.1%). Results were similar using a confirmatory definition of diabetes.
Discussion
Implementing the USPSTF 2021 and ADA 2022 guidelines would increase screening eligibility among US adults by approximately 6 to 7 percentage points, resulting in an approximate 4- to 6-percentage-point increase in prediabetes detection and an approximate 2- to 9-percentage-point increase in undiagnosed diabetes detection.
Screening, prevention, and treatment of diabetes in younger patients remains suboptimal.4-6 Starting diabetes screening at age 35 years may place even greater demands on clinicians to care for younger populations. Expanding health care access, developing targeted outreach for high-risk individuals, and scaling prevention programs will be critical.
While the USPSTF 2021 guideline defines eligibility based on age and BMI, the ADA 2022 guideline considers a broader set of risk factors. Consequently, the ADA 2022 guideline identifies a larger portion of persons with prediabetes or diabetes compared with the USPSTF 2021 guideline but requires screening approximately twice as many people. Screening more than 80% of asymptomatic adults (ADA, 2022) may be cost prohibitive. Harmonizing recommendations may reduce confusion for clinicians and facilitate implementation.
Study limitations included the limited sample size in subgroups and declining response rate in NHANES. The analysis did not consider screening frequency and assumed complete implementation of all screening guidelines.
Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Associate Editor.
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Article Information
Accepted for Publication: March 17, 2022.
Concept and design: Fang, Echouffo-Tcheugui, Selvin.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Fang.
Critical revision of the manuscript for important intellectual content: Fang, Echouffo-Tcheugui, Selvin.
Statistical analysis: Fang, Wang.
Administrative, technical, or material support: Selvin.
Supervision: Echouffo-Tcheugui, Selvin.
Conflict of Interest Disclosures: Dr Selvin reported receiving grants from the National Institutes of Health (NIH) related and unrelated to this work during the conduct of the study and receiving payments from Wolters Kluwer for chapters and laboratory monographs in UpToDate on measurements of glycemic control and screening tests for type 2 diabetes. No other disclosures were reported.
Funding/Support: Dr Echouffo-Tcheugui was supported by NIH/National Heart, Lung, and Blood Institute (NHLBI) grant K23 HL153774. Dr Selvin was supported by NIH/NHLBI grant K24 HL152440.
Role of the Funder/Sponsor: The NIH/NHLBI had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
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