USPSTF: More Screening for Diabetes with High BMI?

This week, the U.S. Preventive Services Task Force (USPSTF) published a new draft recommendation on screening for diabetes and pre-diabetes for people with a high BMI. Until now, the recommendation has been to screen everyone with a BMI over 25 at age 40 and up. But the new recommendation, if it becomes final, would expand screening by lowering the age to 35.

Chien-Wen Tseng is a professor of family medicine at the University of Hawaii and a member of the USPSTF. To her, the rationale for this change as very straightforward:

“We know the rates of prediabetes and diabetes are increasing in people who are younger. Our main reason for dropping the age is to match the screening with where the problem is. If diabetes and prediabetes are occurring at a younger age, then we should be screening at a younger age.”

Primary Benefit: Prevent Diabetes

Oddly enough, the review that produced this recommendation did not find strong evidence of a benefit to screening for diabetes itself. The evidence review states that trials of screening for diabetes found no mortality benefit within 10 years. For other health outcomes, it found insufficient data for a definitive conclusion. But setting aside the question of screening, the data shows a clear benefit for treating newly diagnosed diabetes.

The clearest benefit for screening was found in people with a high BMI and prediabetes. High intensity lifestyle support can provide better health outcomes that last, even more than 20 years later.

But There’s a Catch

In everyday clinical practice, follow-up on prediabetes in people with overweight and obesity is a problem. Simple advice to make lifestyle changes is ineffective, even though it is what patients most often receive. What is effective, however, is high intensity lifestyle support, consistent with the Diabetes Prevention Program. The problem is that less than ten percent of adults at high risk for diabetes actually participate in such programs.

Caroline Apovian is Co-Director of the Center for Weight Management and Wellness at Brigham and Women’s Hospital in Boston. She told us:

“The gap that remains to be filled is follow-up care for those who are identified. Right now, people with obesity seldom get intensive support, pharmacotherapy, or bariatric surgery when it might help them avoid, control, or reverse diabetes. Most are simply advised to eat less, move more, and lose some weight.

“We need to train more doctors to provide the needed care.”

So better screening for diabetes and prediabetes in people with a high BMI is a good start. However, health systems will have to evolve to provide better, more consistent obesity care if we want screening to lead to better health outcomes.

Click here for the draft recommendations and evidence review. For further perspective, click here and here.

An Examination at the Faculty of Medicine, Paris; painting by Henri de Toulouse-Lautrec / WikiArt

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March 18, 2021