The Half-Measure of Screening for Diabetes and Obesity

Half a loaf is better than none, wrote John Heywood in his 1546 book of proverbs. So should we be thrilled that the USPSTF is making a “huge” change to diabetes screening for people with overweight and obesity? Or is this only a half-measure that will do nothing if people don’t have access to care that will improve their health?

We have serious doubts because screening without effective treatment can do more harm than good. And right now, many people with obesity have a tough time getting effective treatment beyond glib advice to lose weight.

Moving the Age for Screening to 35

The news here is quite simple. The USPSTF declared this week that healthcare providers should screen everyone for diabetes or prediabetes starting at the age of 35. That’s five years earlier than it used to be. Task Force member Chien-Wen Tseng says the potential benefits are huge:

“Close to 20% of people don’t know that they have diabetes. Close to 85% of people don’t know they have prediabetes. One of the biggest risk factors for diabetes or prediabetes is overweight or obesity. This affects close to three-fourths of Americans right now. So, it made a lot of sense to go down from 40 to 35.

“The message for both clinicians and for patients is that this is really worth the time spent.”

Sounds Great, But…

This truly does sound great. In both theory and in real life, a person hearing that obesity or overweight is putting them at risk for diabetes can be very motivating. We have countless friends for whom this knowledge was a turning point for seeking better care and better metabolic health.

But the problem is accessing that care. The average experience is utterly ineffective advice to lose weight. Lifestyle interventions can be effective for preventing diabetes, but only if they are intensive. That’s costly. It takes a lot of time and resources. So utilization is low.  In fact, 99 percent of people who could benefit simply don’t get this kind of care, as Edward Gregg and Tannaz Moin describe in a JAMA editorial:

“U.S. enrollment represents less than 1% of the eligible U.S. population, as availability, reimbursement, and engagement present challenges to long-term success.”

Utilization of more intensive options – like anti-obesity meds or metabolic surgery – is even lower. Instead of delivering effective care to reduce the risks of overweight, obesity, and diabetes, the follow-up to screening is most often to deliver glib advice. Watch your weight. Eat less. Move more. Cut carbs. Eat healthy.

Praising the Virtue of Ineffective Approaches

If you want a clue to why people don’t get more help with the dual diagnosis of obesity and diabetes, you can find it in an editorial in JAMA Internal Medicine. Richard Grant, Anjali Gopalan, and Marc Jaffe suggest the real need is not clinical care. It is for more efforts to address the social factors causing this problem. They note that such efforts to date have been “laudable” but ineffective. So they’re calling for more of that stuff that sounds great and hasn’t worked.

This half-loaf approach to obesity and diabetes is taking us nowhere. Screening without access to effective care is just not very helpful.

Click here for the USPSTF recommendation, then here and here for the editorials published with it. For further reporting, click here, here, and here.

Half a Loaf, photograph © Jim Champion / flickr

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August 28, 2021