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Evidence Limited for Screening Most Adults for Type 2 Diabetes
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Evidence Limited for Screening Most Adults for Type 2 Diabetes The US Preventive Services Task Force (USPSTF) has issued a statement that limited evidence exists to recommend screening adults for type 2 diabetes but that screening may be helpful in those with hypertension, according to a report published in the June 3 issue of the Annals of Internal Medicine. "More than 19 million Americans are affected by type 2 diabetes mellitus, which is undiagnosed in one third of these persons," write Susan L. Norris, MD, MPH, from the Oregon Evidence-based Practice Center of the Oregon Health & Science University and Portland Veterans Administration Medical Center, and colleagues. "In addition, it is estimated that more than 54 million adults have prediabetes. Debate continues over the benefits and harms of screening and then treating adults who have asymptomatic diabetes or prediabetes." The goal of this statement was to update the 2003 USPSTF review of the evidence with regard to potential benefits and risks of screening adults for type 2 diabetes and prediabetes in the primary care setting. The reviewers searched MEDLINE and the Cochrane Library for relevant studies and systematic reviews published in English between March 2001 and July 2007 and included trials and observational studies that evaluated the effectiveness and adverse effects of screening interventions. The efficacy of treatments of diabetes and prediabetes were evaluated with randomized controlled trials of patients with disease for 1 year or less. Trials comparing outcomes among patients with and without diabetes were also reviewed. The reviewers abstracted relevant data in duplicate using a standardized template, and they synthesized data in a qualitative fashion. A random-effects meta-analysis determined the effects of interventions in prediabetes on the incidence of diabetes. Limitations of the review were that most of the evidence concerning diabetes treatment came from subgroup analyses vs primary trial data and that participants in intensive lifestyle interventions for prediabetes may not be representative of general prediabetic populations. "Direct evidence is lacking on the health benefits of detecting type 2 diabetes by either targeted or mass screening, and indirect evidence also fails to demonstrate health benefits for screening general populations," the review authors write. "Persons with hypertension probably benefit from screening, because blood pressure targets for persons with diabetes are lower than those for persons without diabetes. Intensive lifestyle and pharmacotherapeutic interventions reduce the progression of prediabetes to diabetes, but few data examine the effect of these interventions on long-term health outcomes." Specific recommendations of the USPSTF with regard to screening for type 2 diabetes mellitus in adults are as follows: Because high blood pressure is a recognized risk factor for cardiovascular complications in people with type 2 diabetes mellitus, blood pressure should be measured. Asymptomatic adults with no symptoms of type 2 diabetes mellitus or evidence of possible complications of diabetes but with sustained blood pressure greater than 135/80 mm Hg (treated or untreated) should be screened for type 2 diabetes mellitus (level of evidence, B). For asymptomatic adults with sustained blood pressure of 135/80 mm Hg or lower, no recommendation has been made regarding screening for type 2 diabetes mellitus (grade: I; insufficient evidence). Screening may be considered on an individual basis when blood pressure is 135/80 mm Hg and when knowledge of diabetes status would facilitate decisions with regard to preventive strategies for coronary heart disease, including consideration of lipid lowering. To screen for diabetes, 3 tests that have been used are fasting plasma glucose, 2-hour postload plasma, and hemoglobin A1c. The American Diabetes Association recommends screening with fasting plasma glucose, defining diabetes as a fasting plasma glucose level of 126 mg/dL or greater, and confirming an abnormal result with a repeated screening test on a separate day. Although the optimal screening interval is still unknown, expert opinion from the American Diabetes Association recommends a screening interval of every 3 years. Information about the 10-year risk for coronary heart disease must be considered when deciding if screening would be helpful on an individual basis. As a hypothetical example, if the risk for coronary heart disease without diabetes was 17% and the risk with diabetes was more than 20%, screening for diabetes would be helpful because diabetes status would determine lipid treatment. In contrast, if the risk without diabetes was 10% and the risk with diabetes was 15%, screening would not influence the decision to use lipid-lowering treatment, and it would not be indicated. "Further research is needed to define the benefits and harms of screening average-risk individuals for type 2 diabetes," the review authors write. "We must learn whether early, aggressive glycemic control in persons with diabetes produces improvements in clinical outcomes after many years of follow-up. . . . Further work is also needed to examine the effect of screening and diagnosis on patient self-efficacy, motivation for lifestyle change, and the potential psychological effects of labeling." Limitations of the review include restriction to studies with mean diabetes duration of 1 year or less; few trials with extended follow-up, which may underestimate the effectiveness of treatment and therefore of screening interventions; difficulty in defining "screened" and "unscreened" populations; participants with prediabetes in studies of intensive lifestyle interventions may not be representative of general prediabetic populations; and flaws in data and assumptions underlying the included trials. "No direct evidence clearly determines whether screening asymptomatic individuals for diabetes or prediabetes alters health outcomes," the authors of the statement conclude. "Evidence shows that persons with diabetes benefit from control of blood pressure and lipid levels, but studies have not included persons with screening-detected diabetes. Persons with hypertension and type 2 diabetes benefit from lower blood pressure targets than persons with hypertension but without diabetes." This statement was conducted by the Oregon Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality. The authors of the statement have disclosed no relevant financial relationships. Ann Intern Med. 2008;148:853-854, 855-868. |
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