On August 24, 2021, the U.S. Preventive Services Task Force (USPSTF) revised their recommendations for type 2 diabetes and pre-diabetes screening. The revision includes a recommendation that screening of all overweight and obese adults should begin at age 35 rather than age 40, per their previous recommendation in 2015.1
This recommendation differs from the 2021 American Diabetes Association (ADA) Standards of Medical Care (referred to as the Standards of Care). The ADA states … “Testing should be considered in adults with overweight or obesity (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) who have one or more of the following risk factors: first-degree relative with diabetes; high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander); history of cardiovascular disease (CVD); hypertension (≥140/90 mmHg or on therapy for hypertension); HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L); women with polycystic ovary syndrome; physical inactivity; other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)”. The ADA Standards of Care recommends screening all other adults beginning at age 45.2
Both guidelines agree on the laboratory criteria for diagnosing prediabetes. Prediabetes can be detected by measuring fasting plasma glucose, HbA1c level, or with an oral glucose tolerance test. A fasting plasma glucose level of 100 to 125 mg/dL (5.55-6.94 mmol/L), an HbA1c level of 5.7% to 6.4%, or a 2-hour postload glucose level of 140 to 199 mg/dL (7.77-11.04 mmol/L) are consistent with prediabetes. Both guidelines also endorse repeat testing carried out at a minimum of 3-year intervals, unless test results are abnormal or symptoms of diabetes occur.
The other significant revision to the current USPSTF recommendation is that consideration of pharmacologic as well as behavioral intervention in overweight people with prediabetes is now included. Again, this is consistent with the ADA Standards of Care. Pharmacologic interventions are effective in reducing the progression to type 2 diabetes and CVD but less effective than lifestyle modification on the need for additional blood pressure and lipid-lowering medications. It is noteworthy that lifestyle interventions have evidence of benefit in reducing the progression to type 2 diabetes as well as reducing other CVD risk factors, such as blood pressure and lipid levels. Both sets of guidelines emphasize that the current data supports that lifestyle intervention (in particular dietary modification and exercise programs which achieve a 7% reduction in body weight or 150 minutes of aerobic exercise) is more effective than pharmacotherapy, but recognize that many people with prediabetes are not able to utilize a lifestyle program and even those who do may derive additional benefit from medications. Although multiple antidiabetic medications have been shown to delay the progression of prediabetes, the best evidence is for metformin. It is notable however that the FDA does not currently approve any medication with an indication for diabetes prevention.
The Centers for Disease Control and Prevention (CDC) has developed the National Diabetes Prevention Program (National DPP).3 The National DPP has developed a year-long lifestyle curriculum for people at risk for diabetes based on National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsored clinical trials that began in the mid-1990s that showed a 58% reduction in annual progression from prediabetes to diabetes and was even more effective if begun after age 65 (71%). A comparison group who took metformin 850mg daily but did not participate in the lifestyle program had an overall reduction in annual progression of 31%. Follow-up of this cohort for over 15 years indicates that both lifestyle and metformin interventions continue to be effective, but the relative benefit of lifestyle over metformin increases over time.4
The CDC program certifies providers of DPP lifestyle programs for Centers for Medicare & Medicaid Services (CMS) and private insurance reimbursement. The curriculum is designed for either live or virtual classes; utilization of telemedicine technology for lifestyle intervention is particularly attractive now to both patients and providers.
The American Medical Association (AMA) has resources on coding of both screening and intervention for medical practices. Enrolling patients in a CDC-certified DPP qualifies practices both for “meaningful use” for those who received federal funds to purchase electronic medical record (EMR) systems and for the CMS “patient-centered medical home” funding.5
The NIDDK has an excellent resource on how to talk with patients about their prediabetes diagnosis.6
Internet links for the references cited below were accessed October 10, 2021:
Charles A. Sneiderman, MD, PhD, DABFM
Medical Director, Culmore Clinic
Bailey’s Crossroads, VA
Published on 10/22/2021