New Guidelines Increase Screening Eligibility for Prediabetes, Diabetes Among US Adults

Elizabeth Selvin, PhD, MPH

The implementation of the US Preventive Services Task Force (USPSTF) 2021 and the American Diabetes Association (ADA) 2022 guidelines would increase screening eligibility for prediabetes and diabetes by nearly 7 percentage points, according to new findings.

Both organizations recommended in these recent updates that lowering the starting age for diabetes screening to 35 years may help facilitate earlier detection and treatment.

Data show an approximate 4- to 6-percentage point increase in prediabetes detection and an approximate 2- to 9-percentage-point increase in undiagnosed diabetes detection with these new guidelines.

“Starting diabetes screening at age 35 years may place even greater demands on clinicians to care for younger populations,” wrote study author Elizabeth Selvin, PhD, MPH, Johns Hopkins Bloomberg School of Public Health. “Expanding health care access, developing targeted outreach for high-risk individuals, and scaling prevention programs will be critical.”

Selvin and colleagues analyzed data from the cross-sectional 2015 - 2020 National Health and Nutrition Examination Survey (NHANES) of the US population. 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 examination were included.

The investigators defined prediabetes as an FPG level of 100 to 125 mg/dL or HbA1c of 5.7% to 6.4% and defined undiagnosed diabetes as an FPG level of ≥126 mg/dL or HbA1c of ≥6.5%. They then defined screening eligibility as

• Aged 40 - 70 years with BMI of ≥25 (USPSTF, 2015)
• Aged 35 - 70 years with BMI of ≥25 (USPSTF, 2021)
• Aged 45 years or older with BMI of ≥25 and ≥1 risk factor (ADA, 2003)
• Aged 35 years or older or a BMI of ≥25 and ≥1 risk factors (ADA, 2022)

As well, they estimated the proportion of US adults eligible for screening based on these guidelines overall and among those with prediabetes or undiagnosed diabetes. From a total of 4836 eligible adults, 4480 (92.6%) had HbA1c, FPG, and BMI data available and were included (mean age, 45.6 years; 51.2% women).

Investigators observed 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. Additionally, eligibility increased from 76.7% (95% CI, 73.8% - 79.3%) to 82.9% (95% CI, 80.1% - 85.3%) when comparing ADA 2003 with ADA 2022 guidelines, according to investigators.

Further, data show screening eligibility increased 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%). For those with undiagnosed diabetes, screening eligibility increased when comparing USPSTF 2015 with USPSTF 2021 guidelines (from 58.7% to 67.8%), but did not increase comparing ADA 2003 with ADA 2022 guidelines (from 97.6% to 99.1%).

“Harmonizing recommendations may reduce confusion for clinicians and facilitate implementation,” investigators concluded.

The research letter, “Prediabetes and Diabetes Screening Eligibility and Detection in US Adults After Changes to US Preventive Services Task Force and American Diabetes Association Recommendations,” was published in JAMA.