tected) diabetes can reduce the progression has not been demonstrated that beginning diabetes control harms of routine screening for type 2 diabetes. …
Clinical Guidelines
Screening for Type 2 Diabetes Mellitus in Adults: Recommendations and Rationale
US Preventive Services Task Force
This statement summarizes the current US Preventive Services Task Force USPSTF recommendations on screening for type 2 diabetes in adults and updates the 1996 recommendations on this topic The complete USPSTF recommendation and rationale statement on this topic, which includes a brief review of the supporting evidence, is available through the USPSTF Web site www preventiveservicesahrqgov and the National Guideline Clearinghouse wwwguidelinegov and in print through the Agency for Healthcare Research and Quality AHRQ Publications Clearinghouse call 800-358-9295 or e-mail ahrqpubs@ahrqgov The
complete information on which this statement is based, including evidence tables and references, is available in the accompanying article in this issue and in the summary of the evidence and systematic evidence review on this topic on the Web sites already mentioned The summary of the evidence is also available in print through the AHRQ Publications Clearinghouse
Ann Intern Med 2003;138:212-214 wwwannalsorg
See related article on pp 215-229
For a list of the
members of the US Preventive Services Task Force, see the Appendix
SUMMARY
OF THE
RECOMMENDATIONS
abetes substantially improves estimates of individual risk for coronary heart disease, which is an integral part of decisions about lipid-lowering therapy
The US Preventive Services Task Force USPSTF concludes that the evidence is insufficient to recommend for or against routinely screening asymptomatic adults for type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose This is a grade I recommendation See Appendix Table 1 for a description of the USPSTF classification of recommendations The USPSTF found good evidence that available screening tests can accurately detect type 2 diabetes during an early, asymptomatic phase See Appendix Table 2 for a description of the USPSTF classification of levels of evidence The USPSTF also found good evidence that intensive glycemic control in patients with clinically detected not screening detected diabetes can reduce the progression of microvascular disease However, the benefits of tight glycemic control on microvascular clinical outcomes take years to become apparent It has not been demonstrated that beginning diabetes control
early as a result of screening provides an incremental benefit compared with initiating treatment after clinical diagnosis Existing studies have not shown that tight glycemic control significantly reduces macrovascular complications, including myocardial infarction and stroke The USPSTF found poor evidence to assess possible harms of screening As a result, the USPSTF could not determine the balance of benefits and harms of routine screening for type 2 diabetes The USPSTF recommends screening for type 2 diabetes in adults with hypertension or hyperlipidemia This is a grade B recommendation The USPSTF found good evidence that, in adults who have hypertension and clinically detected diabetes, lowering blood pressure below conventional target blood pressure values reduces the incidence of cardiovascular events and cardiovascular mortality; this evidence is considered fair when extrapolated to cases of diabetes detected by screening Among patients with hyperlipidemia, there is good evidence that detecting di212 4 February 2003 Annals of Internal Medicine Volume 138 Number 3
CLINICAL CONSIDERATIONS
In the absence of evidence of direct benefits of routine screening for type 2 diabetes,
the decision to screen individual patients is a matter of clinical judgment Patients at increased risk for cardiovascular disease may benefit most from screening for type 2 diabetes, since management of cardiovascular risk factors leads to reductions in major cardiovascular events Clinicians should assist patients in making that choice In addition, clinicians should be alert to symptoms suggestive of diabetes for example, polydipsia and polyuria and test anyone with these symptoms Screening for diabetes in patients with hypertension or hyperlipidemia should be part of an integrated approach to reduce cardiovascular risk Lower targets for blood pressure that is, diastolic blood pressure 80 mm Hg are beneficial for patients with diabetes and high blood pressure The third report of the Adult Treatment Panel III of the National Cholesterol Education Program recommends lower targets for low-density lipoprotein cholesterol for patients with diabetes Attention to other risk factors, such as physical inactivity, diet, and overweight, is also important, both to decrease risk for heart disease and to improve glucose control Three tests have been used to screen for diabetes: fasting plasma
glucose FPG, 2-hour postload plasma glucose, and hemoglobin A1c The American Diabetes Association ADA has recommended the FPG test for screening values 699 mmol/L [ 126 mg/dL] indicate diabetes because it is easier and faster to perform, more convenient and acceptable to patients, and less expensive than other screening tests The FPG test is more reproducible than the
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Screening for Type 2 Diabetes Mellitus in Adults: Recommendations and Rationale
Clinical Guidelines
2-hour plasma glucose test, has less intraindividual variation, and has similar predictive value for development of microvascular complications of diabetes Compared with the FPG test, the 2-hour plasma glucose test may lead to more individuals being diagnosed as diabetic Hemoglobin A1c is more closely related to FPG than to 2-hour plasma glucose, but at the usual cut-points it is less sensitive in detecting lower levels of hyperglycemia The random capillary blood glucose test has been shown to have reasonable sensitivity 75 at a cut-point of 666 mmol/L [ 120 mg/dL] in detecting persons who have an FPG level greater than or equal to 699 mmol/L 126 mg/dL or a 2-hour plasma glucose level greater than or
equal to 111 mmol/L 200 mg/dL, if results are interpreted according to age and time since last meal; however, the random blood glucose test is less well standardized for screening for diabetes The ADA recommends confirmation of a diagnosis of diabetes with a repeated FPG test on a separate day, especially for patients with borderline FPG results and patients with normal FPG levels for whom suspicion of diabetes is high The optimal screening interval is not known The ADA, on the basis of expert opinion, recommends an interval of every 3 years but shorter intervals in high-risk persons Regardless of whether the clinician and patient decide to screen for diabetes, patients should be encouraged to exercise, eat a healthy diet, and maintain a healthy weight, choices that may prevent or forestall the development of type 2 diabetes More aggressive interventions to establish and maintain these behaviors should be considered for patients at increased risk for diabetes, such as those who are overweight, have a family history of diabetes, or have a racial or ethnic background associated with an increased risk for example, Native American persons Intensive programs of lifestyle modification
diet, exercise, and behavior should also be considered for patients who have impaired fasting glucose or impaired glucose tolerance, since several large trials have demonstrated that these programs can significantly reduce the incidence of diabetes in these patients Evidence and recommendations regarding counseling about diet, physical activity, and obesity are provided in the USPSTF evidence summaries Counseling to Promote a Healthy Diet, Counseling to Promote Physical Activity, and Screening and Treatment for Obesity in Adults, available on the Agency for Healthcare Research and Quality Web site at wwwpreventiveservicesahrqgov The brief review of the evidence that is normally included in USPSTF recommendation statements is available in the complete recommendation and rationale statement on the USPSTF Web site wwwpreventiveservicesahrqgov
for diabetes should be based on clinical judgment and patient preference 1 On the basis of expert consensus, the ADA recommends clinicians consider screening for diabetes with the FPG test beginning at age 45 years and at a younger age for individuals with such risk factors as family history, overweight, and hypertension, among others The
American College of Obstetricians and Gynecologists endorses the ADA recommendations 2 The American Heart Association recommends measuring fasting blood glucose in persons 20 years of age and older according to risk for diabetes, as part of overall risk assessment for cardiovascular disease 3 The Canadian Task Force on Preventive Health Care is currently updating its recommendations on diabetes screening
Appendix Table 1 US Preventive Services Task Force Grades
and Recommendations
Grade A Recommendation The USPSTF strongly recommends that clinicians routinely provide [the service] to eligible patients The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms The USPSTF recommends that clinicians routinely provide [the service] to eligible patients The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms The USPSTF makes no recommendation for or against routine provision of [the service] The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and
harms is too close to justify a general recommendation The USPSTF recommends against routinely providing [the service] to asymptomatic patients The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service] Evidence that the [service] is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined
B
C
D
I
The US Preventive Services Task Force USPSTF grades its recommendations according to one of five classifications A, B, C, D, I reflecting the strength of evidence and magnitude of net benefit benefits minus harms
Appendix Table 2 US Preventive Services Task Force Grades
for Strength of Overall Evidence
Grade Good Definition Evidence includes consistent results from well-designed, wellconducted studies in representative populations that directly assess effects on health outcomes Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; generalizability
to routine practice; or indirect nature of the evidence on health outcomes Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes
Fair
Poor
RECOMMENDATIONS
OF
OTHERS
The ADA acknowledged that data from prospective studies were insufficient to determine the benefits of diabetes screening and thus concluded that the decision to test
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The US Preventive Services Task Force USPSTF grades the quality of the overall evidence for a service on a three-point scale good, fair, poor
4 February 2003 Annals of Internal Medicine Volume 138 Number 3 213
Clinical Guidelines
APPENDIX
Screening for Type 2 Diabetes Mellitus in Adults: Recommendations and Rationale
Members of the US Preventive Services Task Force are Alfred O Berg, MD, MPH, Chair University of Washington, Seattle, Washington; Janet D Allan, PhD, RN, Vice-Chair University of Maryland Baltimore, Baltimore, Maryland; Paul Frame, MD Tri-County Family Medicine, Cohocton, and University of Rochester, Rochester, New York; Charles J
Homer, MD, MPH National Initiative for Childrens Healthcare Quality, Boston, Massachusetts; Mark S Johnson, MD, MPH University of Medicine and Dentistry of New JerseyNew Jersey Medical School, Newark, New Jersey; Jonathan D Klein, MD, MPH University of Rochester School of Medicine, Rochester, New York; Tracy A Lieu, MD, MPH Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts; C Tracy Orleans, PhD The Robert Wood Johnson Foundation, Princeton, New Jersey; Jeffrey F Peipert, MD, MPH Women and Infants Hospital, Providence, Rhode Island; Nola J Pender, PhD, RN University of Michigan, Ann Arbor, Michigan; Albert L Siu, MD, MSPH Mount Sinai School of Medicine, New York, New York; Steven M Teutsch, MD, MPH Merck Co, Inc, West Point, Pennsylvania; Carolyn Westhoff, MD, MSc Columbia University, New York, New York; and Steven H Woolf, MD, MPH Virginia Commonwealth University, Fairfax, Virginia
Members of the Task Force at the time these recommendations were finalized
From the US Preventive Services Task Force, Agency for Healthcare Research and Quality, Rockville, Maryland
Requests for Single Reprints: Reprints are available from the USPSTF
Web site
wwwpreventiveservicesahrqgov and in print through the Agency for Healthcare Research and Quality Publications Clearinghouse 800-358-9295
References
1 Screening for diabetes American Diabetes Association Diabetes Care 2002; 25:S21-S24 2 American College of Obstetricians and Gynecologists Guidelines for Womens Health Care 2nd ed Washington, DC: American Coll of Obstetricians and Gynecologists; 2002:210-3 3 Pearson TA, Blair SN, Daniels SR, Eckel RH, Fair JM, Fortmann SP, et al AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases American Heart Association Science Advisory and Coordinating Committee Circulation 2002;106:388-91 [PMID: 12119259]
214 4 February 2003 Annals of Internal Medicine Volume 138 Number 3
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