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CME / ABIM MOC / CE

Can Race-Based Diabetes Screening Thresholds Reduce Disparities?

  • Authors: News Author: Miriam E. Tucker; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 6/10/2022
  • THIS ACTIVITY HAS EXPIRED FOR CREDIT
  • Valid for credit through: 6/10/2023, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for diabetologists/endocrinologists, cardiologists, family medicine and primary care clinicians, internists, public health and prevention officials, pharmacists, nurses, physician assistants and other members of the health care team involved in diabetes screening.

The goal of this activity is for learners to be better able to describe the body mass index threshold for diabetes screening in major racial/ethnic minority populations with benefits and harms equivalent to those of the current diabetes screening threshold in White adults, based on a cross-sectional study using National Health and Nutrition Examination Survey data for 2011 to 2018.

Upon completion of this activity, participants will:

  • Assess the body mass index threshold for diabetes screening in major racial/ethnic minority populations with benefits and harms equivalent to those of the current diabetes screening threshold in White adults, based on a cross-sectional study using National Health and Nutrition Examination Survey data for 2011 to 2018
  • Evaluate the clinical and public health implications of the body mass index threshold for diabetes screening in major racial/ethnic minority populations with benefits and harms equivalent to those of the current diabetes screening threshold in White adults, based on a cross-sectional study using National Health and Nutrition Examination Survey data for 2011 to 2018
  • Outline implications for the healthcare team


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News Author

  • Miriam E. Tucker

    Freelance writer, Medscape

    Disclosures

    Miriam E. Tucker has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has the following relevant financial relationships:
    Own stock, stock options, or bonds from: AbbVie (former)

Editor/Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has no relevant financial relationships.


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CME / ABIM MOC / CE

Can Race-Based Diabetes Screening Thresholds Reduce Disparities?

Authors: News Author: Miriam E. Tucker; CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED FOR CREDIT

CME / ABIM MOC / CE Released: 6/10/2022

Valid for credit through: 6/10/2023, 11:59 PM EST

processing....

Clinical Context

In the United States, diabetes is a leading cause of morbidity and mortality, with adult prevalence of more than 34 million people and annual health care expenditures of approximately $330 billion. Diabetes risk is increased for overweight or obesity vs normal weight, and for racial/ethnic minority vs White populations.

The 2021 US Preventive Services Task Force (USPSTF) recommendations acknowledge that some racial/ethnic groups are at higher risk and may warrant screening at lower ages or body mass indexes (BMIs). Personalizing screening recommendations by race/ethnicity could improve diagnosis and health equity.

Study Synopsis and Perspective

The use of race-based diabetes screening thresholds could reduce the disparity that arises from current screening guidelines in the United States, new research suggests.

In August 2021 the USPSTF lowered the recommended age for type 2 diabetes screening from 40 years to 35 years among people with a BMI of 25 kg/m2 or greater.[1]

However, the diabetes rate among ethnic minorities aged 35 to 70 years in the United States is not just higher overall but, in certain populations, also occurs more frequently at a younger age and at lower BMIs, the new study indicates.

Among people with a BMI below 25 kg/m2, diabetes prevalence is 2 to 4 times higher among Asian, Black, and Hispanic Americans than among the US White population. And the authors of the new study, led by Rahul Aggarwal, MD, predict that if screening begins at age 35 years, the BMI cutoff equivalent to 25 kg/m2 for White Americans would be 18.5 kg/m2 for Hispanic and Black Americans and 20 kg/m2 for Asian Americans.

"While diabetes has often been thought of as a disease that primarily affects adults with overweight or obese weight, our findings suggest that normal weight adults in minority groups have surprisingly high rates of diabetes," Dr Aggarwal, senior resident physician in internal medicine at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News.

"Assessing diabetes risks in certain racial/ethnic groups will be necessary, even if these adults do not have overweight or obese weight," he added.

Not screening in this way "is a missed opportunity for early intervention," he noted.

And both the authors and an editorialist stress that the issue is not just theoretical.

"USPSTF recommendations influence what payers choose to cover, which in turn determines access to preventative services...Addressing the staggering inequities in diabetes outcomes will require substantial investments in diabetes prevention and treatment, but making screening more equitable is a good place to start," said senior author Dhruv S. Kazi, MD, from the Smith Center for Outcomes Research in Cardiology and director of the Cardiac Critical Care Unit at Beth Israel, Boston, Massachusetts.

Screen Minorities at a Younger Age If Current BMI Threshold Kept

In their study, based on data from the National Health and Nutrition Examination Survey (NHANES) for 2011 to 2018, Dr Aggarwal and colleagues also calculated that if the BMI threshold is kept at 25 kg/m2, then the equivalent age cutoffs for Asian, Black, and Hispanic Americans would be 23, 21, and 25 years, respectively, compared with 35 years for White Americans.

The findings were published online May 9 in the Annals of Internal Medicine.[2]

The prevalence of diabetes in those aged 35 to 70 years in the NHANES population was 17.3% for Asian Americans and 12.5% for those who were White (odds ratio [OR], 1.51 vs Whites). Among Black Americans and Mexican Americans, the prevalence was 20.7% and 20.6%, respectively, which was almost twice the prevalence in Whites (OR, 1.85 and 1.80). For other Hispanic Americans, the prevalence was 16.4% (odds ratio, 1.37 vs Whites). All those differences were significant compared with White Americans.

Undiagnosed diabetes was also significantly more common among minority populations, at 27.6%, 22.8%, 21.2%, and 23.5% for Asian, Black, Mexican, and other Hispanic Americans, respectively, versus 12.5% for White Americans.

"The Time Has Come for USPSTF to Offer More Concrete Guidance"

"While there is more work to be done on carefully examining the long-term risk-benefit trade-off of various diabetes screening, I believe the time has come for USPSTF to offer more concrete guidance on the use of lower thresholds for screening higher-risk individuals," Dr Kazi told Medscape Medical News.

The author of an accompanying editorial agrees, noting that in a recent commentary, the USPSTF itself "acknowledged the persistent inequalities across the screening-to-treatment continuum that result in racial/ethnic health disparities in the United States."

The USPSTF also "emphasized the need to improve systems of care to ensure equitable and consistent delivery of high-quality preventive and treatment services, with special attention to racial/ethnic groups who may experience worse health outcomes," continues editorialist Quyen Ngo-Metzger, MD, from the Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California.

For other conditions, including cancer, cardiovascular disease, and infectious disease, the USPSTF already recommends risk-based preventive services.

"To address the current inequity in diabetes screening, the USPSTF should apply the same consideration to its diabetes screening recommendation," Dr Ngo-Metzger notes.

"Implementation Will Require an Eye for Pragmatism"

Asked about how this recommendation might be carried out in the real world, Dr Aggarwal told Medscape Medical News that because all 3 minority groups with normal weight had similar diabetes risk profiles to White adults with overweight, "one way for clinicians to easily implement these findings is by screening all Asian, Black, and Hispanic adults ages 35 to 70 years with normal weight for diabetes, similarly to how all White adults ages 35 to 70 years with overweight are currently recommended for screening."

Dr Kazi said: "I believe that implementation will require an eye for pragmatism," noting that another option would be to have screening algorithms embedded in the electronic health record to flag individuals who qualify.

In any case, "The simplicity of the current one-size-fits-all approach is alluring, but it is profoundly inequitable. The more I look at the empiric evidence on diabetes burden in our communities, the more the status quo becomes untenable."

However, Dr Kazi also noted, "the benefit of any screening program relates to what we do with the information. The key is to ensure that folks identified as having diabetes--or better still, prediabetes--receive timely lifestyle and pharmacological interventions to avert its long-term complications."

This study was supported by institutional funds from the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology. Dr Aggarwal, Dr Kazi, and Dr Ngo-Metzger have disclosed no relevant financial relationships.

Ann Intern Med. Published online May 9, 2022.

Study Highlights

  • Participants in this cross-sectional study were 19,335 nonpregnant US adults aged 18 to 70 years enrolled in NHANES between 2011 and 2018.
  • Logistic regression estimated diabetes prevalence at various BMIs for White, Asian, Black, and Hispanic populations.
  • For each racial/ethnic minority, the equivalent BMI threshold was defined as the BMI at which diabetes prevalence in 35-year-olds in that group equalled that in 35-year-old Whites at a BMI of 25 kg/m2.
  • Undiagnosed diabetes was significantly more common among Asian (27.6%), Black (22.8%), Mexican (21.2%), and other Hispanic populations (23.5%) vs the White population (12.5%).
  • Among adults aged 35 years with BMIs 25 kg/m2, diabetes prevalence in Asian (3.8%; 95% confidence interval [CI], 2.8%-5.1%), Black (3.5%; 95% CI, 2.7%-4.7%), and Hispanic (3.0%; 95% CI, 2.1%-4.2%) populations was significantly higher than in the White population (1.4%; 95% CI, 1.0%-2.0%).
  • Compared with a BMI threshold of 25 kg/m2 in Whites, equivalent thresholds for diabetes prevalence were 20 kg/m2 (range, <18.5-23 kg/m2) for Asian, less than 18.5 kg/m2 (range, <18.5-23 kg/m2) for Black, and 18.5 kg/m2 (range, <18.5-24 kg/m2) for Hispanic populations.
  • If keeping the BMI threshold at 25 kg/m2, then the equivalent age cutoffs for Asian, Black, and Hispanic populations would be 23, 21, and 25 years, respectively, vs 35 years for the White populations.
  • The investigators concluded that among US adults aged 35 to 70 years, Asian, Black, and Hispanic populations have significantly higher rates of diagnosed and undiagnosed diabetes than Whites, particularly among normal weight adults, among whom diabetes prevalence is 2- to 4-fold higher in racial/ethnic minorities than in Whites.
  • Among US adults aged at least 35 years, offering diabetes screening to Black and Hispanic populations with BMIs of at least 18.5 kg/m2 and Asian populations with BMIs of at least 20 kg/m2 would be equivalent to screening White populations with BMIs of at least 25 kg/m2.
  • Screening younger ages could be considered for overweight/obese Asian, Black, and Hispanic populations.
  • Using screening thresholds specific to race/ethnicity could potentially reduce disparities in diabetes diagnosis.
  • This analysis considers only first-time screening (repeated screening may identify fewer persons with diabetes because those diagnosed during the first round of screening would be excluded), yet it provides a more risk-based approach than the one-size-fits-all approach of current screening practices.
  • Given substantial differences in diabetes rates by BMI and age among US racial/ethnic populations, uniform application of a single threshold across all groups would be inequitable, relatively overscreening Whites while underscreening Asian, Black, and Hispanic populations.
  • Future studies should evaluate the cost-effectiveness of various diabetes screening strategies, including expanded, early, or repeated screening in high-risk populations.
  • However, incorporating equity considerations into guidelines should not be delayed while awaiting more thorough data.
  • As recommendations linked to insurance reimbursements heavily influence real-world clinical practice, making screening recommendations more equitable should be a priority.
  • Physiologic and social mechanisms underlying the increased risk of Asian, Black, and Hispanic vs White populations at similar BMIs are incompletely understood.
  • These may include variations in stress exposure, insulin sensitivity, and fat distribution and/or long-standing structural racism, including barriers to accessing high-quality food, safe physical activity, and prevention, screening, and treatment services.
  • Study limitations include insufficient sample size to assess heterogeneity within racial/ethnic groups and the inability to determine whether the thresholds were optimal in any of the groups.

Clinical Implications

  • Among US adults aged at least 35 years, offering diabetes screening to Black and Hispanic populations with a BMI of at least 18.5 kg/m2 and Asian populations with a BMI of at least 20 kg/m2 would be equivalent to screening Whites with a BMI of at least 25 kg/m2.
  • Using screening thresholds specific to race/ethnicity could potentially reduce disparities in diabetes diagnosis.
  • Implications for the Health Care Team: Screening younger ages could be considered for overweight/obese Asian, Black, and Hispanic populations.

 

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