Diabetes guidelines: Screen more people earlier

All adults who are overweight and have additional risk factors for type 2 diabetes are candidates for prediabetes testing, say the new recommendations.

By Susan J. Landers — Posted Jan. 21, 2008

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Stopping diabetes before it starts is the aim of several new recommendations intended to help physicians in the fight to curb the spread of the disease, which affects 7% of the population.

Screening more widely for patients with prediabetes and stepping up preventive measures for those who have started down the path toward type 2 diabetes are among the suggestions made recently by the American Diabetes Assn.

Progression to diabetes among those with impaired glucose tolerance or impaired fasting glucose -- conditions commonly referred to as prediabetes -- is not inevitable, according to the Centers for Disease Control and Prevention.

The ADA provides several tips for physicians, including considering the use of the diabetes medication metformin, to prevent, or at least delay, the full-blown disease. The group's "Standards of Medical Care in Diabetes -- 2008" are in the Jan. 1 Diabetes Care and are updated annually.

The alarming growth in the number of people, particularly youngsters, who have type 2 diabetes has sparked concern about the need to make a preemptive strike to prevent, if possible, the disease and its serious complications, which include heart disease, stroke, blindness and kidney disease. More than 14 million people have been diagnosed with diabetes, and another 6 million are undiagnosed, according to the CDC.

Richard Hellman, MD, president of the American Assn. of Clinical Endocrinologists, praised the ADA recommendations. "I think they have changed, improved and strengthened many parts of their standards."

Dr. Hellman applauded the document's promotion of early prediabetes screening, although he said he would start even earlier by looking for people with insulin resistance syndrome, also called metabolic syndrome.

The latest ADA recommendations include a more liberal interpretation than had been advised in past years of who should be screened for prediabetes, said Irl Hirsch, MD, chair of the panel that drafted the document and a professor of medicine at the University of Washington School of Medicine in Seattle. "Specifically, people who are overweight or obese, or have one or more diabetes risk factors -- those individuals should be screened," he said.

Screening young people is also necessary, he said, because if they become diabetic, they face decades of disease. A recent study found that a large number of teens, particularly minorities, have diabetes, not just prediabetes, Dr. Hirsch said.

"So if you have an overweight Hispanic or African-American adolescent, especially if there is type 2 diabetes in the family or the teen has hypertension, those kids really need to be screened," he said.

Type 2 diabetes in children is still relatively rare, said John Buse, MD, PhD, president for medicine and science at the ADA and director of the University of North Carolina's Diabetes Care Center in Chapel Hill. "But it has gone from a problem that was virtually unheard of to one that does happen with some regularity."

Medication's new role

Using metformin as a preventive measure is another new ADA recommendation. But the drug should be considered only after lifestyle changes have been tried and proven unsuccessful, Dr. Hirsch noted. "You don't just run up with the prescription pad."

Evidence from the Diabetes Prevention Program, a large clinical trial done in the early 2000s, determined that metformin can reverse prediabetes, though not as well as diet and exercise. But metformin was found to be particularly effective among subjects ages 25 to 44 who were at least 60 pounds overweight.

While prescribing metformin as a preventive is still rare, it is gaining interest, said Kenneth Snow, MD, acting chief of the Adult Diabetes Program at Joslin Diabetes Center in Boston. "There are good study data that looked at a number of medications, including metformin, that prevent the rate at which diabetes develops," he said.

But Dr. Snow noted that adding the drug would boost the cost of care for millions with prediabetes. Plus, many of them may not develop diabetes even if they are never treated, he said.

The guidelines also provide recommendations for older patients, Dr. Hirsch noted. "Many of us in the world of endocrinology are seeing older individuals, over age 65, with decades and decades of diabetes, especially type 1 diabetes," he said. "This is a population we didn't have to think about 20 or 30 years ago because there weren't many of them around."

Patients who are functional and cognitively intact and have significant life expectancy should be treated using goals developed for younger patients, according to the guidelines.

The recommendations also call for A1c goals of less than 7% for all nonpregnant adults. This represents a shift to a lower number for the ADA, which had recommended a 7% goal in past years.

A controversial recommendation, included for the first time in the ADA document, is the use of a statin drug for children 10 and older who have type 1 diabetes and whose LDL cholesterol levels remain high -- over 160 mg/dL -- despite adherence to diet and exercise guidelines.

"The big issue is what happens when one takes a statin for 50 years," Dr. Hirsch said. "Nobody can answer that." But because plaque formations in arteries can occur in people in their 20s and because statins have been used for more than 20 years with no evidence of long-term toxicity, "I think that those in the pediatric and lipid community thought this was a safe recommendation."

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Updated recommendations

The American Diabetes Assn. published revised Clinical Practice Recommendations in the Jan. 1 Diabetes Care. Among the guidelines:

  • Testing should be considered for all adults who are overweight or obese and have additional diabetes risk factors.
  • For type 2 diabetes prevention, consider metformin, in addition to lifestyle changes, for those at very high risk: obese, younger than 60, with combined impaired fasting glucose and impaired glucose tolerance, plus other risk factors.
  • The general A1c goal for nonpregnant adults is less than 7%. For selected individual patients, the A1c goal is as close to normal as possible, or less than 6%.
  • A low-carbohydrate diet as well as a low-fat diet can be recommended for weight loss. Closely monitor lipid profiles and kidney function in patients on a low-carbohydrate diet.
  • A statin is recommended for children older than 10 with type 1 diabetes if diet and other lifestyle changes have not succeeded in lowering LDL cholesterol levels to less than 160 mg/dL.

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