No screening for type 2 diabetes in children, adolescents, USPSTF says

New recommendations from the US Preventive Services Task Force (USPSTF) show that there is insufficient evidence to assess the benefit-harm balance of screening for type 2 diabetes in children and adolescents.

In addition, there is also a lack of evidence on the impact of screening for, early detection and treatment of type 2 diabetes on health outcomes in adolescents, the same recommendations explain.

“Adolescents with type 2 diabetes have an increased prevalence of associated chronic comorbidities such as hypertension, dyslipidemia, and nonalcoholic fatty liver disease,” report Carol Mangione, MD, David Geffen School of Medicine, University of California at Los Angeles, and colleagues.

“[However]clinicians should continue to use clinical judgment to determine whether screening is appropriate for individual patients,” they advise.

The new recommendations were published online on September 13 JAMA.

Commenting on the new recommendations in an accompanying editorial, Lori Laffel, MD, MPH, Joslin Diabetes Center, Boston, Massachusetts, and colleagues point out that the prevalence of type 2 diabetes in children and adolescents has increased almost over the past two decades has doubled. from a rate of 0.34 per 1000 in 2001 to a rate of 0.67 per 1000 in 2017, a relative increase of 95% over 16 years.

“The COVID-19 pandemic has further fueled the trend of increasing numbers of adolescents developing type 2 diabetes, likely due to several reasons, including unhealthy lifestyle risk factors such as increased sedentary behavior, decreased physical activity and weight gain,” explain Laffel and colleagues.

In addition, the diagnosis of type 2 diabetes in young patients is not easy, as mounting evidence shows that it is associated with higher morbidity and premature mortality in children and adolescents, likely due to the accelerated onset and progression of microvascular and macrovascular complications.

“These complications occur more frequently and at a younger age in patients with type 2 diabetes in adolescence than in patients with type 1 diabetes in adolescence or in adults who have been diagnosed with type 2 diabetes,” the editorials note .

Systemic review

The USPSTF commissioned a systematic review of the evidence for screening for prediabetes and type 2 diabetes in asymptomatic, nonpregnant patients younger than 18 years of age.

“This review focused on demonstrating the benefits and harms of screening for prediabetes and type 2 diabetes, and the benefits and harms of interventions in screened prediabetes and type 2 diabetes or recently diagnosed type 2 diabetes” , explain the USPSTF members.

It also reviewed the evidence on the effectiveness of interventions for patients with prediabetes to delay or prevent progression to type 2 diabetes. The definitions of prediabetes and type 2 diabetes are the same for children and adolescents as for adults, with type 2 diabetes being defined as a fasting plasma glucose value of 126 mg/dL (5.6-6.9 mmol/L ) and an A1c of 6.5%. or a 2-hour post-exercise glucose level of 200 mg/dL (11.1 mmol/L) or greater.

The task force also made several other recommendations on screening for obesity in children and adolescents, and screening for prediabetes and type 2 diabetes in adults.

The same group also made a separate recommendation on screening for gestational diabetes in pregnant women. The US Food and Drug Administration (FDA) has approved three drugs to treat type 2 diabetes in children: metformin, insulin, and liraglutide (Victoza, Novo Nordisk), a glucagon-like peptide-1 (GLP-1) receptor agonist .

While metformin is effective for treating type 2 diabetes in younger patients, the authors note that it is not FDA-approved to prevent the progression of prediabetes to diabetes.

The task force found no studies that looked at the direct benefits of screening for prediabetes and type 2 diabetes on health outcomes in asymptomatic children and adolescents.

Likewise, they found no studies that looked at the harms of screening for prediabetes and type 2 diabetes in the same patient population. Because some adolescents with prediabetes can return to normal glycemia without intervention, the potential harms of screening in this age group include overdiagnosis and overtreatment, and potential harms from treating type 2 diabetes include induction of hypoglycemia and gastrointestinal side effects. such as nausea and vomiting associated with taking medication.

Importantly, type 2 diabetes rates have been shown to be between four and eight times higher in Native American/Alaska-Native Black and Hispanic/Latino youth than in non-Hispanic White youth.

The authors speculate that structural factors that disproportionately affect nonwhite populations, as well as cultural and environmental influences, and the quality of and access to health care, may contribute to differences in diabetes rates by race and ethnicity.

Lifestyle interventions less effective in adolescents than in adults?

What the Task Force for Children and Adolescents with Prediabetes and Type 2 Diabetes recommends are lifestyle interventions that promote weight loss, improve nutrition, and improve physical activity.

As they point out, obesity and excess adipose tissue – particularly centrally distributed excess adipose tissue – are the most important risk factors for type 2 diabetes in younger patients. Family history of diabetes, including gestational diabetes, is also a strong risk factor.

Risk assessment tools exist to identify young patients at risk for prediabetes and type 2 diabetes; However, there is limited evidence to confirm its accuracy, task force members warn.

In their editorial, Laffel and colleagues emphasize: “Prevention and early detection of type 2 diabetes in children is a top public health priority.

Still, they warn that intense lifestyle weight-loss efforts appear to be less effective in adolescents than in adults.

However, pediatricians and primary care physicians can and should continue to emphasize the importance of healthy lifestyles for children and their families and to keep a close eye on symptoms of hyperglycemia.

Physicians should continue to follow risk-based screening recommendations for type 2 diabetes in overweight and obese adolescents with at least one additional risk factor for type 2 diabetes who have evidence of insulin resistance, including acanthosis nigricans or polycystic ovary syndrome.

The US Centers for Disease Control and Prevention estimates that in 2018, 210,000 children and adolescents under the age of 20 had diabetes, of which approximately 23,000 had type 2 diabetes.

All members of the USPSTF receive travel expenses and a fee for attending USPSTF meetings. Laffel has reported receiving grants from Insulet and Boehringer Ingelheim, and consulting fees from Janssen, Medtronic, Dompe, Provention Bio, Eli Lilly, Roche and Dexcom.

JAMA. Published online September 13, 2022.

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