This news release analyzes results from a study comparing two approaches to screening for diabetes in order to compare their test characteristics, basically the true versus false positives.
The release is light on data supporting its claims that screening guidelines from the US Preventive Services Task Force (USPSTF) pick up too few people when they recommend physicians screen patients that are 40 to 70 years old and are overweight or obese. The Northwestern release suggests these guidelines miss African-Americans and Latinos since they tend to develop type 2 diabetes at younger ages. But it’s also possible that the USPSTF recommendations are already too expansive and catch far too many people under the “dysglycemia” label — a broad term including both “prediabetes” and type 2 diabetes — and therefore harm many who end up being medically diagnosed, labeled and “treated” for a condition that may never go on to hurt them. We can’t lose sight of the fact that high blood sugars is a surrogate marker, the modification of which may never have any clinical benefits, and in fact could be harmful. Maybe the “dysglycemic” term batches together almost everyone on the planet who could, by definition, either be prediabetic or diabetic, which is most of us.
According to the study, the less expansive USPSTF recommendation would leave 53% of patients who had prediabetes or type 2 diabetes undetected. This matters because there is also a significant contrary fact that is overlooked in this study: that screening people with this new “dysglycemia” definition would unfortunately trap millions more Americans into a medical diagnosis, and a label that may not lead to any better health, and could even make their lives worse, burdening them with the complex treatments involved in tight glycemic control which also invites hypoglycemia and weight gain, as well as high costs; all for an uncertain benefit.
Looking at the track record of drug therapies to treat type 2 diabetes, it seems unlikely that medicalizing and medicating millions more Americans on the basis of their alleged “high” blood sugar readings or their race would confer an overall advantage to population health.
The cost of the screening test is not mentioned. But while the testing itself is low cost, the downstream and societal costs are ignored in the release. Costs could be very significant for expanding screening for a surrogate marker for diabetes that may or may not be a problem. The drugs, blood glucose testing, and checking and rechecking of blood sugars is a huge industrial enterprise that involves significant medical resources.
The release does address cost in terms of what it currently costs ($327 billion annually) to treat “prediabetes” (a condition that may not develop into diabetes) and people with type 2 diabetes. It would have been fair of the release to include the estimated cost of additional screening, tests and treatment being proposed.
The release states that “Only 23% of patients with prediabetes or diabetes would be missed if expanded criteria were used to make screening decisions, the study found.”
While the study itself dived into the sensitivity of the tests used in screening, none of that data are shared in the release.
The larger problem is that it’s not clear whether finding more cases of prediabetes or diabetes would actually lead to improvements in outcomes people care about like fewer heart attacks and less nerve damage. The release should have clarified this.
The considerable harms of overdiagnosis which include the risk of unnecessary followup tests and treatment that can cause adverse effects, are not mentioned. There are both benefits and harms associated with broad based screening programs.
There’s not enough information about the study included in the news release to judge the quality of the evidence. The study included specificity and sensitivity statistics based on a large sample size, with results that are consistent with other similar studies.
Labeling possibly normal, healthy Americans with a unfamiliar term like “dysglycemia” that may entail considerable medical and psychological consequences — without any firm proof that it will benefit them — seems like disease-mongering.
The funding sources are satisfactorily explained and detailed.
Are there alternatives to “screening?” That might be a philosophical question, but one has to ask if there is an overall health benefit to more intensive screening. We’re told that “lifestyle programs and some medications have been proven to prevent or delay type 2 diabetes among adults with prediabetes,” though that’s a topic under debate by experts. We also learn that “a large volume of research over the last three decades has demonstrated that treating type 2 diabetes prevents life-threatening complications such as heart attacks, strokes and kidney failure.” But some experts argue that the only proven action that prevents complications are lifestyle changes. The majority of drug and insulin interventions come from trials showing that they can alter sugar levels, but there is very little evidence they prevent complications in type 2 diabetics.
More intensive screening is obviously available.
The release states that the study is the first to “report on how these expanded screening criteria would perform in practice among a nationally representative sample of U.S. adults.” It also mentions that the research builds the study author’s previous work. As noted above, the release should have included more hard data from the study to back up its argument.
There is no inappropriate language with the exception of the use of the term “dysglycemia” to suggest a new disorder encompassing both those with “prediabetes” and type 2 diabetes. This is addressed under the Disease Mongering criteria.
Systematic, Criteria-Driven
Monday at #ADA2021, an infectious disease epidemiologist, a journalist, and a researcher shared perspectives on communication of risk in the era of COVID-19: http://ow.ly/ROfR30rMeE7 @AstleyCM @garyschwitzer @berthahidalgo @ADA_DiabetesPro
Shoutouts to @susan_bewley @drkevinknopf @MichaelBaum11 in this call for more than fawning coverage from press releases for these kinds of stories.
Also, linked history inside goes back 5 years just on Grail apparently trying to become Holy Grail. https://twitter.com/garyschwitzer/status/1408849696416841731
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