Screening for Diabetes - When, How and How Often

Three weeks ago, the US Preventive Services Task Force Recommendations for Screening for Diabetes in the US [1] were published. These made news because the USPSTF has reduced the age of screening to 35 years of age, if overweight or obese (BMI > 25 and BMI > 30 respectively) using either fasting plasma glucose or HbA1c or an oral glucose tolerance test (OGTT). These recommendations are important because insurance companies in the US reimburse the high costs (relative to Indian costs) of these tests based on USPSTF recommendations. For e.g. a fasting plasma glucose test that costs Rs. 70-120 in India costs 15-25 USD (Rs. 1100 to 1800) in the US, 10-15 times the cost in India, which deters Americans from paying for these tests on their own, unless their insurance carrier reimburses the costs fully or sub-totally, which it will usually do if the tests are recommended by the USPSTF.

The USPSTF also suggests that if normal, the screening should be repeated at 3 years. The American Diabetes Association on the other hand recommends screening for everyone above 45 years of age, irrespective of risk and for all adults with one or more risk factors, irrespective of age, with similar recommendations from the American Association of Clinical Endocrinology. This in a country where 13% of adults, 18 years or older have diabetes.

India has 77 million (7.7 crore) people with diabetes, as of 2019, accounting for 10.4% of the adult population and given that for ever Indian with diagnosed diabetes there is one who remains undiagnosed, this number is likely a significant underestimation. The burden of disease is therefore huge and it is an obvious, logical fact that if we want to treat diabetes early and quickly, we need to be able to detect it, in the first place. We also know that there is an extra Indian cardiovascular risk, which is likely related in a large part, to diabetes.

The Indian Council of Medical Research (ICMR) has published guidelines on the management of type 2 diabetes, which include guidelines for detection. They mention simply that all adults above the age of 30 years should undergo screening with fasting plasma glucose or an OGTT. The guidelines underplay HbA1c, simply because this test is not easily available everywhere and there may be issues with quality control. The ICMR also says that screening should be carried out at an even earlier age if there are risk factors (obesity, family history, etc).

Insurance in India will typically not reimburse these tests, but most insurance policies allow a basic annual health check-up where fasting plasma glucose is included.  Given that the penetration of private health insurance is not more than 4-5% in India, with the rest of the 35-40% insurance coverage being Government related (CGHS, ESIS, PM-JAY, etc), where opportunistic screening is not done, the onus again is on us to get our own testing done. The ICMR recommends once a year screening, if pre-diabetic and once every 3 years, if normal, but frankly, if we are getting blood tests done for any reason, we should just include a fasting plasma glucose each time, given the ridiculously low test cost of less than 2 veggie McDonald burgers.

The RSSDI-ESI guidelines are more comprehensive. The Research Society for the Study of Diabetes in India (RSSDI) and the Endocrine Society of India (ESI) published their 2020 clinical practice recommendations last year. There is a significant focus on opportunistic screening, which is defined as screening done by a doctor or allied professional or hospital whenever a person or patient presents for another reason (e.g. relatives of a patient in a hospital, or as part of any blood test done for other causes, etc). The panel recommends the use of questionnaires to assess risk (based on physical activity, family history, age and weight), but practically these would take too much time compared to just doing a fasting plasma glucose test in everyone.

So it’s just best to go with the ICMR guidelines and screen everyone above the age of 30 years, preferably on an annual basis or more frequently, if found to be pre-diabetic.

So, to summarize. Apart from assessing your own cardiovascular risk yourself (where in any case you need to know whether you are diabetic or not) and measuring your own blood pressure regularly, you need to measure your fasting plasma glucose and if possible the HbA1c on a yearly basis.

In future posts, we will examine the use of home measurements for plasma glucose, the cut-off values for the diagnosis of pre-diabetes and diabetes and other parameters needed in our atmasvasth quest to live long, healthy.

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Footnotes

1. US Preventive Services Task Force, Davidson KW, Barry MJ, Mangione CM, et al. Screening for Prediabetes and Type 2 Diabetes: US Preventive Services Task Force Recommendation Statement. JAMA. 2021 Aug 24;326(8):736-743. doi: 10.1001/jama.2021.12531. PMID: 34427594.

2. Chawla R, Madhu SV, Makkar BM, et al; RSSDI-ESI Consensus Group. RSSDI-ESI Clinical Practice Recommendations for the Management of Type 2 Diabetes Mellitus 2020. Indian J Endocrinol Metab. 2020 Jan-Feb;24(1):1-122. doi: 10.4103/ijem.IJEM_225_20. Erratum in: Indian J Endocrinol Metab. 2020 Jul-Aug;24(4):376. PMID: 32699774; PMCID: PMC7328526.