Tailoring screening by race and ethnicity may catch diabetes cases earlier, improve health equity

Diabetes is a leading cause of morbidity and mortality, affecting more than 34 million adults in the United States. Current United States Prevention Services Task Force (USPSTF) guidelines recommend that 35-70 year-old adults with overweight and obese weight (i.e., a BMI of 25 kg/m2 or greater) be screened for diabetes. However, Americans in racial/ethnic minority populations have a higher prevalence of diabetes even at normal weights, are less likely to be aware of their diagnosis, and are more likely to die of diabetes than White Americans.

The USPSTF also released recommendations in 2021 that acknowledge that some racial and ethnic minority populations are at higher risk, which may warrant screening at lower ages or BMIs.

Researchers from Beth Israel Deaconess Medical Center and Harvard Medical School used data from the National Health and Nutrition Examination Survey to determine the BMI 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.

The authors found that among 35-70 year-old Americans with normal weights, individuals from racial/ethnic minorities were at substantially higher risk of diabetes compared with White individuals: 13% of Asian Americans, 10% of Black Americans, 12.2% of Mexican Americans, and 7.0% of other Hispanic Americans had diabetes compared with 3.5% of White Americans.

According to the authors, to identify the same proportion of patients with diabetes as White Americans, clinicians would need to screen 35-70 year-old Asian Americans starting at a BMI of 20 kg/m2 and Black and Hispanic Americans starting at a BMI of 18.5 kg/m2. Moreover, among individuals with a BMI of 25 kg/m2 or greater, it would be equitable to initiate diabetes screening in individuals from racial/ethnic minorities starting at younger ages: Asian Americans at 23 years, Black Americans at 21 years, and Hispanic Americans at 25 years.

Thus, expanding diabetes screening to lower BMIs or younger ages in racial/ethnic minority populations may improve equity in diabetes care in the US. The authors recommend that future studies should examine the long-term health effects and cost-effectiveness of implementing screening thresholds specific to race/ethnicity to reduce disparities in diabetes diagnosis.

An editorial by Quyen Ngo-Metzger, MD, MPH, calls on the USPSTF to update its diabetes screening and preventative services recommendations to reflect the differential risk for diabetes among different racial/ethnic groups.