Online Test for Prediabetes: Overkill or Wakeup Call?
Results may needlessly worry some, researcher says; others call it an urgent need to alert Americans early and get them the medical care necessary to avoid costly care later
The launch of an online test to gauge prediabetes risk in adult Americans, promoted by the American Medical Association (AMA), the Centers for Disease Control and Prevention (CDC) and the American Diabetes Association (ADA), has fueled debate about whether it is helpful or maybe more harmful.1,2
What started as an effort to be proactive, the AMA, CDC and ADA, partnering with the Ad Council, launched a PSA campaign to target those at risk of diabetes, inviting the public to take an online test.2,3 This quick and accessible format asks 7 questions to tease out risk for prediabetes, including age; gender; history of diabetes and high blood pressure; and, physical activity, weight and height status.
From the information gathered, a score from 1 to 10 is tallied with the intent of representing the individual's risk of getting type 2 diabetes from low to high.
On which side of the debate do you fall?
Con: Test Too Sensitive; Overestimates
“The test yields too many false positives,” says Saeid Shahraz, MD, assistant professor of medicine at Tufts University Medical Center and lead author of a study on the value of the test. With his colleagues, they calculated how many people in the general population would fail the test, publishing the results in JAMA Internal Medicine.1 He found that 3 out of 5 of those 40 and older, and 8 of 10 of those age 60 and older, would be categorized as high risk and told they have prediabetes.1
"The American Diabetes Association calls it a wake up call; we call it too much worrying about a condition that didn't exist 10 years ago," Dr. Shahraz told EndocrineWeb.
Dr. Shahraz and his coauthors utilized data from the 2013-2014 NHANES (National Health and Nutrition Examination Survey) for individuals older than 18 and without type 2 diabetes.4 They selected NHANES questions that closely matched those in the online test and calculated how many people would be classified as high risk for diabetes based on their NHANES answers.1
Of 10,175 participants, 96.5% responded with complete information for all the questions.1 When the results were applied to the general population, 3 out of 5 of those over 40, and 8 out of 10 of those over 60 would be classified as being at high risk for prediabetes.1
"This is just a crude [oversimplied] test," Dr. Shahraz told Endocrine Web. “Those who get a score that classifies them as high risk are likely to see a doctor, get blood glucose testing and those results will be fine,” he said, “which will needlessly worry people who don't have prediabetes.” One unintended consequence of “medicalizing'' prediabetes could be reducing health care access to patients already diagnosed with type 2 diabetes with the increased demand of testing so many others, according to Dr. Shahraz.
Pro: Test Uncovers the Undiagnosed With Diabetes
"This test is information for the individual to [learn] their personal risk to motivate them to speak with their health care provider," said Robert Ratner, MD, chief scientific and medical officer of the ADA. "Any further diagnostics are up to the shared decisions from that conversation.”
"This prediabetes risk test is a welcome addition'' to helping physicians determine who is at risk, said J. Michael Gonzalez-Campoy, MD, PhD, FACE, medical director and CEO of the Minnesota Center for Obesity, Metabolism and Endocrinology, and an editorial board member for EndocrineWeb.
Here is his rationale. “Two-thirds of adults in the U.S. are overweight or obese by body mass index (BMI) standards,”4 he noted. "It is impossible from this simple metric to determine who among them will have hyperglycemic disorders. The 2011-2014 NHANES database documents that.''3
“NHANES data also found that 12.6% of adults, age 20 and older, have diabetes, but that 3% of those are as yet undiagnosed,”3 said Dr. Gonzalez-Campoy.
More compelling, “an estimated 86 million adults over age 20 had prediabetes in 2013, up from 70 million in 2010,”4 said Dr. Gonzalez-Campoy. "So we have resorted to testing to identify potentially at-risk individuals for hemoglobin A1c, fasting glucose, oral glucose tolerance test,'' Dr. Gonzalez-Campoy said. The problem is that there are too many people with prediabetes and diabetes who have not yet been diagnosed in the USA in 2016.4,5 The earlier the diagnosis is made in the evolution of hyperglycemia, the easier it is to prevent complications. In the progression of disease, there is a genetic predisposition, then weight gain with the development of insulin resistance, then prediabetes and ultimately diabetes.4,5
Take-Away for Clinicians
In Dr. Gonzalez-Campoy's view, the risk test should be viewed this way: "It is designed, without the need for lab testing of all people, to select out those who are at [potentially] highest risk of having hyperglycemia. This does allow for earlier awareness and more prompt intervention.''
Patients who do test in the prediabetes range (A1C of 5.7 to 6.4%, fasting blood glucose of 100-125 mg/dl, oral glucose tolerance test (OGTT) of 140-199 mg/dl) should get counseling on lifestyle interventions, according to the ADA and CDC.
According to the CDC, a focus on weight loss and learning to eat a less processed, higher fiber diet can cut the risk of developing diabetes in half.4 Without a change in diet and physical activity, 15 to 30% of individuals with prediabetes will develop type 2 diabetes within 5 years.4,6
Regardless of your position on the value of the quiz, it's out there. Clinicians should be prepared to address concerns from individuals who think they may be headed for diabetes given the results of this quiz. Every office should have a protocol to handle such calls.