Who should be screened for type 2 diabetes - and when?

- Jennifer Middleton, MD, MPH

The current issue of AFP reviews screening recommendations for type 2 diabetes in both a review article ("Diabetes Mellitus: Screening and Diagnosis") and a discussion of the United States Preventive Service Task Force (USPSTF)'s recommendation to screen all overweight and obese adults aged 40-70 for diabetes. These screening recommendations are at odds, however, of the practices of many employers and health insurers seeking to gather more data about their insured employees. 

Last year, the USPSTF released a "B" recommendation that non-pregnant adults aged 40-70 who are also overweight or obese should be screened for type 2 diabetes. A fasting glucose, a glucose tolerance test, or a serum hemoglobin A1C are all reasonable options for screening. The USPSTF recommends repeating screening, if initial results are normal, every 3 years. Treatment of patients with impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) can forestall the development of type 2 diabetes, and identifying asymptomatic individuals with IGT or IFG is a laudable goal. 

These recommendations, however, are quite different than the practice of my current employer regarding biometric screenings. Once a year, I either submit to a fasting glucose level and lipid profile or forfeit several hundred dollars in health insurance premiums. These biometric screenings do not take into account risk factors, and they don't care what the evidence base says about whom we should be screening and when. (For the record, I do not meet USPSTF guidelines to be screened for diabetes or lipid disorders.) Employers and health insurers are indiscriminately testing everyone as a way to measure its insured population, assess its risks, and encourage individuals with abnormal results to engage in treatment and lifestyle changes. 

Those aims are not unreasonable, but they come at a cost. Applying these screening tests more often than currently recommended is not inexpensive and can also create the risk of false positive results. It also requires employees to share what should be protected health data with employers; although these screenings are often touted as "optional," the risk of forfeiting what may be hundreds of dollars may border on coercive. 

These complex issues can put family physicians in a difficult spot. Although I don't want to order annual lipid profiles and fasting glucose levels for my patients who don't need them, I also don't want my patients to suffer unnecessary healthcare costs. It seems unlikely that these programs are going away, but what can we, as family physicians and healthcare providers, do to orient these programs more in the direction of the evidence base? It may be time for us to speak up on this issue, both as individuals and our organized medical societies.

Efforts to do so to date have had mixed results. Last year, employees at one university protested vehemently against their employers' new biometric screening and health survey policy, and, in 2014, the United States Equal Employment Opportunity Commission brought a lawsuit against a large U.S. employer for their penalty-heavy requirement for employees to undergo biometric screenings. Although the EEOC lost their suit, those university employees succeeded in delaying the new biometric screening policy and creating a task force to examine the issue in greater depth. 

Certainly, there can be benefits to employees of incentivizing healthy lifestyles. Providing coverage for smoking cessation classes and medications, for weight loss programs and gym memberships, even for lactation support services are all worthwhile. Ensuring that employer health programs are meeting both employees' and employers' needs, however, will likely continue to be a balancing act. As long as the financial power of the equation lies with the employers, we will need to advocate for our patients, the employees.

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