It seems that every time clinicians have gotten comfortable with whatever guideline comes their way, another new set of recommendations comes to the fore. Despite the annoyance of having to keep up with what is current (there are always apps for that), the bigger picture is that medicine is an ever-evolving field. It's one where old wisdoms are always being challenged or confirmed based on available evidence what is popularly known as evidence-based medicine.
As described on its own web page, the United States Preventive Services Task Force (USPSTF) is an independent panel of experts in primary care and prevention who systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. These reviews are published as [USPSTF] recommendations on the Task Force Web site and/or in a peer-reviewed journal.
The Task Force does not factor cost into their assessments.
Recently, the organization updated its recommendations (last done in 2008) for screening for abnormal blood glucose, to include adults aged 40 to 70 years old who are overweight or obese. Additionally, clinicians should offer these patients with abnormal results intensive behavioral counseling interventions to promote a healthful diet and physical activity (B Recommendation). This B recommendation indicates that the evidence shows a net benefit, or moderate certainty, that the benefit is moderate to substantial.
What makes this so different from the recommendations from 2008? The Task Force had advised screening for asymptomatic individuals with hypertension (blood pressure > 135/80). Presumably, the most current guideline decreases the number of people that fall under this umbrella. Whether this is good or bad largely depends, it seems, on what organization you're affiliated with.
The key point to the new recommendation is not from any net benefit from the screening itself, but more from the behavioral intervention programs.
We recommend screening for abnormal glucose because we see a benefit," said William R Phillips, MD, professor in family medicine at the University of Washington, Seattle, "but the benefit comes from big behavior changes, and to get these big behavior changes for the at-risk group, you need a big behavior intervention. ... Just doing the blood test isn t going to get you there.
As per the USPSTF publication in the Annals of Internal Medicine, there is inadequate evidence that the simple act of measuring blood glucose is associated with any reduction in death and disability from cardiovascular disease.
The Diabetes Prevention Program at the National Institutes of Health (NIH) implemented a strategy which called for combining counseling, a healthy diet, increasing physical activity and maintaining contact over extended periods to be effective in achieving measurable improvements.
On balance, in our review of what we felt was the best evidence, we came to the conclusion that the evidence was stronger and more reliable for the behavioral intervention, than for the pharmacological intervention, Dr. Phillips said.
Abnormal glucose metabolism involves risk factors such as being overweight or obese, having a higher percentage of abdominal fat, physical inactivity and smoking. In accordance, advocating for patients to make lifestyle changes to reduce their risk for developing diabetes rather than just taking medications is paramount.
It certainly legitimizes physician credibility with the population of patients who are distrustful of doctors; seeing them as agents of big pharma. The harms associated with promoting such interventions are nil, whereas the there are measurable harms from drug therapy (i.e. side effects or adverse drug events).
As with anything else in medicine, clinical discretion is advised. There are populations which have higher risk of developing diabetes, and those include people with: family history of diabetes; personal history of gestational diabetes (up to 50 percent will develop overt diabetes within five years); polycystic ovarian syndrome; African Americans, Native American, Native Hawaiians or Pacific Islanders.
What is crucial to understand is that patients need to have the support and information to feel empowered to make substantial changes in their daily lives. The best patient care is one that incorporates a multi-disciplinarian approach, especially as the role of internists are stretched increasingly thin.
