Academy Comments to USPSTF re: Diabetes Screening Recommendation

November 4, 2014

United States Preventive Services Task Force
540 Gaither Road
Rockville, Maryland 20850

Re: Draft Recommendation Statement: Screening for Abnormal Glucose and Type 2 Diabetes Mellitus

The Academy of Nutrition and Dietetics applauds the United States Preventive Services Task Force (USPSTF) on its Draft Recommendation Statement for Screening for Abnormal Glucose and Type 2 Diabetes Mellitus (the “Recommendation”), particularly that providers screen for prediabetes. As the burden of prediabetes reaches 86 million American adults, it is a critical time to expand the current screening recommendation to include those at risk for prediabetes. We also support USPSTF’s inclusion of screening intervals every three years for adults at low-risk for diabetes with normal blood glucose levels. Furthermore, we applaud USPSTF for considering six new lifestyle interventions to show benefits in preventing and delaying diabetes, as well as improving clinical outcomes.

With over 75,000 members comprised of registered dietitian nutritionists (RDNs), dietetic technicians, registered (DTRs) and advanced degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States. We are committed to improving the nation’s health through food and nutrition, and providing medical nutrition therapy (MNT) and other nutrition counseling services to meet the health needs of all citizens, including those with diabetes and prediabetes. Overall, the Academy supports the findings of the Recommendation, and we offer the following comments to provide clarity and further strengthen the Recommendation.

Provider Type/Expertise:

The Academy asks the USPSTF to clarify its definition of “clinician” as used in the Recommendation for providing screenings and interventions. In other recommendations, such as the “Healthy Diet and Physical Activity: Counseling Adults with High Risk for CVD,1 the USPSTF reviewed the providers who delivered interventions. While not defining one provider, USPSTF gave a range of providers who had been demonstrated as effective in performing the Diabetes Prevention Program (DPP) and the PREMIER intervention, including a dietitian, a nutritionist, a health educator, or a psychologist. Several other sources highlight the importance of having a RDN provide interventions to improve outcomes for patients with diabetes or prediabetes. One study found that individualized MNT provided by a RDN is effective in reducing the HbA1C level in patients diagnosed with prediabetes2. The American Diabetes Association’s (ADA) Standards of Medical Care in Diabetes- 2014 recommend that screening should be carried out in the health care setting3. The Standards also recommend referrals of patients to a RDN for MNT. The Academy’s Evidence Analysis Library (EAL) recommends that RDNs should “ensure that all individuals are screened for risk of type 2 diabetes,” with appropriate referral after receiving the results of the screening4. The RDN will “work with other healthcare professionals to determine the appropriate actions to be taken, based on the results of the screening.” Referrals should be made to a RDN for MNT, or to a health care provider for further laboratory tests, among others. Furthermore, at least three of the lifestyle intervention studies used by USPSTF to reach its Recommendation specifically utilized RDNs to provide the intervention.5 Therefore, the Academy asks that USPSTF include a list of providers most effectively demonstrated as able to perform the intensive lifestyle interventions, specifically including RDNs on the list.

Effectiveness of Interventions The Academy suggests that the USPSTF further define the intensive lifestyle interventions to be included in the Recommendation, specifically the USPSTF’s summary thereof. Based on the evidence review, the USPSTF found that “[l]ifestyle interventions and pharmacological interventions both appear to be effective at delaying or preventing progression to Diabetes Mellitus (DM) in persons with IFG (Impaired Fasting Glucose) or IGT (Impaired Glucose Tolerance).6 Furthermore, under “Benefits of Early Detection and Treatment,” the USPSTF found adequate evidence that intensive lifestyle modifications result in a lower incidence of diabetes, cardiovascular mortality, and all-cause mortality.” We would urge the USPSTF to clarify its recommendation regarding intensive lifestyle interventions by using the definition given by the Community Preventive Services Task Force in the Community Guide to Diabetes Prevention and Control7:

“Combined diet and physical activity promotion programs aim to prevent type 2 diabetes among people who are at increased risk of the disease. These programs actively encourage people to improve their diet and increase their physical activity using the following:

  • Trained providers in clinical or community settings who work directly with program participants for at least 3 months
  • Some combination of counseling, coaching, and extended support
  • Multiple sessions related to diet and physical activity, delivered in-person, or by other methods8.”

Risk Factors

The draft recommendation lists risk factors under the section “Patient Population under Consideration”. We support including women with a history of gestational diabetes mellitus (GDM) as those at high risk of developing type 2 diabetes, since intervention and follow-up of this population can have a long-term benefit in reducing disabilities, work days missed, and improving quality of life. We urge the USPSTF to consider establishing a treatment and follow-up plan that assists women with GDM or a history of GDM in order to reduce their 10-year risk of type 2 diabetes. Many women are lost to follow-up after the glucose challenge post-test, making it difficult to continue prevention programs9. We would also like to note the increasing prevalence of prediabetes and type 2 diabetes in children and adolescents, and urge the USPSTF to consider developing recommendations on screening in this population.10

Closing

The Academy appreciates the opportunity to comment on this important recommendation. We believe that clarifying the type of provider for both screening and intervention to be in line with the ADA’s Standards of Care will best facilitate the substance of the Recommendation. Furthermore, by defining intensive lifestyle interventions in line with the Community Preventive Services Task Force’s definition, USPSTF would pave the way for improved prevention and treatment services for patients with diabetes based on proven lifestyle intervention programs.

Please contact either Mary Pat Raimondi at (312) 899-1731, or by email at [email protected], or Stefanie Winston at (202) 775-8277, ext. 6006, or by email at [email protected], with any questions or requests for additional information.

Sincerely,

Mary Pat Raimondi, MS, RDN Vice President, Strategic Policy and Partnerships
Academy of Nutrition and Dietetics

Stefanie Winston, Esq.
Director, HHS Legislation and Policy
Academy of Nutrition and Dietetics

1 Final Recommendation Statement: Healthy Diet and Physical Activity: Counseling Adults with High Risk for CVD. U.S. Preventive Services Task Force. August 2014.

2 Parker AR, Byham-Gray L, Denmark R, Winkle PJ: The Effect of Medical Nutrition Therapy by a Registered Dietitian Nutritionist in Patients with Pre-diabetes Participating in a Randomized Controlled Clinical Research Trial. Journal Academy of Nutrition and Dietetics: Published on line Sept 14, 2014; Journal Academy of Nutrition and Dietetics: DOI:

3 American Diabetes Association. Standards of medical care in diabetes: 2014. Diabetes Care. 2014; 37 Suppl 1: S14-S80. Accessed October 29, 2014.

4 Academy of Nutrition and Dietetics, Evidence Analysis Library. Prevention of Type 2 Diabetes Project 2014. Accessed October 29, 2014.

5 Armato J, DeFronzo RA, Abdul-Ghani M, et al. Successful treatment of prediabetes in clinical practice: targeting insulin resistance and cell dysfunction. Endocr Pract. 2012; 18(3): 342-50; Katula JA, Vitolins MZ, Morgan TM, et al. The Healthy Living Partnerships to Prevent Diabetes study: 2-year outcomes of a randomized controlled trial. Am J Prev Med. 2013; 44(4 Suppl 4); S324-32; Penn L, White M, Oldroyd J, et al. Prevention of type 2 diabetes in adults with impaired glucose tolerance: the European Diabetes Prevention RCT in Newcastle upon Tyne, UK. BMC Public Health. 2009; 9:342.

6 Draft Recommendation Statement: Abnormal Glucose and Type 2 Diabetes Mellitus in Adults: Screening. U.S. Preventive Services Task Force. October 2014.

7 The Community Guide to Diabetes Prevention and Control: Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among People at Increased Risk, Community Preventive Services Task Force. July 2014.

8 Other methods could include web-tools, social networking, email, etc. (The Community Guide to Diabetes Prevention and Control: Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among People at Increased Risk, Community Preventive Services Task Force. July 2014.

9 Nielsen, et al. From Screening to Postpartum follow-up—the determinants and barriers for gestational diabetes mellitus (GDM) services, a systematic review. BMC Pregnancy and Childbirth 2014. Accessed November 3, 2014.

10 May AL, Kuklina EV, Yoon PW. Prevalence of cardiovascular disease risk factors among US adolescents, 1999-2008. Pediatrics. 2012 Jun;129(6):1035-41.