Certain racial and ethnic groups should be screened earlier for diabetes

OWell-used medical guidelines that ignore the race and ethnicity of patients could do more harm than good when it comes to catching diabetes in people of color. New searchpublished Monday in the Annals of Internal Medicine, suggests that people from certain racial and ethnic groups should be screened for diabetes at a lower body mass index than non-Hispanic whites — a recommendation that contradicts recent guidelines of the United States Preventive Services Task Force.

It’s an admittedly tricky proposition, to reaffirm the role of race and ethnicity at a time when medicine is trying to shed race-based tools – like an algorithm used to assess kidney function – that have helped to the vast health disparities in the United States. The authors of the article acknowledged this in interviews with STAT.

They argue, however, that using a one-size-fits-all approach to screening, when diabetes is two to four times more prevalent and more deadly among blacks, Hispanics and Asian Americans, is likely to lead to under-diagnosis of the disease, and widening health gaps.

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The current guidelines, released by the task force last year, recommend doctors screen adults aged 35 to 70, with a BMI of 25 or more, for prediabetes and type 2 diabetes. But the data analyzed by the authors of the paper show that certain racial and ethnic groups would need to be screened at lower BMIs to detect diabetes at the same rates as whites – a BMI of 18.5 for Black Americans and Hispanic Americans and 20 for Asian Americans.

“That’s the case we’re making: that if you’re looking for a test that’s equally sensitive in all subgroups, then you take the lowest risk subgroup…which is white Americans, then you use it. as a threshold, and then adjust it for everyone,” said Dhruv Kazi, lead author of the paper. “It’s actually possible that people from racial and ethnic minorities need an even more sensitive threshold.”

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In other words, even at “normal weight”, non-white people are several times more likely to have diabetes than white people, which calls into question BMI as an effective way to determine the risk of developing diabetes. in patients.

“I feel comfortable saying that while we are moving away from race-based equations that have done more harm than good, we should embrace risk-based equations, even though much of that risk comes with race,” Kazi said. “There’s no way to get fair diabetes screening if we ignore this risk gradient.”

Neil Powe, chief of medicine at Zuckerberg San Francisco General Hospital, and one of the people who led the effort to change the kidney disease equation, said a ‘unified threshold’ for diabetes would be desirable. , one “that is not standardized to one race and does not disadvantage one group more than another. Clinicians should also consider factors other than race, age, and BMI, such as family history, history of gestational diabetes, and sedentary lifestyle.

Lead author Rahul Aggarwal became interested in the issue of racial and ethnic differences in diabetes risk after his mother was diagnosed with the disease while Aggarwal was in medical school at Boston University.

Neeru Aggarwal was a healthy young woman with an average BMI and a regular exercise routine. The diagnosis shocked his family, causing his son to wonder if there was any science behind the high rates of diabetes, or “high sugar,” he’s seen anecdotally in his family members and his community. He remembers how, at gatherings, relatives had to watch the amount of carbohydrates they ate or refuse desserts – all painful restrictions when faced with appetizing plates of Indian food.

“We often think of diabetes as purely a lifestyle disease, that people get it because they have a bad diet, don’t exercise enough,” said Aggarwal, resident physician at Beth Israel. Deaconess Medical Center. “But in reality, it’s a multifactorial process.”

Kazi, also Native American and an associate professor at Harvard Medical School, went through something similar when his parents were diagnosed with diabetes in their 30s and 40s, despite being thin.

Kazi and Aggarwal claim that their article is not intended to offer a perfect solution to a complex problem. “We’re making more of a comparative argument between different racial/ethnic groups, but we’re not actually saying that’s the exact threshold for testing. And that’s something that’s an important area of ​​future work,” Aggarwal said.

BMI and broad race and ethnicity labels are often crude measures of risk, used as proxies for other things, but they are available tools, and the issues of continuing to underdiagnose diabetes are huge. Diabetes can lead to heart attack, vision problems, dialysis, and a number of other health issues and complications. But early intervention can significantly reduce the risk of complications and death. The researchers hoped to offer interim advice that doctors and patients could adopt immediately, while researchers work on a more sophisticated risk calculation.

“The damage is quite catastrophic,” Aggarwal said. “So identifying diabetes appropriately and early can actually have a substantial impact on patient morbidity and mortality.”

For Licy Yanes Cardozo, a physician-scientist at the University of Mississippi Medical Center and a practicing endocrinologist, the findings of this article reinforce the data physicians already have about unequal health outcomes and serve as a call to action. . Physicians can modify their screening practices immediately, using formal guidelines as a starting point, but using their judgment based on the patient. “It really puts the power back into the doctors,” she said. “Using the same rule for every patient was never a good idea in medicine.”

Cardozo, co-author of an article on eliminating racism in endocrinology, wants to see official USPSTF guidelines changed to allow for greater flexibility in diabetes screening practices. Only when these physician guidelines change will Medicare and insurers be required to cover early detection of diabetes at a lower BMI.

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