Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
According to the Centers for Disease Control and Prevention’s (CDC’s) 2020 National Diabetes Statistics Report, an estimated 13% of all U.S. adults (age ≥18 years) have diabetes, and 34.5% meet criteria for prediabetes.1 The prevalence of prediabetes and diabetes are higher in older adults. Of those with diabetes, 21.4% were not aware of or did not report having diabetes, and only 15.3% of persons with prediabetes reported being told by a health professional that they had this condition.1 Estimates of the risk of progression from prediabetes to diabetes vary widely, perhaps because of differences in the definition of prediabetes or the heterogeneity of prediabetes itself.2 A large cohort study of persons with prediabetes reported that the risk of developing diabetes increased with increasing A1c level and with increasing body mass index (BMI).3
Diabetes is the leading cause of kidney failure and new cases of blindness among adults in the United States. It was estimated to be the seventh leading cause of death in the United States in 2017.1 Screening asymptomatic adults for prediabetes and type 2 diabetes may allow earlier detection, diagnosis, and treatment, with the ultimate goal of improving health outcomes.
The USPSTF concludes with moderate certainty that screening for prediabetes and type 2 diabetes and offering or referring patients with prediabetes to effective preventive interventions has a moderate net benefit (Table).
Refer to the Table for more information on the USPSTF recommendation rationale and assessment. For more details on the methods the USPSTF uses to determine the net benefit, see the USPSTF Procedure Manual.4
Patient Population Under Consideration
This recommendation applies to nonpregnant adults ages 35 to 70 years seen in primary care settings who do not have symptoms of diabetes and are overweight or obese.
Assessment of Risk
Several factors are associated with the risk of developing prediabetes and type 2 diabetes in adults, including overweight and obesity, older age, family history, history of gestational diabetes, history of polycystic ovarian syndrome, and dietary and lifestyle factors.5,6 The prevalence of diabetes is higher among American Indian/Alaska Native (14.7%), non-Hispanic Black (11.7%), and Latinx/Hispanic persons (12.5%) than among non-Hispanic White (7.5%) and Asian persons (9.2%).1 Clinicians should consider screening at an earlier age and lower BMI in persons who are members of certain racial/ethnic groups (Black/African American, American Indian/Alaskan Native, Asian American, Hispanic/Latino, or Native Hawaiian/Pacific Islander persons), or who have a family history of diabetes, a history of gestational diabetes, or a history of polycystic ovarian syndrome.
Prediabetes and type 2 diabetes can be detected by measuring fasting plasma glucose level, hemoglobin A1c (HbA1c) level, or with an oral glucose tolerance test. A fasting plasma glucose level of 126 mg/dL or greater, an HbA1c level of 6.5% or greater, or a 2-hour postload glucose level of 200 mg/dL or greater are consistent with the diagnosis of type 2 diabetes. A fasting plasma glucose level of 100 to 125 mg/dL, an HbA1c level of 5.7% to 6.4%, or a 2-hour postload glucose level of 140 to 199 mg/dL are consistent with prediabetes.7
HbA1c is a measure of long-term blood glucose concentration and is not affected by acute changes in glucose levels due to stress or illness. Because HbA1c measurements do not require fasting, they are more convenient than using a fasting plasma glucose level or an oral glucose tolerance test. Both fasting plasma glucose and HbA1c levels are simpler to measure than performing an oral glucose tolerance test. The oral glucose tolerance test is done in the morning in a fasting state; blood glucose concentration is measured 2 hours after ingestion of a 75-g oral glucose load. The diagnosis of prediabetes or type 2 diabetes should be confirmed with repeat testing before starting interventions.7
Evidence on the optimal screening interval for adults with an initial normal glucose test result is limited. Cohort and modeling studies suggest that screening every 3 years may be a reasonable approach for adults with normal blood glucose levels.8-10
Both lifestyle interventions that focus on diet, physical activity, or both and metformin have demonstrated efficacy in preventing or delaying progression to diabetes in persons with prediabetes.2 However, metformin has not been approved for this specific indication by the U.S. Food and Drug Administration.
There are several other factors that clinicians and patients may want to consider as they discuss preventive interventions for prediabetes. In addition to preventing progression to diabetes, lifestyle interventions have a beneficial effect on weight, blood pressure, and lipid levels (increasing high-density lipoprotein cholesterol and lowering triglycerides). Metformin has a beneficial effect on weight, but it does not appear to affect blood pressure, or to consistently improve lipid levels.2 In the Diabetes Prevention Program (DPP) (which serves as a model for many lifestyle intervention programs in the United States), lifestyle intervention was more effective than metformin in preventing or delaying diabetes. In secondary analyses of the DPP, lifestyle intervention was effective in all subgroups, while metformin was less effective (or not effective) in older persons (age ≥60 years), persons with lower BMI (<35 kg/m2), and persons with a lower baseline fasting plasma glucose level (95 to 109 mg/dL).11
Additional Tools and Resources
The CDC has several resources related to the diagnosis, prevention, and treatment of prediabetes and type 2 diabetes at https://www.cdc.gov/diabetes/index.html.
The National Institutes of Health has several resources related to screening, diagnosis, prevention, and management of prediabetes and type 2 diabetes at https://www.niddk.nih.gov/health-information/professionals/clinical-tools-patient-management/diabetes.
The Community Preventive Services Task Force recommends diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk, available at https://www.thecommunityguide.org/findings/diabetes-combined-diet-and-physical-activity-promotion-programs-prevent-type-2-diabetes.
Other Related USPSTF Recommendations
The USPSTF recommends offering or referring adults with a BMI of 30 kg/m2 or greater to intensive, multicomponent behavioral interventions.12 The USPSTF recommends offering or referring adults who are overweight (BMI >25 kg/m2) and have additional cardiovascular risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity to prevent cardiovascular disease (CVD).13
When final, this recommendation will replace the 2015 USPSTF recommendation statement on screening for abnormal blood glucose and type 2 diabetes mellitus in asymptomatic adults. In 2015, the USPSTF recommended screening for abnormal blood glucose as part of cardiovascular risk assessment in adults ages 40 to 70 years who are overweight or obese. The USPSTF also recommended that clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity.14 For the current draft recommendation statement, the USPSTF recommends screening for prediabetes and type 2 diabetes in adults ages 35 to 70 years who are overweight or obese, and that clinicians should offer or refer patients with prediabetes to effective preventive interventions. Based on epidemiologic evidence, the USPSTF has decreased the age at which to begin screening to 35 years.15
Scope of Review
To update its 2015 recommendation statement, the USPSTF commissioned a systematic review2 of the evidence on screening for prediabetes and type 2 diabetes in asymptomatic nonpregnant adults and preventive interventions for those with prediabetes. This review focused on direct evidence on the benefits and harms of screening for prediabetes and type 2 diabetes and the benefits and harms of interventions (such as behavioral counseling focused on diet, physical activity, or both, or pharmacotherapy for glycemic, blood pressure, or lipid control, compared with no treatment or usual care) for screen-detected prediabetes and type 2 diabetes or recently diagnosed type 2 diabetes. The review also looked at the evidence on the effectiveness of interventions for prediabetes to delay or prevent progression to type 2 diabetes.
Benefits of Early Detection and Treatment
Screening for Diabetes
The USPSTF found two randomized clinical trials (RCTs), the Anglo-Danish-Dutch Study of Intensive Treatment In People with Screen Detected Diabetes in Primary Care (ADDITION)-Cambridge (n=20,184 participants)16,17,18 and the Ely study (n=4,936 participants),19-21 that evaluated the effect of screening for diabetes on health outcomes. ADDITION-Cambridge was a cluster randomized trial that randomized practices to no screening, screening followed by intensive treatment of screen-detected diabetes (HbA1c target <7.0%, blood pressure target ≤135/85 mm Hg, and cholesterol targets, and low-dose aspirin use unless contraindicated), or screening followed by routine care of screen-detected diabetes. In the Ely study, persons with screen-detected diabetes were managed by primary care providers as they deemed appropriate. Neither trial found a reduction in all-cause or type-specific mortality with screening compared with no screening over about 10 years of followup, which notably may have been too short to detect an effect on health outcomes. Neither trial found statistically significant differences in cardiovascular events, quality of life, nephropathy, or neuropathy between screening and control groups, but data collection was limited to a minority of trial participants for these outcomes.
Interventions for Screen-Detected Type 2 Diabetes or Prediabetes
One RCT (ADDITION-Europe)22-25 evaluated interventions for persons with screen-detected type 2 diabetes. It found no difference over 5 to 10 years of followup between an intensive multifactorial intervention aimed at controlling glucose, blood pressure, and cholesterol and routine care in the risk of all-cause mortality, cardiovascular-related mortality, occurrence of a first cardiovascular event, chronic kidney disease, visual impairment, or neuropathy.
Thirty-eight trials assessing behavioral or pharmacologic interventions for prediabetes reported on health outcomes.2 Overall, trials found no differences in all-cause mortality, CVD events, or quality of life scores, or only small improvements in scores that are not likely clinically significant. Followup duration in most of these trials may have been too short to detect an effect on health outcomes. One trial, the Da Qing Diabetes Prevention Study, found lower all-cause mortality (28.1% vs. 38.4%; hazard ratio [HR], 0.71 [95% CI, 0.51 to 0.99] and 45.7% vs. 56.3%; HR, 0.74 [95% CI, 0.61 to 0.89]) and CVD-related mortality (11.9% vs. 19.6%; HR, 0.59 [95% CI, 0.36 to 0.96] and 29.6% vs. 22.0%; HR, 0.67 [95% CI, 0.48 to 0.94]) for a 6-year combined lifestyle intervention group compared with a control group at 23 and 30 years, respectively, but not at earlier followup.26,27 However, this trial is limited by baseline differences between intervention and control groups that are likely to bias results in favor of the intervention.
Interventions for Newly or Recently Diagnosed Type 2 Diabetes
The U.K. Prospective Diabetes Study (UKPDS) and two other studies reported the effect of interventions for newly diagnosed diabetes on health outcomes. The UKPDS found that all-cause mortality, diabetes-related mortality, and myocardial infarction were improved with intensive glucose control with sulfonylureas or insulin over 20 years (10-year posttrial assessment) but not at shorter followup. Intensive glucose control was associated with a decreased risk for all-cause mortality (relative risk [RR], 0.87 [95% CI, 0.79 to 0.96]), diabetes-related mortality (RR, 0.83 [95% CI, 0.73 to 0.96]), and myocardial infarction (RR, 0.85 [95% CI, 0.74 to 0.97]) over 20 years.28,29 For overweight persons, intensive glucose control with metformin decreased all-cause mortality (RR, 0.64 [95% CI, 0.45 to 0.91]), diabetes-related mortality (RR, 0.58 [95% CI, 0.37 to 0.91]), and myocardial infarction (RR, 0.61 [95% CI, 0.41to 0.89]) at the 10-year followup, and benefits were maintained in the long term.29,30
The other two studies found no difference between intervention and control groups in all-cause mortality and risk of myocardial infarction; however, these studies were limited by short duration of followup, small study size, or both. The Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) trial31,32 found no statistically significant difference in all-cause mortality between those randomized to group education and those randomized to the control group over 1 and 3 years of followup. Another trial (n=150)33 found no statistically significant difference in myocardial infarction over 7 years of followup.
Effects of Interventions for Prediabetes on Progression to Diabetes
Twenty-three trials compared lifestyle interventions with a control group for delaying or preventing the onset of type 2 diabetes.2 In most trials (18 trials), the lifestyle interventions focused on both diet/nutrition and physical activity, and most (18 trials) delivered high-contact lifestyle interventions, defined as intervention contact time of more than 360 minutes. Meta-analysis of the 23 trials found that lifestyle interventions were associated with a reduction in progression to diabetes (pooled RR, 0.78 [95% CI, 0.69 to 0.88]; 12,915 participants). In post hoc analyses, the DPP reported that lifestyle intervention was effective in all subgroups and treatment effects did not differ by age, sex, race or ethnicity, or BMI after 3 years of followup.11
Several trials also reported the effects of lifestyle interventions on intermediate outcomes. In pooled analyses, lifestyle interventions were associated with a reduction in weight and BMI (pooled weighted mean difference [WMD], -1.2 kg [95% CI, -1.6 to -0.7 kg] and pooled WMD, -0.54 kg/m2 [95% CI, -0.76 to -0.33 kg/m2], respectively). In addition, lifestyle interventions were associated with a reduction in both systolic and diastolic blood pressure (pooled WMD, -1.7 mm Hg [95% CI, -2.6 to -0.8 mm Hg] and pooled WMD, -1.2 mm Hg [95% CI, -2.0 to ‑0.4 mm Hg], respectively), and high-contact lifestyle interventions were associated with reduced triglycerides and increased high-density lipoprotein cholesterol.2
Fifteen trials evaluated pharmacologic interventions to delay or prevent diabetes.2 For metformin, meta-analysis of three trials found that it was associated with a reduction in the incidence of diabetes (pooled RR, 0.73 [95% CI, 0.64 to 0.83]).2 In post hoc analyses, the DPP reported that the effect of metformin compared with placebo was not statistically significantly different after 3 years of followup for subgroups defined by age, sex, or race or ethnicity. The analysis did report a statistically significant effect modification by BMI, with greater effect on diabetes incidence for persons with a higher BMI (e.g., reduction in diabetes incidence, 53% [95% CI, 36% to 65%] for BMI ≥35 kg/m2 vs. 3% [95% CI, -36% to 30%] for BMI of 22 to <30 kg/m2). For both thiazolidinediones and alpha glucosidase inhibitors, meta-analysis of three trials each found associations with a reduction in the incidence of diabetes, but the results were limited by imprecision and inconsistency across trials.2 Other pharmacologic interventions seeking to delay or prevent diabetes have been studied, but only in one study each.2
Two trials reported the effects of metformin on intermediate outcomes. DPP (n=2,155) reported greater decreases in weight for persons receiving metformin compared with those receiving placebo (-2.0 kg [95% CI, -3.2 to -0.8 kg]).11 The PREVENT-DM trial of metformin also found that participants in the intervention group had greater decreases in weight and BMI, but the differences were not statistically significant.34 Both trials reported no significant difference in blood pressure among persons receiving metformin compared with placebo.33,34 DPP reported a greater increase in high-density lipoprotein for persons receiving metformin compared with those receiving placebo after 3 years (difference between groups, 0.40 [95% CI, 0.15 to 0.65]) but no difference between groups for other lipids,35 whereas the PREVENT-DM study (n=92) found no statistically significant difference in lipid levels between metformin and control groups at 1 year.34
Harms of Screening and Treatment
Some of the trials reporting on the benefits of screening and interventions for prediabetes and type 2 diabetes also reported harms. Overall, the ADDITION-Cambridge and Ely trials, and a pilot study of ADDITION-Cambridge,20,21,36-38 did not find clinically significant differences between screening and control groups in measures of anxiety, depression, worry, or self-reported health. However, the results suggest possible short-term increases in anxiety (at 6 weeks) among persons screened and diagnosed with diabetes compared with those screened and not diagnosed with diabetes.
Harms of interventions for screen-detected or recently diagnosed type 2 diabetes were sparsely reported and when reported, rare and not significantly different between intervention and control groups across trials.2 The UKPDS trial reported one patient out of 911 in the intervention group receiving insulin who died from hypoglycemia, and serious hypoglycemic events requiring medical attention in 1% (6/619) of participants receiving chlorpropamide, 1.5% (9/615) of participants receiving glibenclamide, 1.8% (16/911) of participants receiving insulin, and 0.7% (6/896) of participants in the conventional care group.28
Several trials reported on harms associated with interventions for prediabetes. Four studies of pharmacotherapy interventions reported on any hypoglycemia and found no difference between interventions and placebo over 8 weeks to 5 years. Three trials found higher rates of gastrointestinal adverse events associated with metformin. In studies of lifestyle interventions that reported on musculoskeletal events, one found no significant difference between groups for rates of joint sprains/strains or muscle or joint aches over 1 year, one found few cases of musculoskeletal problems (<1% per group), and one (DPP) found higher rates of musculoskeletal symptoms per 100 person-years in the intensive lifestyle intervention group than in the control group (24.1 vs. 21.1 events per 100 person-years; p<0.017).2
More research is needed to evaluate the following.
- More research is needed on the effects of screening among racial/ethnic groups (Black, Indigenous, Hispanic/Latinx and Asian populations) that have a higher prevalence of diabetes than White persons.
- Clinical trials and additional modeling studies are needed to better elucidate the optimal frequency of screening and the age at which to start screening.
- More U.S. data are needed on the effects of lifestyle interventions and medical treatments for screen-detected prediabetes and diabetes on health outcomes over a longer followup period, particularly in those populations at highest risk of diabetes.
- More research is needed on the natural history of prediabetes, including the identification of factors associated with risk of progression to diabetes or reversion to normoglycemia.
- More research is needed on how best to increase uptake of lifestyle interventions, especially among populations at highest risk for progression to diabetes and adverse health outcomes.
The American Diabetes Association39 recommends universal screening for prediabetes and diabetes, using a fasting plasma glucose level, 2-hour plasma glucose level during a 75-g oral glucose tolerance test, or HbA1c level, for all adults age 45 years or older, regardless of risk factors, and screening overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) adults with one or more risk factors, regardless of age. If the results are normal, it recommends repeat screening at a minimum of 3-year intervals. The American Association of Clinical Endocrinology40 recommends universal screening for prediabetes and diabetes for all adults age 45 years or older, regardless of risk factors, and screening persons with risk factors for diabetes (regardless of age). Testing for prediabetes and diabetes can be done using a fasting plasma glucose level, 2-hour plasma glucose level during a 75-g oral glucose tolerance test, or HbA1c level. It recommends repeat screening every 3 years.
Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed February 12, 2021.
Jonas D, Crotty K, Yun JD, et al. Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 207. AHRQ Publication No. 21-05276-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2021.
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Rubin KH, Glintborg D, Nybo M, et al. Development and risk factors of type 2 diabetes in a nationwide population of women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2017;102(10):3848-3857.
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Herman WH, Ye W, Griffin SJ, et al. Early detection and treatment of type 2 diabetes reduce cardiovascular morbidity and mortality: a simulation of the results of the Anglo-Danish-Dutch Study of Intensive Treatment in People With Screen-Detected Diabetes in Primary Care (ADDITION-Europe). Diabetes Care. 2015;38(8):1449-1455.
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Chung S, Azar KM, Baek M, et al. Reconsidering the age thresholds for type 2 diabetes screening in the U.S. Am J Prev Med. 2014;47(4):375-381.
Echouffo-Tcheugui JB, Simmons RK, Williams KM, et al. The ADDITION-Cambridge trial protocol: a cluster-randomised controlled trial of screening for type 2 diabetes and intensive treatment for screen-detected patients. BMC Public Health. 2009;9:136.
Simmons RK, Echouffo-Tcheugui JB, Sharp SJ, et al. Screening for type 2 diabetes and population mortality over 10 years (ADDITION-Cambridge): a cluster-randomised controlled trial. Lancet. 2012;380(9855):1741-1748.
Echouffo-Tcheugui J, Simmons R, Prevost A, et al. Long-term effect of population screening for diabetes on cardiovascular morbidity, self-rated health, and health behavior. Ann Fam Med. 2015;13(2):149-157.
Simmons RK, Rahman M, Jakes RW, et al. Effect of population screening for type 2 diabetes on mortality: long-term follow-up of the Ely cohort. Diabetologia. 2011;54(2):312-319.
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Griffin SJ, Rutten G, Khunti K, et al. Long-term effects of intensive multifactorial therapy in individuals with screen-detected type 2 diabetes in primary care: 10-year follow-up of the ADDITION-Europe cluster-randomised trial. Lancet Diabetes Endocrinol. 2019;7(12):925-37.
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|Benefits of detection and early intervention||
|Harms of early detection and intervention and treatment||The USPSTF found adequate evidence to bound the harms of screening for prediabetes and type 2 diabetes and treatment of screen-detected or recently diagnosed prediabetes and type 2 diabetes as no greater than small.|
|USPSTF assessment||The USPSTF concludes with moderate certainty that screening for prediabetes and type 2 diabetes and offering or referring patients with prediabetes to effective preventive interventions has a moderate net benefit.|
Abbreviations: CVD=cardiovascular disease; USPSTF=U.S. Preventive Services Task Force.