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Draft Recommendation Statement

Prediabetes and Type 2 Diabetes in Children and Adolescents: Screening

December 14, 2021

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.

Recommendation Summary

Population Recommendation Grade
Asymptomatic children and adolescents younger than age 18 years The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in children and adolescents. See the "Practice Considerations" section for additional information regarding the I statement. I

Additional Information

Tools
Related Resources
  • Screening for Prediabetes and Type 2 Diabetes in Children and Adolescents (Consumer Guide): Draft Recommendation | Link to File

Full Recommendation:

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.

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The Centers for Disease Control and Prevention estimate that as of 2018, 210,000 children and adolescents younger than age 20 years (or 25 per 10,000 U.S. youths) have diabetes, of which approximately 23,000 have type 2 diabetes.1 Youth with type 2 diabetes have an increased prevalence of associated chronic comorbid conditions, including hypertension, dyslipidemia, and nonalcoholic fatty liver disease. Data indicate that the incidence of type 2 diabetes is rising; from 2002–2003 to 2014–2015, incidence has increased from 9.0 cases per 100,000 children and adolescents to 13.8 cases per 100,000 children and adolescents.2 Most of the increase in the incidence rate is in non-White and non-Asian children and adolescents.3 Approximately 1 in 5 adolescents ages 12 to 18 years had prediabetes during 2005 to 2016.4

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The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in children and adolescents. There is a lack of evidence on the effect of screening and early detection and treatment of type 2 diabetes on health outcomes in youth, and the balance of benefits and harms cannot be determined.

See 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.5

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Patient Population Under Consideration

This recommendation applies to children and adolescents younger than age 18 years without known diabetes or prediabetes or symptoms of diabetes or prediabetes.

Definitions of Prediabetes and Type 2 Diabetes

Diabetes refers to a range of metabolic disorders characterized by hyperglycemia. Type 2 diabetes is characterized by insulin resistance and progressive loss of β-cell insulin secretion. In contrast, type 1 diabetes is the result of autoimmune β-cell destruction, usually leading to absolute insulin deficiency. Prediabetes is the term used for individuals whose blood glucose levels (measured by plasma glucose level or glycated hemoglobin level [HbA1c]) are considered higher than normal but do not meet criteria for diabetes.

A fasting plasma glucose level of 126 mg/dL (7.0 mmol/L) or greater, an HbA1c level of 6.5% or greater, or a 2-hour postload glucose level of 200 mg/dL (11.1 mmol/L) or greater are consistent with the diagnosis of type 2 diabetes. A fasting plasma glucose level of 100 to 125 mg/dL (5.6 to 6.9 mmol/L), an HbA1c level of 5.7% to 6.4%, or a 2-hour postload glucose level of 140 to 199 mg/dL (7.8 to 11.0 mmol/L) are consistent with prediabetes.6 The diagnosis of prediabetes or type 2 diabetes should be confirmed with repeat testing before starting interventions.6

Screening Tests

Although there is insufficient evidence to recommend for or against screening, prediabetes and type 2 diabetes can be detected by measuring fasting plasma glucose or HbA1c level, or with an oral glucose tolerance test. HbA1c is a measure of long-term blood glucose concentration and is not affected by acute changes in glucose levels. The oral glucose tolerance test is performed in the morning in a fasting state, with blood glucose concentration measured 2 hours after ingestion of a 75-g oral glucose load.

Treatment and Preventive Interventions

Lifestyle interventions to achieve weight loss, improve diet, and increase physical activity are often recommended for youth diagnosed with prediabetes and diabetes. The Centers for Disease Control and Prevention recommend programs that increase exercise and improve nutrition;7,8 these programs include extensive education on promoting self-management skills and establishing individualized plans for self-monitoring of glycemic targets. Formal programs to improve diet and increase exercise are often paired with pharmacotherapy.9,10 The U.S. Food and Drug Administration has approved three drugs for treatment of type 2 diabetes in children: metformin, insulin, and liraglutide. While metformin has demonstrated improvements in body mass index (BMI), fasting glucose level, and insulin resistance, it is not approved by the U.S. Food and Drug Administration to prevent the progression of prediabetes to diabetes.11

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Diabetes (both type 1 and type 2) is the third most common chronic disease in childhood.12 Many of the diabetes complications experienced by adults (such as kidney failure, non-injury–related lower-limb amputations, and blindness) begin in childhood, and more children and adolescents with type 2 diabetes have these complications than those with type 1 diabetes.13

Compared with non-Hispanic White youth, the type 2 diabetes rate in Native American/American Indian, Black, and Hispanic youth has been shown to be 8, 5, and 4 times higher, respectively.14 Causes of these differences are not well understood, but structural factors that disproportionately affect non-White populations may contribute significantly to differences by race and ethnicity, as well as cultural and environmental influences and quality of and access to healthcare.15

Obesity and excess adipose tissue, especially when centrally distributed, are the most important risk factors for type 2 diabetes in younger persons.15-17 Family history is also a strong risk factor.15,18-21 Risk assessment tools are also available to help identify children and adolescents at increased risk for prediabetes and type 2 diabetes.22,23

Type 2 diabetes is much more common in older than younger children, often presenting at the onset of puberty.24 This timing is likely related to physiologic, but transient, pubertal insulin resistance that can be exacerbated by metabolic challenges related to obesity.15,25,26 Twenty two percent to 52% of children and adolescents with prediabetes return to normal glycemia or normal glucose tolerance without intervention over 6 months to 2 years.3

Potential Harms

Because some youth with prediabetes may revert to normal glycemia without intervention, potential harms of screening include labeling, overdiagnosis, and overtreatment. Potential harms caused by treatment of type 2 diabetes include hypoglycemia and gastrointestinal issues (e.g., nausea or vomiting) related to medication use.

Other Related USPSTF Recommendations

The USPSTF has other recommendations on screening for obesity in children and adolescents (B recommendation) and screening for prediabetes and type 2 diabetes in adults (B recommendation).27,28

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Scope of Review

The USPSTF commissioned a systematic review of the evidence on screening for prediabetes and type 2 diabetes in asymptomatic, nonpregnant persons younger than age 18 years.3 This review focused on evidence on the benefits and harms of screening for prediabetes and type 2 diabetes and the benefits and harms of interventions for screen-detected prediabetes and type 2 diabetes or recently diagnosed type 2 diabetes. The USPSTF focused on effects of screening and interventions on health outcomes, including mortality, cardiovascular morbidity, chronic kidney disease, amputation, skin ulcers, visual impairment, neuropathy, and quality of life. 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

The USPSTF found no studies addressing the direct benefits of screening for type 2 diabetes and prediabetes on health outcomes in asymptomatic children and adolescents.

Two randomized, controlled trials examined the benefits of interventions for screen-detected or recently diagnosed type 2 diabetes and prediabetes on health outcomes. The first and larger study was the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study (n=699), which randomly assigned adolescents with obesity (BMI ≥85th percentile for age and sex) and recently diagnosed type 2 diabetes to metformin monotherapy, metformin plus rosiglitazone, or metformin plus a lifestyle intervention.3,10 No statistically significant differences were found in rates of diabetic ketoacidosis or renal impairment. However, studies were underpowered to detect differences in these health outcomes.3 The second study was a 16-week trial that compared metformin and placebo in 82 treatment-naïve adolescents ages 10 to 16 years with previous or newly diagnosed type 2 diabetes.29 It reported that zero participants in the metformin group developed diabetic ketoacidosis and one person in the control group developed diabetic ketoacidosis; however, this study was also underpowered for this outcome and this was also not the primary outcome for the study. Neither trial reported on other health outcomes.3

One fair-quality randomized, controlled trial examined the benefits of interventions to prevent progression to type 2 diabetes. The study (n=75) compared a lifestyle modification program focused on both diet/nutrition and physical activity with standard care for adolescents ages 10 to 16 years with obesity (BMI >95th percentile) and prediabetes.30 The trial reported that no participants developed diabetes during the 6-month trial; however, the overall attrition rate was high (23%), and some participants were withdrawn from the study because they started taking metformin.30

Harms of Screening and Treatment

The USPSTF found no studies addressing the harms of screening for type 2 diabetes and prediabetes in asymptomatic children and adolescents.

Two previously mentioned intervention trials (n=781) reported on harms associated with treatment of youth recently diagnosed with type 2 diabetes. The TODAY study reported that 4 youths had severe hypoglycemia. It also reported that more youths had repeated mild hypoglycemia in the group that received metformin plus rosiglitazone (n=10 [4.3%] for metformin monotherapy vs. n=19 [8.2%] for metformin plus rosiglitazone vs. n=8 [3.4%] for metformin plus lifestyle; p=0.05). The 16-week trial comparing metformin monotherapy with placebo reported zero hypoglycemic events requiring medical attention in either study group.29

Gastrointestinal events were common in both studies. In the TODAY study, lower rates of gastrointestinal symptoms were reported in the metformin plus rosiglitazone group than in the metformin monotherapy or metformin plus lifestyle intervention groups. The 16-week trial reported that more youths treated with metformin than with placebo had abdominal pain (25% vs. 12%) and nausea or vomiting (17% vs. 10%).29 Other adverse events were reported in both studies; however, events were varied, and most found no difference between groups or reported that events were not attributed to study interventions.3

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More studies are needed that address the following areas:

  • The effects of screening on health outcomes in child and adolescent populations reflective of the prevalence of diabetes in the United States, particularly racial and ethnic groups that have a higher prevalence of diabetes than White persons.
  • The effects of lifestyle interventions, pharmacotherapy, or both for treatment of screen-detected prediabetes and diabetes on health outcomes in children and adolescents, particularly in racial and ethnic groups that have a higher prevalence of diabetes than White persons.
  • Trials (both screening and intervention) focusing on health outcomes such as mortality, cardiovascular morbidity, chronic kidney disease, amputation, visual impairment, neuropathy, and quality of life that are of sufficient duration and sample size.
  • The natural history of prediabetes, including the identification of factors associated with risk of progression to diabetes or reversion to normoglycemia.
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The American Diabetes Association recommends risk-based screening for type 2 diabetes in children after onset of puberty or age 10 years who have overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) and one or more additional risk factors for diabetes.9 In children who are deemed at high risk, it recommends screening every 3 years if tests are normal or more frequently if BMI increases.

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1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. https://www.cdc.gov/diabetes/data/statistics-report/index.html. Accessed November 2, 2021.
2. Divers J, Mayer-Davis EJ, Lawrence JM, et al. Trends in incidence of type 1 and type 2 diabetes among youths - selected counties and Indian reservations, United States, 2002-2015. MMWR Morb Mortal Wkly Rep. 2020;69(6):161-165.
3. Jonas D, Vander Schaff E, Riley S. Screening for Prediabetes and Type 2 Diabetes Mellitus in Children and Adolescents: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 216. AHRQ Publication No. 21-05288-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2021.
4. Andes LJ, Cheng YJ, Rolka DB, Gregg EW, Imperatore G. Prevalence of prediabetes among adolescents and young adults in the United States, 2005-2016. JAMA Pediatr. 2020;174(2):e194498.
5. U.S. Preventive Services Task Force. Procedure Manual. https://uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual. Accessed November 2, 2021.
6. American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2020. Diabetes Care. 2020;43(Suppl 1):S14-S31.
7. Centers for Disease Control and Prevention. Prevent Type 2 Diabetes in Kids. https://www.cdc.gov/diabetes/prevent-type-2/type-2-kids.html. Accessed November 2, 2021
8. National Collaborating Centre for Women's and Children's Health. Diabetes (Type 1 and Type 2) in Children and Young People: Diagnosis and Management. NICE Guideline No. 18. London: National Institute for Health and Care Excellence; 2015.
9. American Diabetes Association. 13. Children and adolescents: standards of medical care in diabetes-2020. Diabetes Care. 2020;43(Suppl 1):S163-S182.
10. Zeitler P, Hirst K, Pyle L, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med. 2012;366(24):2247-2256.
11. American Diabetes Association. 3. Prevention or delay of type 2 diabetes: standards of medical care in diabetes-2020. Diabetes Care. 2020;43(Suppl 1):S32-S36.
12. Allen PJ, Vessey JA. Primary Care of the Child With a Chronic Condition. 4th ed. Maryland Heights, MO: Mosby-Yearbook; 2004.
13. Centers for Disease Control and Prevention. National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2011.
14. Dabelea D, Mayer-Davis EJ, Saydah S, et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014;311(17):1778-86.
15. Arslanian S, Bacha F, Grey M, Marcus MD, White NH, Zeitler P. Evaluation and management of youth-onset type 2 diabetes: a position statement by the American Diabetes Association. Diabetes Care. 2018;41(12):2648-2668.
16. Awa WL, Fach E, Krakow D, et al. Type 2 diabetes from pediatric to geriatric age: analysis of gender and obesity among 120,183 patients from the German/Austrian DPV database. Eur J Endocrinol. 2012;167(2):245-254.
17. Liu LL, Lawrence JM, Davis C, et al. Prevalence of overweight and obesity in youth with diabetes in USA: the SEARCH for Diabetes in Youth study. Pediatr Diabetes. 2010;11(1):4-11.
18. Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics. 2013;131(2):364-382.
19. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000;136(5):664-672.
20. Pinhas-Hamiel O, Zeitler P. The global spread of type 2 diabetes mellitus in children and adolescents. J Pediatr. 2005;146(5):693-700.
21. Dabelea DH, Hamman RF, Knowler WC. Chapter 15. Diabetes in youth. In: Diabetes in America. 3rd ed. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases; 2018.
22. Hannon TS, Dugan TM, Saha CK, McKee SJ, Downs SM, Carroll AE. Effectiveness of computer automation for the diagnosis and management of childhood type 2 diabetes: a randomized clinical trial. JAMA Pediatr. 2017;171(4):327-334.
23. DuBose KD, Cummings DM, Imai S, Lazorick S, Collier DN. Development and validation of a tool for assessing glucose impairment in adolescents. Prev Chronic Dis. 2012;9:E104.
24. Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr. 1996;128(5 Pt 1):608-615.
25. Ball GD, Huang TT, Gower BA, et al. Longitudinal changes in insulin sensitivity, insulin secretion, and beta-cell function during puberty. J Pediatr. 2006;148(1):16-22.
26. Amiel SA, Sherwin RS, Simonson DC, Lauritano AA, Tamborlane WV. Impaired insulin action in puberty: a contributing factor to poor glycemic control in adolescents with diabetes. N Engl J Med. 1986;315(4):215-219.
27. US Preventive Services Task Force. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2017;317(23):2417-2426.
28. US Preventive Services Task Force. Screening for prediabetes and type 2 diabetes: US Preventive Services Task Force recommendation statement. JAMA. 2021;326(8):736-743.
29. Jones KL, Arslanian S, Peterokova VA, Park JS, Tomlinson MJ. Effect of metformin in pediatric patients with type 2 diabetes: a randomized controlled trial. Diabetes Care. 2002;25(1):89-94.
30. Savoye M, Caprio S, Dziura J, et al. Reversal of early abnormalities in glucose metabolism in obese youth: results of an intensive lifestyle randomized controlled trial. Diabetes Care. 2014;37(2):317-324.

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Rationale Assessment
Benefits of Early Detection and Intervention and Treatment
  • Inadequate evidence, due to a lack of studies, that screening for type 2 diabetes and prediabetes in asymptomatic children and adolescents improves health outcomes.
  • Inadequate evidence that interventions for screen-detected type 2 diabetes and prediabetes improve health outcomes. Few trials reported on the effect of treatment on health outcomes; all studies were underpowered for included health outcomes.
  • Inadequate evidence that interventions for prediabetes delay or prevent progression to type 2 diabetes. Limited evidence is available from a single, small trial.
Harms of Early Detection and Intervention and Treatment
  • Inadequate evidence, due to a lack of studies, to determine the harms of screening for type 2 diabetes and prediabetes in asymptomatic children and adolescents.
  • Inadequate evidence to determine the harms of interventions for prediabetes, screen-detected type 2 diabetes, or recently diagnosed type 2 diabetes. Limited evidence from two trials is available.
USPSTF Assessment The evidence on screening for type 2 diabetes is lacking, and the balance of benefits and harms cannot be determined.
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