Case Study

A 12-year-old child, J.G., presents as a new patient to your clinic for a wellness visit. J.G. states that they have no current health concerns. J.G.'s parents report that J.G. has no significant medical history but that J.G. has gained 8.1 kg (18 lb) since their last wellness visit and lives a sedentary lifestyle. The parents also relay that there is a family history of type 2 diabetes mellitus in J.G.'s maternal and paternal grandparents. J.G.'s body mass index is 26 kg per m².

Case Study Questions

1. According to the U.S. Preventive Services Task Force (USPSTF) recommendation statement, is screening for prediabetes and type 2 diabetes recommended for this patient?

• A. Yes, there is high certainty that the net benefit of screening is substantial.

• B. No, there is high certainty that screening has no net benefit.

• C. Yes, there is high certainty that the net benefit of screening is moderate.

• D. No, there is high certainty that the harms of screening outweigh the benefits.

• E. The current evidence is insufficient to assess the balance of benefits and harms of screening.

2. Based on the available evidence reviewed by the USPSTF, which one of the following statements about prediabetes and type 2 diabetes in children and adolescents is not correct?

• A. Type 2 diabetes is now the most common form of diabetes in children and adolescents.

• B. The incidence of type 2 diabetes in children and adolescents is increasing.

• C. Prediabetes and type 2 diabetes can be detected in children and adolescents by measuring fasting plasma glucose or A1C levels or with an oral glucose tolerance test.

• D. The definition of prediabetes and diabetes is the same for children and adolescents as it is for adults.

• E. Children and adolescents with type 2 diabetes have an increased prevalence of associated chronic comorbid conditions, including hypertension, dyslipidemia, and nonalcoholic fatty liver disease.

3. According to the USPSTF recommendation statement, which of the following statements about screening for prediabetes and type 2 diabetes in children and adolescents are correct?

• A. Children and adolescents with prediabetes will not revert to normal glycemia without intervention.

• B. There are potential harms of screening for pre-diabetes, including labeling, overdiagnosis, and overtreatment.

• C. Lifestyle interventions to achieve weight loss, improve diet, and increase physical activity are often recommended for children and adolescents diagnosed with prediabetes and type 2 diabetes.

• D. The U.S. Food and Drug Administration has approved metformin to prevent the progression of prediabetes to diabetes in children and adolescents.

Answers

1. The correct answer is E. The USPSTF commissioned a review of the evidence on screening for prediabetes and type 2 diabetes in asymptomatic, nonpregnant people younger than 18 years (children and adolescents) without known prediabetes or diabetes.¹ The USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for prediabetes and type 2 diabetes in children and adolescents, giving this recommendation an I statement, which is neither a recommendation for nor against screening.² This assessment was based on a lack of evidence on the effect of early detection and treatment of prediabetes and type 2 diabetes on health outcomes in children and adolescents. Physicians should continue to use their clinical judgment to determine whether screening is appropriate for individual patients. This is a new recommendation; the USPSTF has not previously released a recommendation on this topic.

2. The correct answer is A. In 2018, about 210,000 children and adolescents younger than 20 years were diagnosed with diabetes, of whom 23,000 (approximately 11%) were diagnosed with type 2 diabetes.² Prediabetes and type 2 diabetes can be detected in children and adolescents by measuring fasting plasma glucose or A1C levels or with an oral glucose tolerance test. These are the same methods used to detect prediabetes and diabetes in adults, and the same diagnostic criteria are used for all ages. Many of the diabetes complications experienced by adults can begin in childhood.² Children and adolescents with type 2 diabetes have an increased prevalence of associated chronic comorbid conditions, including hypertension, dyslipidemia, and nonalcoholic fatty liver disease.²

3. The correct answers are B and C. There is a transient physiologic period of insulin resistance observed in adolescents going through puberty, which can be exacerbated by metabolic changes related to obesity. Some children and adolescents will revert from a prediabetic state back to normal glycemia without intervention, which can cause potential harms of screening, including labeling, overdiagnosis, and overtreatment. Lifestyle interventions to achieve weight loss, improve diet, and increase physical activity are often recommended for children and adolescents diagnosed with prediabetes and type 2 diabetes. Pharmacotherapy is often used in conjunction with lifestyle interventions in the treatment of type 2 diabetes. The U.S. Food and Drug Administration has approved metformin, insulin, and liraglutide (Saxenda) for the treatment of type 2 diabetes in children and adolescents. There currently is no U.S. Food and Drug Administration–approved drug to prevent the progression of prediabetes to diabetes in this population.¹

This PPIP quiz is based on the recommendations of the USPSTF. More information is available in the USPSTF Recommendation Statement and supporting documents on the USPSTF website (https://www.uspreventiveservicestaskforce.org). The practice recommendations in this activity are available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prediabetes-type2-diabetes-children-adolescents-screening.

The views expressed in this work are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the U.S. Department of Defense, or the U.S. government.