THE SCIENCE
OF HEALTH
Unequal
Diabetes Care
U.S. screening guidelines miss
too many people of color
By Claudia Wallis
Rahul Aggarwal was in medical school when he got the surpris-
ing news that his mother—a fit woman in her 40s—had been diag-
nosed with type 2 diabetes. “I always thought of diabetes as a dis-
ease of people at higher weights and with certain lifestyle
practices,” he recalls, “but my mom was an Indian American wom-
an with a healthy weight and good diet and exercise practices.”
Aggarwal, now a clinical fellow at Beth Israel Deaconess Medical
Center in Boston, began thinking about how diabetes seems to
disproportionately affect certain ethnic and racial groups. Those
musings were the seed of an eye-opening study published earlier
this year in the Annals of Internal Medicine. It quantified diabe-
tes risk in minority groups to determine if current screening rec-
ommendations are equitable. Spoiler alert: they are not.
The current standard was released in 2021 by the U.S. Preven-
tive Services Task Force (uspstf), which issues evidence-based
guidance on disease prevention. The recommendation is to test
adults aged 35 to 70 for diabetes if they are overweight or obese,
defined as having a body mass index (BMI) of 25 kg/m2 or more.
Aggarwal and his collaborators looked at the lowest-risk individ-
uals eligible for screening under that rubric: 35-year-olds who are
just barely overweight (with a BMI of 25). Within this cohort about
26 Scientific American, August 2022
Claudia Wallis is an award-winning science journalist
whose work has appeared in the New York Times, Time, Fortune
and the New Republic. S he was science editor at Time a nd
managing editor of S cientific American Mind.
1.4 percent of white Americans have blood glucose levels in the
diabetic range, so the researchers were shocked to find that the
rate was about double for Hispanics and even higher among Black
and Asian Americans. They concluded that to detect diabetes
equally across all these groups, you would need to test Asian Amer-
icans with a BMI of 20 and Black and Hispanic individuals with a
BMI of just 18.5—measures considered to be in the healthy range.
In a second analysis, the investigators looked at diabetes prev-
alence by age and concluded that to match the efficacy of screen-
ing white people at 35, providers would need to screen Hispanic
Americans at 25, Asian Americans at 23 and Black Americans at
21. Medicine has been eliminating race-based scoring that made
some tests, such as an assessment of kidney function, less sensi-
tive to disease in Black people. But in the case of diabetes screen-
ing, the one-size-fits-all standard may be the problem.
Because diabetes is a complex disease involving diet, life habits,
genetics and psychosocial factors, it’s not easy to say why vulnera-
bility would vary among demographic groups. There is some evi-
dence that Asian Americans have more abdominal fat at lower body
weights than do people of other ethnicities, which raises risk. “A lot
of studies suggest it’s better to measure the waist-hip ratio instead
of using BMI [to assess risk],” says Quyen Ngo-Metzger of the Kai-
ser Permanente Bernard J. Tyson School of Medicine. Chronic stress
has also been linked to diabetes risk, she says, and that could
include the stress of experiencing racism.
Ngo-Metzger, who was the uspstf’s scientific director from
2012 to 2019, notes that “most studies of diabetes were done in
middle-aged white individuals,” and that’s what screening stan-
dards were based on. She argues that they should be revised. “The
study found that you would miss so many Blacks, Hispanics and
Asians when you use these guidelines. I think it’s a disservice.”
The uspstf is unlikely, however, to revisit its guidelines soon,
usually waiting three to five years, says Michael J. Barry of Massa-
chusetts General Hospital, a task force vice chair. The uspstf is
committed to health equity, he says, but it needs more evidence
that altering its recommendations would result in better long-term
outcomes for patients—an issue the new study does not address.
Still, it seems obvious that detecting—and treating—diabetes
earlier in communities where it is often missed would lead to
improved health. Harvard University cardiologist Dhruv Kazi,
senior author on the A  nnals s tudy, points out that diabetes takes
an outsize toll on Americans of color. “Black individuals with dia-
betes are more than twice as likely to end up on dialysis than white
individuals with diabetes,” he notes. They are also more likely to
lose limbs and vision to undertreated diabetes. Kazi attributes these
tragic disparities to “structural” inequities such as poor access to
health care, high-quality food and opportunities for exercise.
Like Ngo-Metzger, Kazi would like to see screening guidelines
better reflect individual risk factors that include race and ethnic-
ity. Without such changes, he says, insurers may refuse to cover
diabetes testing in people who have a BMI below 25 or who are
younger than 35. Fixing larger social inequalities would require
major changes, Kazi concedes, “but making screening more equi-
table is a good place to start.”
Illustration by Fatinha Ramos