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Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. Clarifying statements for osteoporosis screening and tobacco use have also been added. The rationale for including these two statements is presented in Appendix A. Diabetes mellitus DM is a syndrome characterized by either an absolute or a relative deficiency of insulin in various organ systems of the body. The inability of these organ systems to utilize glucose thus exposes all tissues of the body to chronic excess glucose in the bloodstream, or hyperglycemia ADA, a.

DM has three main types: Type 2 diabetes, which accounts for about. Gestational diabetes mellitus GDM is diabetes that arises or is diagnosed in pregnancy, typically during the second and third trimesters of pregnancy. It accounts for about , diabetic patients annually in the United States and occurs in approximately 2 to 10 percent of pregnant women NIDDK, Although most women recover from GDM after giving birth, they have an increased risk of developing type 2 diabetes in the future Turok et al.

Furthermore, their offspring are at significantly increased risk of being overweight and insulin resistant throughout childhood Boerschmann et al. By , it is estimated that the rate of adult diabetes in the United States will triple, from 1 in 10 now to 1 in 3 Boyle et al. No striking gender difference in the rates of diabetes exist between men and women in the United States ADA, b.

However, a gender difference in the burden of this disease does appear to exist. Narayan and colleagues found that women have a significantly higher estimated lifetime risk of developing diabetes than men The authors further estimated that women diagnosed with diabetes at age 40 years will lose The consequences of diabetes appear to be more severe for women as well.

In a study to assess whether trends in mortality rates among adults with diabetes had changed, Gregg and colleagues found that between the to and to survey periods for the National Health and Nutrition Examination Survey, the all-cause mortality rate for men with diabetes decreased by Furthermore, recent data indicate that women with diabetes are at high risk for developing cardiovascular disease. Women with diabetes were found to be four to six times more likely to develop cardiovascular disease.

Women with diabetes are more than three times more likely to have a stroke as women without diabetes but no prior history of a cardiovascular event. In fact, women with diabetes have a stroke risk profile similar to that of non-diabetic women who have had a prior stroke Ho et al. In addition to having one of the highest diabetes rates in the world 8. This may be in part due to increased screening conducted in the United States. Although the incidence of preexisting diabetes in pregnancy has increased over the past decade, the incidence of GDM has remained relatively stable since the late s because of better recognition of the disease and more aggressive intervention, according to a Southern California Kaiser Permanente study Lawrence et al.

This suggests that the complications of GDM for both mother and infant can be reduced even further by better detection and prevention and more aggressive management of this condition Crowther et al. Many women who are first diagnosed with diabetes during pregnancy are classified as having GDM. However, it is possible that many had preexisting or pregestational type 2 diabetes.

If a woman who has had GDM is not tested after delivery, the diabetes may have persisted and her next pregnancy may be incorrectly classified as recurrent GDM instead of preexisting diabetes.

This distinction is important, because preexisting diabetes could be associated with more serious consequences for the fetus, including cardiac, neurological, and vascular anomalies, than diabetes that arises in the second and third trimesters of pregnancy Jenkins et al.

Cases of GDM increase with maternal age and occur 7 to 10 times more often among pregnant women age 24 and older than among women younger than 24 years old Reece, , suggesting that universal screening may be the most effective in the latter group Marquette et al. GDM is itself a risk factor for type 2 diabetes. Women who have GDM during pregnancy have a seven-fold increased risk for the development of type 2 diabetes after delivery, which persists for their lifetime Reece et al.

One large, population-based study of , women found that 20 percent of women with GDM progressed to type 2 diabetes within nine years of pregnancy Feig et al. Furthermore, the children of women with a history of GDM are at an increased risk for obesity and diabetes compared to other children Reece, The primary risk factors for type 1 diabetes are genetics and family history ADA, a , diseases of the pancreas Buxbaum and Eloubeidi, , and infections or illnesses Hober and Sane, The number one risk factor for type 2 diabetes is obesity Chan et al.

Besides obesity, other risk factors for developing type 2 diabetes include impaired glucose tolerance or impaired fasting glucose, insulin resistance, ethnic background, high blood pressure, a history of gestational diabetes, a sedentary lifestyle, family history, polycystic ovary syndrome, and older age ADA, a.

A number of risk factors have been consistently linked to the development of GDM during pregnancy, including a history of GDM in a prior pregnancy, previously having had a large for gestational age LGA infant, obesity, a strong immediate family history of type 2 diabetes or GDM and a history of unexplained fetal death Mayo Clinic, Obesity is an excess amount of subcutaneous body fat in proportion to lean body mass.

The most common measure of obesity is the body mass index BMI. If BMI is 25 to The rapid increase in diabetes in recent decades has closely paralleled the increase in obesity and overweight in the general population Wang et al.

The United States currently has the highest obesity rate in the world, with more than 30 percent of adults, or 77 million, considered obese. By , if the secular rate of increase continues, it is estimated that nearly 90 percent of Americans will be overweight and 51 percent will be obese Wang et al. Obesity-related diseases account for nearly 10 percent of all medical spending in the United States Finkelstein et al. Overall there are a variety of factors that play a role in obesity.

This makes it a complex health issue to address. The risk factors for obesity include overeating; lack of exercise; genetics; environment; and some diseases and drugs. However, experts have concluded that the two chief causes of obesity are a sedentary lifestyle and the overconsumption of high-calorie foods Vainio and Bianchini, Thus, most obesity interventions are directed toward modifying these two lifestyle factors.

Bright Futures does not specifically address screening for diabetes. The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for gestational diabetes. The USPSTF recommends that all clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.

Department of Defense DOD Clinical Practice Guidelines recommend that physicians consider screening for diabetes and encourage aerobic exercise and diet to achieve weight loss and prevent the progression of pre-diabetes to diabetes VA, Numerous health professional associations and other organizations recommend screening for diabetes as part of preventive care for women. The American Diabetes Association, for example, recommends. Little evidence indicates that screening for GDM improves health outcomes.

For this reason, the USPSTF concluded that the evidence is insufficient to recommend for or against routine screening for gestational diabetes. Discussions should include information about the uncertainty of benefits and harms as well as the frequency of positive screening test results. There are no existing interventions to prevent GDM from occurring in pregnancy. However, some bodies have considered it important to screen pregnant women for GDM because these women are at increased risk for having infants with excessive birth weight and require operative delivery or infants with increased neonatal morbidity.

While the American Academy of Family Physicians AAFP recognizes that more studies are needed to unequivocally support the benefit of universal screening for GDM, it also identifies that universal screening for GDM at 24 to 28 weeks of gestation is recommended by many experts.

The recommendation is based on consensus, disease-oriented evidence, expert opinion, and case series Serlin and Lash, In support of the recommendation, AAFP also notes that most obstetric practices employ this strategy. Its recommendation is based on limited or inconsistent scientific evidence. The value of early detection of diabetes, other than type 1 diabetes, remains controversial because of the lack of an established evidence base.

Randomized trials have established the benefits of interventions to prevent or delay diabetes Knowler et al. However, no randomized control trial has established the benefits of early detection of diabetes. The Diabetes Control and Complications Trial DCCT , an almost year study sponsored by the National Institutes of Health found that maintaining blood glucose levels as close to normal as possible slowed the development and progression of the eye, kidney, and nerve damage caused by diabetes Genuth, It also found that any sustained lowering of blood glucose was beneficial.

The most significant side effect of intensive treatment in the DCCT was an increase in the risk for hypoglycemia, or low blood glucose, including episodes severe enough to require additional medical assistance Genuth, The Diabetes Prevention Program DPP , another intervention study, was designed to assess whether modest weight reduction through dietary changes and increased physical activity or treatment with oral diabetes medication could prevent or delay the onset of type 2 diabetes.

Results from this study showed that participants who were pre-diabetic could sharply reduce their risk of developing diabetes with a modest loss of weight through dietary changes and increased physical activity The Diabetes Prevention Program Research Group, Taking oral diabetes medication could also reduce risk, although less dramatically.

Since the conclusion of the DPP study, additional data analyses continue to provide important insights into the value of lifestyle changes in helping people prevent type 2 diabetes and its complications.

One analysis found that DPP participants with specific genetic profiles had a significantly increased risk of developing diabetes and selective responses to specific interventions Florez et al.

It is possible that subgroups of individuals will not respond well to standard interventions or that some responders may respond very well to a particular treatment on the basis of their genetic profile. Nutritional support and exercise also can have a significant impact on the incidence and severity of diabetes.

The DPP found that just 30 minutes of moderate physical activity a day, coupled with a 5 to 10 percent reduction in body weight, produced a 58 percent reduction in the incidence of diabetes Knowler et al.

Some studies showed a positive impact of the intervention on BMI or weight status, but there is too much heterogeneity in terms of study design, theoretical underpinning, and target population to be able to draw firm conclusions about which intervention approaches are more effective than others Lemmens et al. More research is urgently needed to extend the body of evidence in this area of prevention. The only intervention for obesity that has been shown to have great benefit for preventing other complications of obesity is surgery Valezi et al.

Gastric bypass surgery has been shown to ameliorate diabetes Gill et al. However, this is an invasive surgical intervention, and an estimated 5 percent or more of people have serious or life-threatening complications after gastric bypass surgery Picot et al.

The primary gaps in preventive services not already addressed by the provisions set forth in the ACA reviewed in this section were screening for diabetes in all women and screening for gestational diabetes among pregnant women, especially those identified to be at high risk for developing gestational diabetes.

The committee found insufficient evidence to support screening for diabetes in all women. The evidence provided to support a recommendation for gestational diabetes is based on current federal practice policy from IHS and the VA as well as current practice and clinical professional guidelines such as those set forth by AAFP and ACOG.

The committee recommends for consideration as a preventive service for women: Invasive cervical neoplasia is a low-prevalence cancer with a lengthy pre-invasive phase that is amenable to screening and early detection. Persistent infection with 1 of 20 high-risk HPV types is the necessary precursor for the development of squamous cell carcinoma and adenocarcinoma of the uterine cervix Plummer et al.

HPV infection is highly prevalent and is sexually acquired with the onset of sexual intercourse, typically resolving within 24 months Insinga et al. Progression from persistent infection to precursor lesion high-grade squamous intraepithelial lesion or cervical intraepithelial neoplasia [CIN] grade 2 [CIN2] or CIN3 can be a lengthy process, with the year risk for the development of these lesions even for the highest-risk viral types being approximately 17 percent Khan et al.

Even after precursor lesions, the risk of progression to invasive disease is about 31 percent in 30 years McCredie et al. On the basis of the current understanding of the natural history or HPV infection and cervical carcinogenesis, it is recommended that adult women with a history of sexual activity undergo periodic screening as part of their routine preventive care. In , 12, cases of invasive cervical cancer were diagnosed and 4, deaths were estimated to have occurred in the United States CDC, a , and the incidence of cervical cancer has been steadily decreasing in the United States and Western Europe since the introduction of formal and informal cytological screening programs in the s.

By , the rate of mortality in the United States has decreased from Despite these tremendous gains, women with poor access to health care services and specifically women from communities of color have lagged significantly behind and currently represent a disproportionate share of cervical cancer incidence and mortality NCI, b; Saslow et al.


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