Fasting Blood Glucose Screening is Most Appropriate
For this 47-year-old woman with hypertension and obesity (BMI 37), fasting blood glucose screening for type 2 diabetes is the single most appropriate test among the options provided. 1, 2
Why Diabetes Screening Takes Priority
The USPSTF provides a Grade B recommendation specifically for screening adults with hypertension for type 2 diabetes, with moderate certainty that this leads to substantial benefit in preventing cardiovascular events and death. 1, 2 This patient meets multiple high-risk criteria:
- Hypertension for 5 years - a specific indication for diabetes screening 1
- Severe obesity (BMI 37) - far exceeds the BMI ≥25 kg/m² threshold that triggers screening recommendations 2, 3
- Age 47 years - above the 45-year threshold where screening becomes routine 2, 4, 3
The combination of hypertension and obesity creates compounded cardiovascular risk, and undiagnosed diabetes in hypertensive patients substantially elevates cardiovascular morbidity and mortality well before clinical diagnosis. 2, 5 The prevalence of undiagnosed diabetes in hypertensive patients ranges from 15-20%, making this a high-yield screening intervention. 5
Why Fasting Blood Glucose is the Preferred Test
The American Diabetes Association recommends fasting plasma glucose (FPG) as the best screening test because it is easier and faster to perform, more convenient and acceptable to patients, less expensive, and more reproducible than other screening tests. 1, 4
- Greater convenience and lower cost compared to oral glucose tolerance testing
- Better reproducibility with less intraindividual variation
- Similar predictive value for development of microvascular complications
- Diagnostic threshold: FPG ≥126 mg/dL indicates diabetes (confirm with repeat testing) 4, 3
Why Other Options Are Less Appropriate
Fecal occult blood testing (Option A) - Colorectal cancer screening typically begins at age 45-50 years in average-risk individuals, but this patient's immediate cardiovascular risk from undiagnosed diabetes takes precedence. [@general medical knowledge]
Pap smear (Option C) - While cervical cancer screening is important, current guidelines recommend screening every 3-5 years depending on method used. This is not the most urgent preventive need in a patient with multiple diabetes risk factors. [@general medical knowledge]
Lung cancer screening (Option D) - Not indicated without significant smoking history (typically ≥20 pack-years). [@general medical knowledge]
Implementation Strategy
Screen annually rather than the standard 3-year interval recommended for lower-risk populations, given her controlled hypertension and severe obesity. [@8@, @10@] The European Society of Cardiology explicitly recommends fasting plasma glucose as part of routine laboratory investigations for all hypertensive patients. [@10@]
Do not delay diabetes screening even when blood pressure is "controlled" - metabolic abnormalities often precede overt diabetes diagnosis by years, and cardiovascular risk is substantially elevated during this pre-diagnostic period. [2, @10@]
Critical Management Points
If screening reveals impaired fasting glucose (100-125 mg/dL): 2
- Consider HbA1c measurement or oral glucose tolerance test for definitive diagnosis
- Initiate intensive lifestyle intervention targeting weight reduction and increased physical activity
- Implement aggressive cardiovascular risk factor management
Intensive blood pressure treatment in adults with both hypertension and diabetes leads to approximately 50% reduction in cardiovascular events over 5 years, but this benefit requires knowing the diabetes diagnosis. [@10