Assessment of Pakistani individual for Diabetes in a resource constraint
Abdul Basit, Asher Fawwad, Musarrat Riaz, Bilal Tahir, Maria Khalid, Abdul
Aim: Assessment of Pakistani individuals who are
at risk of developing diabetes using a RAPID (risk assessment of Pakistani
individuals for diabetes) score.
Methodology: This observational study was a sub-analysis
of National Diabetes Survey of Pakistan (NDSP)conducted from 2016-2017 in all
provinces of Pakistan. Ethical approval was obtained from National Bioethics
Committee (NBC) Pakistan RAPID score, a validated and published scoring scale
to assess risk of diabetes, originally developed from community-based surveys
was used. The risk score is assessed by parameters namely; age, waist to hip
ratio and positive family history of the disease. Subjects with score greater ?
4 is considered at risk of DM. Information regarding social-demography and
anthropometric measures, were obtained by a designed questionnaire on one-to-one
interview bases by survey officers. Data was analyzed using Statistical Package
for Social Sciences (SPSS) version 20.
Results: A total of 4905 individuals were assessed,
of which (n=2205) were male and (n=2700) were female. Mean age of participants
was 41.82 ± 14.19 years. Significant differences between males and
females were observed in BMI (p< 0.0001). RAPID score predicted that 1268 (25.9%) individuals would have risk of diabetes while 3637(74.1%) individuals had no risk of diabetes with a sensitivity of 45.36% and a specificity of 76.39%. The comparison of oral glucose tolerance test (OGTT) with RAPID score estimated that 20.2% subjects with normal glucose tolerance and 33.7% prediabetics were at risk of DM. It also estimated that 54.6% subjects who were newly diagnosed with DM by WHO criteria were not at risk. Conclusion: A simple diabetes risk score, based on a set of variables can be used for the identi?cation of high risk individuals for early intervention to delay or prevent type 2 diabetes. Community based awareness programs are needed to educate people regarding healthy lifestyle in order to reduce the risk of diabetes. Introduction Type 2 Diabetes is amongst the most common chronic disease and a serious public health challenge of 21st century for both the developed and developing world. (1-2). The increasing prevalence is not only contributing to health burden; a significant economic impact is also noted (3). According to International Diabetes Federation (IDF), it is anticipated to foresee people with diabetes in 2011 will rise approximately by two-fold in 2030, about 366 to 552 million (4) very old reference bhaiya should be used 2017 atlas reference. The 2nd National Diabetic Survey of Pakistan (NDSP) showed that approximately 26% of population is suffering from diabetes (5). This high prevalence is fueled by ageing, physical inactivity, unhealthy food intake and stress of diverse origins (6-9). However, the effect of these environmental factors varies with variance in genome (10). With maternal gene predominance, the lifetime risk of developing diabetes to that of background individual, escalates to 40% in single parental disease, and about 70% if both parents are affected (11). Recent statistics has revealed that more than one fourth of total diabetic population are unaware of their disease (12,13). Laboratory screening modalities including fasting blood glucose, HbA1c, OGTT are efficient in detecting diabetes. (14-15) However, mass screening is essential for early detection and appropriate intervention of the disease, a cost-effective measure in resource limited health care system (16-17). For this reason, The American Diabetes Association (ADA) recommends regular screening for type 2 diabetes beginning at the age of 45 years repeating subsequently after every 3 years (18). Various models have been proposed for risk assessment of diabetes, but results are almost always heterogenous. This includes the British, Canadian, Australian, German, Chinese and Indian risk assessment models comprising of designed questionnaires, anthropometric, demographic, family history and elementary lifestyle information (19-24) A similar algorithm was designed named, RAPID (risk assessment of Pakistani individuals for diabetes) for identification of high risk individuals through readily available variables without pharmacological invention or physician interpretation (25). This study demonstrates the validation of preformed scoring system in the epidemiological and population-based survey conducted in Pakistan in 2016-2017. Secondly, the predictability of future diabetes through the risk stratification score and diagnostic modality is also assessed. Methodology This community based observational study was a sub-analysis of National Diabetes Survey of Pakistan (NDSP) conducted from February 2016 to August 2017 in all 4 provinces of Pakistan. Ethical approval was obtained from National Bioethics Committee (NBC) of Pakistan. All Pakistani individuals aged 20 years or more, were eligible to participate after obtaining informed consent and informed about the purpose of the survey. Detailed information regarding demographic, anthropometric and medical examination were obtained with the help of pre-designed questionnaire. All information was gathered by one-to-one based interview by a trained survey officers. Height was measured to the nearest of 0.1cm in standing erect posture vertically and weight was recorded with nearest of 0.1 kg with participants in light clothes and without shoes by paramedical staff. Waist circumference was measured at the midpoint between the lower margin of the least palpable rib and the top of the iliac crest and hip circumference was measured around the widest portion of the buttocks, with the tape parallel to the floor. Central obesity was diagnosed as waist circumference ? 90 cm and ? 80 cm and / or waist-to-hip ratio (WHR) ? 0.9 and ? 0.8 in males and females respectively (25). Detailed methodology has been published earlier (5). RAPID score was used in the study to estimate the risk of diabetes. RAPID score, a validated and published scoring scale to assess risk of diabetes, originally developed from community-based surveys was used. The risk score is assessed by parameters namely; age, waist to hip ratio and positive family history of the diabetes. Subjects with score greater ? 4 are considered at risk of diabetes (25). Figure 1: Flow diagram Total sample n = 10834 Already known diabetic Excluded from the study After given 75 gm of glucose Normal population Pre-diabetic Diabetic Known Diabetic Missing any RAPID score parameter Complete RAPID score parameter Missing any RAPID score parameter Complete RAPID score parameter Missing any RAPID score parameter Complete RAPID score parameter Excluded from the study Excluded from the study Excluded from the study Final analysis Statistical analysis Continuous variables like age, weight, height, BMI, systolic and diastolic blood pressure were presented in the form of mean and standard deviation. Categorical variables i.e. gender, family history of diabetes and hypertension presented as frequency with percentage. Independent t-test was used for continuous variables and chi-square test was used for categorical variables. Parameters of age, waist to hip ratio and positive family history of diabetes was examined using multivariate logistic regression, p-value < 0.05 was considered statistically significant. Statistical Package for Social Sciences (SPSS) version 20.0 was used for analyses. Results A total of 4905 participants were screened for RAPID score. The baseline characteristics of males (n=2205) and females (n=2700) of the study participants are shown in table-1. Mean age of the participants was 41.82 ± 14.19 years. Mean BMI and waist-hip ratio (WHR) were 26.84 ± 5.84 kg/m2 and 0.94 ± 0.2, respectively. Significant differences between males and females were observed in BMI (p< 0.0001). Majority of subjects were married and non-users of tobacco. No significant difference was found in biochemical characteristics between males and females except for HDL-cholesterol (mg/dl) and triglycerides (mg/dl) (p<0.0001). RAPID score predicted that 1268 (25.9%) individuals would have risk of diabetes while 3637(74.1%) individuals had no risk of diabetes with a sensitivity of 45.36% and a specificity of 76.39% (table 2). Figure 2 shows comparison of oral glucose tolerance test (OGTT) with RAPID score. RAPID score estimated that 20.2% subjects with normal glucose tolerance and 33.7% prediabetics were at risk of DM. It also estimated that 54.6% subjects who were newly diagnosed with DM by WHO criteria were not at risk. Table 1: Demographic and biochemical characteristics of study population Variables Male Female P-value Total n 2205 2700 4905 Age (years) 42.96±15.03 40.89±13.4 <0.0001 41.82± 14.19 Marital status Single 379(17.5%) 384(14.6%) <0.0001 763(15.9%) Married 1787(82.5%) 2240(85.4%) 4027(84.1%) Tobacco addiction Yes 606(27.8%) 144(5.5%) <0.0001 750(15.6%) No 1572(72.2%) 2486(94.5%) 4058(84.4%) Family history of diabetes Yes 644(29.2%) 735(27.2%) 0.124 1379(28.1%) No 1561(70.8%) 1965(72.8%) 3526(71.9%) Weight (kg) 73.64±14.87 65.73±14.7 <0.0001 69.3±15.29 Height (cm) 168.45±9.98 154.9±9.64 <0.0001 160.99±11.89 Body mass index (kg/m2) 26±5.23 27.52±6.2 <0.0001 26.84±5.84 Waist circumference (cm) 92.13±13.69 91.64±14.59 0.228 91.86±14.19 Hip circumference (cm) 101.18±14.75 102.09±17.66 0.106 101.68±16.43 Waist-to-hip ratio 0.94±0.15 0.94±0.23 0.559 0.94±0.2 Systolic blood pressure (mmHg) 125.19±16.87 124.3±19.23 0.093 124.7±18.22 Diastolic blood pressure (mmHg) 83.07±12.04 83.31±13.73 0.535 83.2±13.01 Fasting blood sugar (mg/dl) 93.59±38.84 92.56±36.99 0.345 93.02±37.83 Random blood sugar (mg/dl) 129.7±52.78 130.06±48.18 0.806 129.9±50.29 Cholesterol (mg/dl) 192.43±58.46 191.46±59.57 0.626 191.85±59.12 Triglycerides (mg/dl) 191.9±128.8 169.03±109.68 <0.0001 178.2±118.23 High density lipoprotein (mg/dl) 30.75±11.52 34.17±14.96 <0.0001 32.8±13.78 Low density lipoprotein (mg/dl) 121.76±38.37 121.52±39.26 0.857 121.62±38.9 Table 2: Sensitivity and specificity analysis of RAPID score RAPID Score WHO GTT Classification DM NGT or PDM Total At risk 230 1038 1268 Not at risk 277 3360 3637 Total 507 4398 4905 Sensitivity 45.36% Specificity 76.39% Here, DM = Diabetes Mellitus PDM= Pre-Diabetes Mellitus (Includes Impaired & Fasting Glucose Tolerance) NGT = Normal Glucose Tolerance Figure 2: Comparison of OGTT with RAPID Score Discussion This study demonstrates the simplified and convenient diabetes risk score (RAPID), an efficient screening tool used for early detection of type 2 diabetes among Pakistani population. This risk score includes the basic parameters such as age, waist to hip ratio and family history. It is noninvasive, convenient and cost-effective score for an ordinary individual to access a risk of diabetes. It helps to identify high risk individuals for developing diabetes. Among the modifiable risk factors that played a considerable role in earlier studies was obesity, measured by BMI or waist circumference (27). In the present study, both BMI and waist circumference increases the risk of diabetes at cutoff points which was similar to the study conducted by Aekplakorn W. et.al. (27) Moreover, most of our diabetic patients fall in the category of obesity, according to new standardization of WHO for overweight (23-27kg/m²) and obesity (?27.5kg/m²) (28). Strong risk factor of type 2 diabetes is a family history of diabetes. (29) In one of the earlier study, reduced physical activity is the convincing finding of family history of diabetes. (29) In this study, family history was non-significant which was similar to a study conducted in Canada. (19) Robust impact of BMI and family history leading to increased risk of diabetes was observed in English young individuals. (32) Age played a significant role in our study as seen in other risk prediction models (19,22,27) and increase incidence in middle aged population was noted earlier in the past three decades. (30) This risk prediction score of diabetes has specificity 76.39% and a sensitivity 45.36% which is opposite to a survey conducted in Oman with specificity of 65% and sensitivity of 79%. (26) In earlier population-based study use of oral glucose tolerance test (OGTT) is impractical to identify high risk individuals. Furthermore, nearly 40% subjects with former normal OGTT 3-5 years earlier develops incident diabetes (31). Similarly, in our study almost one fifth of subjects with normal OGTT are at risk of developing diabetes in their future. 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