Risk assess risk of diabetes, originally developed from community-based

RiskAssessment of Pakistani individual for Diabetes in a resource constraintsociety KhalidAbdul Basit, Asher Fawwad, Musarrat Riaz, Bilal Tahir, Maria Khalid, AbdulBasitABSTRACTAim: Assessment of Pakistani individuals who areat risk of developing diabetes using a RAPID (risk assessment of Pakistaniindividuals for diabetes) score.Methodology: This observational study was a sub-analysisof National Diabetes Survey of Pakistan (NDSP)conducted from 2016-2017 in allprovinces of Pakistan. Ethical approval was obtained from National BioethicsCommittee (NBC) Pakistan RAPID score, a validated and published scoring scaleto assess risk of diabetes, originally developed from community-based surveyswas used. The risk score is assessed by parameters namely; age, waist to hipratio and positive family history of the disease.

Subjects with score greater ?4 is considered at risk of DM. Information regarding social-demography andanthropometric measures, were obtained by a designed questionnaire on one-to-oneinterview bases by survey officers. Data was analyzed using Statistical Packagefor 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 participantswas 41.82 ± 14.19 years.

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Significant differences between males andfemales were observed in BMI (p< 0.0001). RAPID score predicted that 1268 (25.9%) individuals would have risk ofdiabetes while 3637(74.1%) individuals had no risk of diabetes witha sensitivity of 45.

36% and a specificity of 76.39%. The comparisonof 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 werenewly diagnosed with DM by WHO criteria were not at risk.Conclusion:A simple diabetes risk score, based on a setof variables can be used for the identi?cation of high risk individuals forearly intervention to delay or prevent type 2 diabetes. Community basedawareness programs are needed to educate people regarding healthy lifestyle inorder to reduce the risk of diabetes.

IntroductionType 2 Diabetes is amongst the most commonchronic disease and a serious public health challenge of 21stcentury for both the developed and developing world. (1-2). The increasing prevalenceis not only contributing to health burden; a significant economic impact isalso noted (3). According to International Diabetes Federation (IDF), it isanticipated to foresee people with diabetes in 2011 will rise approximately bytwo-fold in 2030, about 366 to 552 million (4) very old reference bhaiya should be used 2017 atlasreference. The 2nd National Diabetic Surveyof Pakistan (NDSP) showed that approximately 26% of population is sufferingfrom diabetes (5).  This high prevalenceis fueled by ageing, physical inactivity, unhealthy food intake and stress ofdiverse origins (6-9). However, the effect of these environmental factorsvaries with variance in genome (10). With maternal gene predominance, thelifetime risk of developing diabetes to that of background individual,escalates to 40% in single parental disease, and about 70% if both parents areaffected (11).

Recent statistics has revealed that more thanone fourth of total diabetic population are unaware of their disease (12,13).Laboratory screening modalities including fasting blood glucose, HbA1c, OGTTare efficient in detecting diabetes. (14-15) However, mass screening isessential for early detection and appropriate intervention of the disease, acost-effective measure in resource limited health care system (16-17). For thisreason, The American Diabetes Association (ADA) recommends regular screeningfor type 2 diabetes beginning at the age of 45 years repeating subsequentlyafter every 3 years (18). Various models have been proposed for riskassessment of diabetes, but results are almost always heterogenous. Thisincludes the British, Canadian, Australian, German, Chinese and Indian riskassessment 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 ofhigh risk individuals through readily available variables withoutpharmacological invention or physician interpretation (25).

This studydemonstrates the validation of preformed scoring system in the epidemiologicaland population-based survey conducted in Pakistan in 2016-2017. Secondly, thepredictability of future diabetes through the risk stratification score anddiagnostic modality is also assessed.  MethodologyThis community based observational study was asub-analysis of National Diabetes Survey of Pakistan (NDSP) conducted from February2016 to August 2017 in all 4 provinces of Pakistan. Ethical approval wasobtained from National Bioethics Committee (NBC) of Pakistan. All Pakistaniindividuals aged 20 years or more, were eligible to participate after obtaininginformed consent and informed about the purpose of the survey. Detailedinformation regarding demographic, anthropometric and medical examination wereobtained with the help of pre-designed questionnaire. All information wasgathered by one-to-one based interview by a trained survey officers. Height was measured to the nearest of 0.

1cm instanding erect posture vertically and weight was recorded with nearest of 0.1 kgwith participants in light clothes and without shoes by paramedical staff.Waist circumference was measured at the midpoint between the lower margin ofthe least palpable rib and the top of the iliac crest and hip circumference was measured around the widest portion ofthe buttocks, with the tape parallel to the floor.  Centralobesity was diagnosed as waist circumference ? 90 cm and ? 80 cm and / orwaist-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 therisk of diabetes. RAPID score, a validated and published scoring scale toassess risk of diabetes, originally developed from community-based surveys wasused. The risk score is assessed by parameters namely; age, waist to hip ratioand positive family history of the diabetes. Subjects with score greater ? 4 areconsidered at risk of diabetes (25).

                 Figure1: 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                        StatisticalanalysisContinuous variables like age, weight, height, BMI,systolic and diastolic blood pressure were presented in the form of mean andstandard deviation. Categorical variables i.e. gender, family history ofdiabetes and hypertension presented as frequency with percentage. Independentt-test was used for continuous variables and chi-square test was used forcategorical variables. Parameters of age, waist to hip ratio and positivefamily history of diabetes was examined using multivariate logistic regression,p-value < 0.05 was considered statistically significant. Statistical Packagefor Social Sciences (SPSS) version 20.

0 was used for analyses.ResultsA total of 4905 participants were screenedfor 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 theparticipants was 41.

82 ± 14.19 years. Mean BMI and waist-hip ratio (WHR) were26.84 ± 5.84 kg/m2 and 0.94 ± 0.

2, respectively. Significantdifferences between males and females were observed in BMI (p< 0.0001). Majorityof subjects were married and non-users of tobacco. No significant differencewas found in biochemical characteristics between males and females except forHDL-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 norisk of diabetes with a sensitivity of 45.36% and a specificity of76.39% (table 2). Figure 2 shows comparison of oral glucosetolerance test (OGTT) with RAPID score.

RAPID scoreestimated 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 werenewly diagnosed with DM by WHO criteria were not at risk.

Table 1: Demographic andbiochemical 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 analysisof 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      DiscussionThis study demonstrates the simplified andconvenient diabetes risk score (RAPID), an efficient screening tool used forearly detection of type 2 diabetes among Pakistani population. This risk scoreincludes the basic parameters such as age, waist to hip ratio and familyhistory. It is noninvasive, convenient and cost-effective score for an ordinaryindividual to access a risk of diabetes.

It helps to identify high riskindividuals for developing diabetes.Among the modifiable risk factors that playeda considerable role in earlier studies was obesity, measured by BMI or waistcircumference (27). In the present study, both BMI and waist circumferenceincreases the risk of diabetes at cutoff points which was similar to the studyconducted by Aekplakorn W. et.al. (27) Moreover,most of our diabetic patients fall in the category of obesity, according to newstandardization of WHO for overweight (23-27kg/m²) and obesity (?27.5kg/m²) (28).

  Strong risk factor of type 2 diabetes is afamily history of diabetes. (29) In one of the earlier study, reduced physicalactivity is the convincing finding of family history of diabetes. (29) In thisstudy, family history was non-significant which was similar to a studyconducted in Canada. (19) Robust impact of BMI and family history leading toincreased risk of diabetes was observed in English young individuals. (32) Ageplayed 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 earlierin the past three decades. (30)This risk prediction score of diabetes hasspecificity 76.39% and a sensitivity 45.

36% which is opposite to a surveyconducted in Oman with specificity of 65% and sensitivity of 79%. (26) Inearlier population-based study use of oral glucose tolerance test (OGTT) isimpractical to identify high risk individuals. Furthermore, nearly 40% subjectswith former normal OGTT 3-5 years earlier develops incident diabetes (31).Similarly, in our study almost one fifth of subjects with normal OGTT are atrisk of developing diabetes in their future.

 Conclusion: A simple diabetes risk score, based on a setof variables can be used for the identi?cation of high risk individuals forearly intervention to delay or prevent type 2 diabetes. Hence, community-basedawareness programs are needed to educate people regarding healthy lifestyle inorder to reduce the risk of diabetes. References: 1.     Gujral UP, Pradeepa R, WeberMB, Narayan KM, Mohan V. Type 2 diabetes in South Asians: similarities anddifferences with white Caucasian and other populations.

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