Validating prediction scales of type 2 diabetes mellitus in Spain: the SPREDIA-2 population-based prospective cohort study protocol

External validation of three diabetes prediction scores in a Spanish cohort: does adding high risk for depression improve the validation of the FINDRISC score (FINDRISC-MOOD)?

OBJECTIVES

To evaluate the external validity of the FINDRISC, DESIR and ADA risk scores for the prediction of diabetes in a Spanish population aged >45 years and to test the possible improvement of FINDRISC by adding a new variable of high risk of depression when Patient Health Questionnaire-9 (PHQ-9) questionnaire score ≥10 (FINDRISC-MOOD).

DESIGN

Prospective population-based cohort study.

SETTING

10 primary healthcare centres in the north of the city of Madrid (Spain).

PARTICIPANTS

A total of 1242 participants without a history of diabetes and with 2-hour oral glucose tolerance test (OGTT) plasma glucose <200 mg/dL (<11.1 mmol/L) were followed up for 7.3 years (median) using their electronic health records (EHRs) and telephone contact.

PRIMARY AND SECONDARY OUTCOME MEASURES

Diabetes risk scores (FINDRISC, DESIR, ADA), PHQ-9 questionnaire and 2-hour-OGTT were measured at baseline. Incident diabetes was defined as treatment for diabetes, fasting plasma glucose ≥126 mg/dL (≥7.0 mmol/L), new EHR diagnosis or self-reported diagnosis. External validation was performed according to optimal cut-off, sensitivity, specificity and Youden Index. Comparison between diabetes risk scores, including FINDRISC-MOOD (original FINDRISC score plus five points if PHQ-9 ≥10), was measured by area under the receiver operating characteristic curve (AUROC).

RESULTS

During follow-up, 104 (8.4%; 95% CI, 6.8 to 9.9) participants developed diabetes and 185 had a PHQ-9 score ≥10. The AUROC values were 0.70 (95% CI, 0.67 to 0.72) for FINDRISC-MOOD and 0.68 (95% CI, 0.65 to 0.71) for the original FINDRISC. The AUROCs for DESIR and ADA were 0.66 (95% CI, 0.63 to 0.68) and 0.66 (95% CI, 0.63 to 0.69), respectively. There were no significant differences in AUROC between FINDRISC-MOOD and the other scores.

CONCLUSIONS

The results of FINDRISC-MOOD were like those of the other risk scores and do not allow it to be recommended for clinical use.

Incidence of T2DM and the role of baseline glycaemic status as a determinant in a metropolitan population in northern Madrid (Spain)

AIM

To estimate the incidence of T2DM and assess the effect of pre-T2DM (isolated impaired fasting glucose [iIFG], isolated impaired glucose tolerance [iIGT] or both) on progress to T2DM in the adult population of Madrid.

METHODS

Population-based cohort comprising 1,219 participants (560 normoglycaemic and 659 preT2DM [418 iIFG, 70 iIGT or 171 IFG-IGT]). T2DM was defined based on fasting plasma glucose or HbA1c or use of glucose-lowering medication. We used a Cox model with normoglycaemia as reference category.

RESULTS

During 7.26 years of follow-up, the unadjusted incidence of T2DM was 11.21 per 1000 person-years (95 %CI, 9.09-13.68) for the whole population, 5.60 (3.55-8.41) for normoglycaemic participants and 16.28 (12.78-20.43) for pre-T2DM participants. After controlling for potential confounding factors, the baseline glycaemic status was associated with higher primary effect on developing T2DM was iIGT (HR = 3.96 [95 %CI, 1.93-8.10]) and IFG-IGT (3.42 [1.92-6.08]). The HR for iIFG was 1.67 (0.96-2.90). Obesity, as secondary effect, was strongly significantly associated (HR = 2.50 [1.30-4.86]).

CONCLUSIONS

Our incidence of T2DM is consistent with that reported elsewhere in Spain. While baseline iIGT and IFG-IGT behaved a primary effect for progression to T2DM, iIFG showed a trend in this direction.

Comparison of the Finnish Diabetes Risk Score Model With the Metabolic Syndrome in a Shanghai Population

AIMS

This study aimed to compare the diagnostic accuracy of the metabolic syndrome with the Finnish Diabetes Risk Score (FINDRISC) to screen for type 2 diabetes mellitus (T2DM) in a Shanghai population.

METHODS

Participants aged 25-64 years were recruited from a Shanghai population from July 2019 to March 2020. Each participant underwent a standard metabolic work-up, including clinical examination with anthropometry. Glucose status was tested using hemoglobin A1c (HbAlc), 2h-post-load glucose (2hPG), and fasting blood glucose (FBG). The FINDRISC questionnaire and the metabolic syndrome were examined. The performance of the FINDRISC was assessed using the area under the receiver operating characteristic curve (AUC-ROC).

RESULTS

Of the 713 subjects, 9.1% were diagnosed with prediabetes, whereas 5.2% were diagnosed with T2DM. A total of 172 subjects had the metabolic syndrome. A higher FINDRISC score was positively associated with the prevalence of T2DM and the metabolic syndrome. Multivariable linear regression analysis demonstrated that the FINDRISC had a linear regression relationship with 2hPG levels (b'= 036, p < 0.0001). The AUC-ROC of the FINDRISC to identify subjects with T2DM among the total population was 0.708 (95% CI 0.639-0.776), the sensitivity was 44.6%, and the specificity was 90.1%, with 11 as the cut-off point. After adding FBG or 2hPG to the FINDRISC, the AUC-ROC among the total population significantly increased to 0.785 (95% CI 0.671-0.899) and 0.731 (95% CI 0.619-0.843), respectively, while the AUC-ROC among the female group increased to 0.858 (95% CI 0.753-0.964) and 0.823 (95% CI 0.730-0.916), respectively (p < 0.001). The AUC-ROC of the metabolic syndrome to identify subjects with T2DM among the total and female population was 0.805 (95% CI 0.767-0.844) and 0.830 (95% CI 0.788-0.872), respectively, with seven as the cut-off point.

CONCLUSIONS

The metabolic syndrome performed better than the FINDRISC model. The metabolic syndrome and the FINDRISC with FBG or 2hPG in a two-step screening model are both efficacious clinical practices for predicting T2DM in a Shanghai population.

Validation of the Finnish Type 2 Diabetes Risk Score (FINDRISC) with the OGTT in Health Care Practices in Europe

AIMS

/hypothesis. To determine the best cut-off threshold value of the Finnish Diabetes Risk Score (FINDRISC) for the detection of diabetes and non-diabetic hyperglycaemia in people 35 years or older at primary health care settings in Europe.

METHODS

Cross-sectional study in 11,444 adults from primary health care centres using community and opportunistic screening approaches. All participants completed the FINDRISC questionnaire and underwent a 2-hour oral glucose tolerance test (OGTT). The FINDRISC performance was assessed by the area under the curve (AUC) using receiver operating characteristics (ROC) analysis. The sensitivity, specificity, Youdeńs index, positive and negative prediction values for different FINDRISC cut-offs were calculated.

RESULTS

The optimal FINDRISC value for detecting both diabetes or glucose impairment in the community - screened sample was 14 point with the associated AUC 0.75,5 (95 %CI 0.73,7-0.77,3). The optimal score in the opportunistic screening sample was 16 with the associated AUC only 0.60,4 (95% CI 0.56, 4-0.64, 4).

CONCLUSIONS/INTERPRETATION

The FINDRISC is a non-invasive tool useful for detecting people with unknown diabetes and glucose impairment in people visiting primary health centres in Europe.

Assessment of risk of diabetes by using Indian Diabetic risk score (IDRS) in Indian population

AIMS

To screen the Indian population for Type 2 Diabetes Mellitus (DM) based on Indian Diabetes Risk Score. Our main question was; Does Indian Diabetic risk score (IDRS) effectively screen diabetic subjects in Indian population?

METHODS

Multi-centric nationwide screening for DM and its risk in all populous states and Union territories of India in 2017. It is the first pan India DM screening study conducted on 240,000 subjects in a short period of 3 months based on IDRS. This was a stratified translational research study in randomly selected cluster populations from all zones of rural and urban India. Two non-modifiable (age, family history) and two modifiable (waist circumference & physical activity) were used to obtain the score. High, moderate and low risk groups were selected based on scores.

RESULTS

In this study 40.9% subjects were detected to be high risk, known or newly diagnosed DM subjects in urban and rural regions. IDRS could detect 78.1% known diabetic subjects as high risk group. Age group 50-59 (17.4%); 60-69 (22%); 70-79 (22.8%); >80 (19.2%) revealed high percentage of subjects. ROC was found to be 0.763 at CI 95% of 0.761-0.765 with statistical significance of p < 0.0001. At >50 cut off, youden index showed the sensitivity of 78.05 and specificity of 62.68. Regression analysis revealed that IDRS and Diabetes are significantly positively associated.

CONCLUSIONS

Data reveals that IDRS is a good indicator of high risk diabetic subjects.

Relationship of the Adherence to a Mediterranean Diet and Its Main Components with CRP Levels in the Spanish Population

Background: Adherence to a Mediterranean diet seems to be inversely associated with C-reactive protein (CRP) concentration. A 14-point Mediterranean Diet Adherence Screener (MEDAS) has been developed to assess dietary compliance. Objective: The aim of this study was to assess whether each of the MEDAS questions as well as their final score were associated with the levels of CRP in general Spanish population.

METHODS

Cross-sectional analysis of 1411 subjects (mean age 61 years, 43.0% males) randomly selected from the general population. CRP levels were determined by a commercial ELISA kit. Adherence to the Mediterranean diet was measured by the 14-point MEDAS. Results: There was an inverse correlation between adherence to the Mediterranean diet and the CRP concentration, even after adjusting by age, gender, hypertension, metabolic syndrome, body mass index, statin treatment and hypertension treatment (p = 0.041). Subjects who consume ≥2 servings of vegetables per day (p = 0.003), ≥3 pieces of fruit per day (p = 0.003), ≥1 serving of butter, margarine, or cream per day (p = 0.041) or ≥3 servings of fish/seafood per week (p = 0.058) had significantly lower levels of CRP. Conclusions: Adherence to a Mediterranean-type diet measured by a simple questionnaire is associated with lower CRP concentration. However, this association seems to be particularly related to a higher consumption of vegetables, fruits, dairy products, and fish.

Evaluating FINDRISC as a screening tool for type 2 diabetes among overweight adults in the PREVIEW:NZ cohort

AIMS

This study aimed to evaluate the efficacy of a high (≥12) Finnish diabetes risk (FINDRISC) score in identifying undiagnosed prediabetes and type 2 diabetes (T2D) in an New Zealand population of overweight and obese individuals, across a variety of ethnic groups.

METHODS

We estimated the efficacy of elevated FINDRISC scores in predicting prediabetes and T2D in 424 overweight adults with no prior diagnosis recruited for the PREVention of diabetes through lifestyle Interventions in Europe and Worldwide (PREVIEW) study. All participants who completed the FINDRISC questionnaire during a pre-screening phase with a score of ≥12 were then screened using a 2h oral glucose tolerance test (2h-OGTT) to identify undiagnosed dysglycaemia.

RESULTS

Of the 424 participants, 65% (n=280) were pre-diabetic and 7% (n=32) had undiagnosed T2D. A higher FINDRISC score was significantly associated with prediabetes and T2D (P=0.02). There was a significant association between ethnicity and glycaemic status (normal vs prediabetes/T2D, P=0.02). Increasing the FINDRISC cut-off to ≥15 resulted in a non-significant increase in the proportion of participants correctly classified with dysglycaemia. ROC-AUC=0.6 with sensitivity=0.6026 (95% CI: 0.5459-0.6573) and specificity=0.5536 (95% CI: 0.4567-0.6476). Isolated impaired fasting glucose (IFG) was more efficient in predicting dysglycaemia than isolated impaired glucose tolerance (IGT).

CONCLUSIONS

The FINDRISC questionnaire is a useful and efficacious screening tool to identify unknown prediabetes and T2D in overweight New Zealanders, particularly in Maori individuals.

Prevalence of peripheral artery disease (PAD) and factors associated: An epidemiological analysis from the population-based Screening PRE-diabetes and type 2 DIAbetes (SPREDIA-2) study

AIM

To describe the prevalence of Peripheral Artery Disease (PAD) in a random population sample and to evaluate its relationship with Mediterranean diet and with other potential cardiovascular risk factors such as serum uric acid and pulse pressure in individuals ranged 45 to 74 years.

METHODS

Cross-sectional analysis of 1568 subjects (mean age 6.5 years, 43% males), randomly selected from the population. A fasting blood sample was obtained to determine glucose, lipids, and HbA1C levels. An oral glucose tolerance test was performed in non-diabetic subjects. PAD was evaluated by ankle-brachial index and/or having a prior diagnosis.

RESULTS

PAD prevalence was 3.81% (95% CI, 2.97-4.87) for all participants. In men, PAD prevalence was significantly higher than in women [5.17% (95% CI, 3.74-7.11) vs. 2.78% (95% CI, 1.89-4.07); p = 0.014]. Serum uric acid in the upper quartile was associated with the highest odds ratio (OR) of PAD (for uric acid > 6.1 mg/dl, OR = 4.31; 95% CI, 1.49-12.44). The remaining variables more strongly associated with PAD were: Heart rate >90 bpm (OR = 4.16; 95%CI, 1.62-10.65), pulse pressure in the upper quartile (≥ 54 mmHg) (OR = 3.82; 95%CI, 1.50-9.71), adherence to Mediterranean diet (OR = 2.73; 95% CI, 1.48-5.04), and former smoker status (OR = 2.04; 95%CI, 1.00-4.16).

CONCLUSIONS

Our results show the existence of a low prevalence of peripheral artery disease in a population aged 45-74 years. Serum uric acid, pulse pressure and heart rate >90 bpm were strongly associated with peripheral artery disease. The direct association between Mediterranean diet and peripheral artery disease that we have found should be evaluated through a follow-up study under clinical practice conditions.

Risk factors associated with the carotid intima-media thickness and plaques: ESPREDIA Study

OBJECTIVE

To evaluate whether there were any differences in the risk factor profile associated with either the intima-media thickness (IMT) or the presence of carotid plaques.

METHODS

Cross-sectional study in 1475 subjects between 45 and 75years, randomly selected from the population of the Northwest area of Madrid (Spain). They had a physical exam, blood analysis, and ultrasound measurement of the IMT and of the presence of plaques.

RESULTS

Mean IMT was 0.725±0.132mm. Forty seven percent of the participants had carotid plaques. In multivariate analysis, factors directly associated with the IMT were, age (β0.227, P<.0001), sex (β0.104, P<.0001), presence of hypertension (β0.082, P=.002), diabetes (β0.130, P<.0001) and current smoking (β0.107, P<.0001), systolic blood pressure (SBP) (β0.219, P<.0001) and LDL-cholesterol levels (β0.074, P=.003), and inversely, diastolic blood pressure (DBP) (β-0.124, P=.001), HDL-cholesterol (β-0.111, P<.0001) and triglyceride levels (β-0.060, P=.028). The presence of plaques was directly associated with age (OR1.08; 95%CI: 1.05-1.10), sex (OR1.95; 95%CI: 1.52-2.51), current smoking (OR2.75; 95%CI: 1.92-3.95), history of hypertension (OR1.58; 95%CI: 1.22-2.04) or diabetes (OR1.84; 95%CI: 1.31-2.58), statin treatment (OR1.56; 95%CI: 1.19-2.04) and SBP (OR1.03; 95%CI: 1.02-1.05), and inversely with DBP (OR0.98; 95%CI: 0.96-0.99).

CONCLUSION

Factors associated with the IMT and the presence of plaques are similar, a finding that support a continuum between muscular layer hypertrophy and arteriosclerosis development.

Clinical applicability and cost-effectiveness of DIABSCORE in screening for type 2 diabetes in primary care

AIMS

To evaluate the applicability and cost-effectiveness of a clinical risk score (DIABSCORE) to screen for type 2 diabetes in primary care patients.

METHODS

Multicenter cross-sectional study of 10,508 adult no previously diagnosed with diabetes, in 2 Spanish regions (Canary Islands and Valencian Community). The variables comprising DIABSCORE were age, waist to height ratio, family history of diabetes and gestational diabetes. ROC curves were obtained; the diabetes prevalences odds ratios (HbA1c ≥6.5%) between patients exposed and not exposed to DIABSCORE ≥100, and to fasting blood glucose ≥126mg/dL were calculated. The opinions of both the professionals and the patients concerning DIABSCORE were collected, and a cost-effectiveness analysis was performed.

RESULTS

In both regions, the valid cut-off point for diabetes (DIABSCORE=100), showed an area under the curve >0.80. The prevalences odds ratio of diabetes for DIABSCORE ≥100 was 9.5 (3.7-31.5) in Canarian and 18.3 (8.0-51.1) in Valencian; and for glucose ≥126mg/dL it was, respectively, 123.0 (58.8-259.2) and 303.1 (162.5-583.8). However, glucose ≥126mg/dL showed a low sensitivity (below 48% in both communities) as opposed to DIABSCORE ≥100 (above 90% in both regions). Professionals (100%) and patients (75%) satisfaction was greater when using DIABSCORE rather than glucose measurement for diabetes screening. The cost of each case of diabetes identified was lower with DIABSCORE ≥100 (7.6 € in Canarian and 8.3 € in Valencian) than glucose ≥126mg/dL (10.8 € and 10.5 €, respectively).

CONCLUSIONS

DIABSCORE is an applicable and cost-effective screening method for type 2 diabetes in primary care.

Healthy lifestyle and normal waist circumference are associated with a lower 5-year risk of type 2 diabetes in middle-aged and elderly individuals: Results from the healthy aging longitudinal study in Taiwan (HALST)

Type 2 diabetes mellitus (DM) is known to be closely associated with lifestyle and obesity and has a prevalence that increases with age. This study aimed to assess the short-term composite effect of diet, physical activity, psychosocial health, and waist circumference (WC) on the incidence of DM in the elderly and to provide a lifestyle-based predictive index.We used baseline measurements (2009-2013) of 5349 community-dwelling participants (aged 55 years and older, 52% female) of the Healthy Aging Longitudinal Study in Taiwan (HALST) for fasting plasma glucose, HbA1C, serum cholesterol, triglycerides, blood pressures, WC, and outcomes of home-visit questionnaire. Principal component analysis (PCA) was used to identify participants with a healthy lifestyle (HLF: higher diet, physical activity, and psychosocial scores) and a lower WC, with cutoffs determined by the receiver-operating characteristics. A Cox regression model was applied to 3424 participants without DM at baseline by linking to their National Health Insurance records (median follow-up of 3.1 years).In total, 247 new DM cases (7.2%) were identified. The HLF and lower WC group had a relative risk (RR) of DM of 0.54 (95% CI 0.35-0.82) compared to the non-HLF and higher WC group. When stratified by the presence of impaired glucose tolerance (IGT) or metabolic syndrome (MS), only participants with IGT/MS showed significant risks (RR 0.55; 95% CI 0.33-0.92). However, except for WC, the individual lifestyle factors were nonsignificant in the overall model without PCA.A composite protective effect of HLF and normal WC on DM within 5 years was observed, especially in those with IGT or MS. Psychosocial health constituted an important lifestyle factor in the elderly. The cutoffs identified could be used as a lifestyle-based risk index for DM. Maintaining an HLF to prevent DM is especially important for the elderly.

Performance of the Finnish Diabetes Risk Score and a Simplified Finnish Diabetes Risk Score in a Community-Based, Cross-Sectional Programme for Screening of Undiagnosed Type 2 Diabetes Mellitus and Dysglycaemia in Madrid, Spain: The SPREDIA-2 Study

Aim

To evaluate the performance of the Finnish Diabetes Risk Score (FINDRISC) and a simplified FINDRISC score (MADRISC) in screening for undiagnosed type 2 diabetes mellitus (UT2DM) and dysglycaemia.

Methods

A population-based, cross-sectional, descriptive study was carried out with participants with UT2DM, ranged between 45–74 years and lived in two districts in the north of metropolitan Madrid (Spain). The FINDRISC and MADRISC scores were evaluated using the area under the receiver operating characteristic curve method (ROC-AUC). Four different gold standards were used for UT2DM and any dysglycaemia, as follows: fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), HbA1c, and OGTT or HbA1c. Dysglycaemia and UT2DM were defined according to American Diabetes Association criteria.

Results

The study population comprised 1,426 participants (832 females and 594 males) with a mean age of 62 years (SD = 6.1). When HbA1c or OGTT criteria were used, the prevalence of UT2DM was 7.4% (10.4% in men and 5.2% in women; p<0.01) and the FINDRISC ROC-AUC for UT2DM was 0.72 (95% CI, 0.69–0.74). The optimal cut-off point was ≥13 (sensitivity = 63.8%, specificity = 65.1%). The ROC-AUC of MADRISC was 0.76 (95% CI, 0.72–0.81) with ≥13 as the optimal cut-off point (sensitivity = 84.8%, specificity = 54.6%). FINDRISC score ≥12 for detecting any dysglycaemia offered the best cut-off point when HbA1c alone or OGTT and HbA1c were the criteria used.

Conclusions

FINDRISC proved to be a useful instrument in screening for dysglycaemia and UT2DM. In the screening of UT2DM, the simplified MADRISC performed as well as FINDRISC.