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The Arab Risk (ARABRISK): Translation and validation
Abstract
The Canadian Risk (CANRISK) is a self-administered questionnaire that identifies people at high risk for developing type 2 diabetes. The purpose of this study was to translate the CANRISK into the Arabic language and evaluate the reliability and validity of the Arabic version of the CANRISK (ARABRISK). In this cross-sectional study design, the CANRISK was first translated into Arabic according to the World Health Organization forward/backward translation protocol for translating assessment tools. Subsequently, the ARABRISK was administered to a convenience sample of people in Jordan and in the capital of Saudi Arabia (Riyadh). The test-retest reliability and convergent validity of the ARABRISK with fasting plasma glucose (FPG) were examined. A total of 538 participants were recruited from Jordan and Riyadh. The ARABRISK total score ranged from 3-59 (mean=25, SD=12). The ARABRISK score reflected high agreement for test-retest reliability (ICC3,1=.98, CI=.97-.99) and correlated significantly with FPG (r=0.3, P=.01). The ARABRISK was developed and reflected high reliability and validity in Jordan and Riyadh.
... The Canadian Diabetes Risk Questionnaire (CanRisk) (Robinson et al., 2011) is a recently developed risk calculator that was modified from the FINDRISC to identify risk (Guo et al., 2018), Arabic (Alghwiri et al., 2014), ...
... into the instrument. (Alghwiri et al., 2014;Guo et al., 2018;Lourenço et al., 2021), and we found 0.99 which was similar to the literature. , 2015). ...
... knowledge there are only three versions of CanRisk adapted and validated. These are Chinese(Guo et al., 2018), Arab(Alghwiri et al., 2014) and Brazilian Portuguese(Lourenço et al., 2021) language versions of the CanRisk. To ensure psychometric robustness when tools created in one cultural context are used in another, empirical verification is required. ...
Objectives: The aim of the study was to examine the test-retest reliability and external validity of the Canadian Diabetes Risk Questionnaire (CanRisk). Materials and Methods: Individuals over 40 years of age without any disease were included in the study. Participants were administered the CanRisk, Nottingham Health Profile (NHP), and Visual Analog Scale (VAS). CanRisk test-retest validity was calculated with the interclass correlation coefficient (ICC), and external validity was calculated with the Pearson correlation coefficient. Results: The study included 1349 participants, 549 men and 755 women (mean age 50.03 ± 8.05 years). CanRisk test-retest validity was found to be excellent (0.99). Its external validity was evaluated by examining its correlation with NHP, and it was found that there was a statistically significant, positive weak correlation (p<0.05, r= 0.23). Conclusion: CanRisk -TR was found to be a reliable and valid questionnaire to predict diabetes risk.
... Among these, FINDRISC provided the basis for CAN-RISK, which was modified to account for different ethnicities in Canada and has since been translated into Arabic as the Arab Diabetes Risk Assessment Questionnaire (ARABRISK). A tool validated by researchers in Saudi Arabia and Jordan [11], ARABRISK consists of questions addressing 12 risk factors for diabetes and categorizes individuals as being at very high risk, high risk, or low to moderate risk of being diagnosed with diabetes within the next 10 years. ...
... In our survey, we used the Arabic version of CANRISK [11], a validated tool with high reliability and validity in Saudi and Jordanian populations that consists of 12 questions used to assess the risk of developing T2DM. Although CANRISK was developed for adults aged 40-74 years old, it can also be used by younger adults, according to the Canadian Task Force on Preventive Health Care's recommendations on screening for T2DM in adults [14]. ...
... In that light, the percentage of participants with a high risk of developing T2DM in our study could be 26% (n = 1187). Second, because CANRISK was translated into Arabic and validated by Alghwiri et al. and showed high reliability and validity in Saudi and Jordanian populations [11], we did not conduct a pilot study to validate the survey. Nevertheless, no study to date has confirmed the validity of the tool among young adults in Saudi Arabia. ...
Type 2 diabetes mellitus (T2DM) is a chronic disease with ever-increasing prevalence worldwide. In our study, we evaluated the prevalence of the risk of developing T2DM in Saudi Arabia and investigated associations between that risk and various sociodemographic characteristics. To those ends, a web-based cross-sectional survey of Saudi nationals without diabetes, all enrolled using snowball sampling, was conducted from January 2021 to January 2022. The risk of developing T2DM was evaluated using a validated risk assessment questionnaire (ARABRISK), and associations of high ARABRISK scores and sociodemographic variables were explored in multivariable logistic regression modeling. Of the 4559 participants, 88.1% were 18 to 39 years old, and 67.2% held a college or university degree. High ARABRISK scores were observed in 7.5% of the sample. Residing in a midsize city versus a large city was associated with a lower ARABRISK risk score (p = 0.007), as were having private instead of governmental insurance (p = 0.005), and being unemployed versus employed (p < 0.001). By contrast, being married (p < 0.001), divorced or widowed (p < 0.001), and/or retired (p < 0.001) were each associated with a higher ARABRISK score. A large representative study is needed to calculate the risk of T2DM among Saudi nationals.
... Targeted screening for dysglycemia with a screening questionnaire as a first step has been shown to be successful in detecting dysglycemia and allowing early intervention 10,[17][18][19][20][21] . Attempts to construct a Saudi diabetes risk score proposed previously [28][29][30] included various limitations preventing their wide adoption. Therefore, we aimed to develop a valid and easy to administer tool, so that the selection of variables and their relative weights to be included in the Saudi Diabetes Risk Score (SADRISC) are best suited to identify Saudi individuals who have undiagnosed type 2 diabetes or prediabetes. ...
... However, the predictive validity of the developed SADRISC model was confirmed to be better with the area under the curve of 0.76 compared with 0.71 for the FINDRISC. Three previous attempts to develop type 2 diabetes risk scores that included participants from Saudi Arabia have been carried out [28][29][30] . However, each of them had serious limitations preventing their use in practice. ...
... Additional limitations were lack of standardization of equipment used for measurements, and variability as a result of inadequate standardization of measurement techniques. The second study 29 included only a small sample of Saudis from Riyadh (81 men and 20 women). In addition, only fasting blood glucose was used to diagnose dysglycemia, which would exclude those with impaired glucose tolerance requiring an OGTT to be detected, and which constituted the majority of people with dysglycemia among people free of known diabetes, as also shown in the present study. ...
Aim:
To develop a non- invasive risk score to identify Saudis having prediabetes or undiagnosed type 2 diabetes (T2DM) METHODS: Non-diabetic adult Saudis were recruited randomly using stratified two-stage cluster sampling method. Demographic, dietary, lifestyle variables, personal and family medical history were collected using a questionnaire. Blood pressure, and anthropometric measurements were taken. Body mass index (BMI) was calculated. 1-hour oral glucose tolerance test (1h OGTT) was conducted. Glycated hemoglobin (HbA1c), fasting (FPG) and 1h plasma glucose (1-hPG) were measured, and obtained values used to define prediabetes and T2DM (dysglycemia). Logistic regression models were used for assessing association between various factors, and dysglycemia, and Hosmer-Lemeshow summary statistics to assess the goodness-of-fit.
Results:
791 men and 612 women were included, of whom 69 were found to be diabetic, and 259 prediabetic. Prevalence of dysglycemia was 23%, increasing with age, reaching 71% in adults aged ≥ 65 years. In univariate analysis age, BMI, waist circumference (WC), use of antihypertensive medication, history of hyperglycemia, low physical activity, short sleep and family history of diabetes were statistically significant. Final model for Saudi Diabetes Risk Score (SADRISC) constituted of: sex, age, WC, history of hyperglycemia and family history of diabetes, with score ranging from 0 to 15. Its fit based on assessment using ROC curve was good with AUC 0.76 (95% CI 0.73-0.79). Proposed cut-point for dysglycemia is 5 or 6, with sensitivity and specificity being approximately 0.7.
Conclusion:
SADRISC is a simple tool which can effectively distinguish Saudis at high risk of dysglycemia.
... ARABRISK is an Arabic version of the Canadian Diabetes Risk Assessment Questionnaire (CANRISK), which was adapted and validated for the use in Arab-speaking individuals in Saudi Arabia and Jordan. [8] ...
... ARABRISK is a reliable and valid scale for the use in Arab-speaking individuals. [8] AR-ABRISK score is interpreted by adding up raw scores for each of the 12 items and divided into 3 risk categories: low risk < 21; moderate risk 21 to 32; and high risk ≥ 33. [8] The ethical approval was attained from the University of Jordan ethical committee, Amman, Jordan and Rehabilitation Research Chair, King Saud University, Riyadh, Saudi Arabia to conduct this research. ...
... [8] AR-ABRISK score is interpreted by adding up raw scores for each of the 12 items and divided into 3 risk categories: low risk < 21; moderate risk 21 to 32; and high risk ≥ 33. [8] The ethical approval was attained from the University of Jordan ethical committee, Amman, Jordan and Rehabilitation Research Chair, King Saud University, Riyadh, Saudi Arabia to conduct this research. Each eligible participant signed a written informed consent. ...
A significant rise in the prevalence of type 2 diabetes mellitus (T2DM) in the Middle-east and North Africa (MENA) region has seen over the last few decades. The present observational study aimed to evaluate and compare the risk of developing T2DM in the cities of Riyadh and Amman using the Arab Diabetes Risk Assessment Questionnaire (ARABRISK).
The ARABRISK was administered in a total of 1116 healthy male and female individuals in the age group of 40 to 74 years with no prior history of diabetes in the city of Riyadh (Saudi Arabia) and Amman (Jordan). ARABRISK is an Arabic version of the Canadian Diabetes Risk Assessment Questionnaire (CANRISK), which was adapted and validated for the use in Arab-speaking individuals in Saudi Arabia and Jordan.
The participants from Amman region had higher mean total ARABRISK score compared to the Riyadh region for all categories of ARABRISK. However, the difference was significant in both low- and high-risk categories (P = .02 and P = .01, respectively) but not significant for moderate category (P = .17). In the Riyadh population, female participants had significantly higher ARABRISK total scores compared to male in both moderate- and high-risk categories (P = .01). However, in the Amman population, male participants had significantly higher ARABRISK total scores compared to female in both low- and moderate-risk categories (P = .01).
The present study suggested an increased risk of developing T2DM in the cities of Riyadh and Amman. However, the population of Amman had a higher risk of developing T2DM compared to the population of Riyadh.
... The ADADRT was translated and validated among the Malaysians [18]. The CANRISK was translated into different languages and tested for its validity and reliability, e.g., among the Arab [19] and the Chinese population [20]. ...
... and correlated significantly with FPG (r = 0.3, P = 0.01). The ARABRISK was developed and reflected high reliability and validity in Jordan and Riyadh [19]. The utility of AUSDRISK to identification and follow up of T2DM risk groups after lifestyle modification was proved by previous research [23]. ...
Objective
The current study aimed to translate the Australian Type 2 Diabetes Risk Assessment tool (AUSDRISK) into the Arabic language and evaluate the reliability and validity of the resultant Arabic version among Egyptians. The AUSDRISK was translated into Arabic language using the World Health Organization (WHO) forward and backward translation protocol. Using the WHO cluster sampling, a sample of 18+ years 719 Egyptians was randomly selected through a population-based household survey. Each participant was interviewed to fill the AUSDRISK Arabic version risk score and undergo confirmatory testing for fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT). Test-retest reliability and convergent validity were computed.
Results
Most of the study participants were physically active (60.5%) and females (69.3%). The Arabic version of the AUSDRISK reflected statistically significant perfect positive correlation (r = 1 and p < 0.01) for test re-test reliability as well as a significant moderate positive correlation with each of FPG (r = 0.48, p < 0.01) and OGTT (r = 0.52, p < 0.01) for the criterion-related (convergent) validity. The recalibrated noninvasive AUSDRISK Arabic version proved to be a simple, reliable, and valid predictive tool, and thereof, its employment for opportunistic mass public screening is strongly recommended. This can reduce diabetes mellitus Type 2disease burden and health expenditure.
... The socio-demographic variables reflect the characteristics of the sample. They were taken from the ARABRISK questionnaire [19], a questionnaire that identifies individuals at high risk of developing T2DM. The socio-demographic variables were: gender, age, and level of education. ...
... The variable 'presence of family history for diabetes' represents the familiarity or genetic factor and was taken from the ARABRISK questionnaire [19]. ...
Introduction: The prevalence of type 2 diabetes mellitus (T2DM) in Lebanon is ranked twelfth in the MENA region. However, few studies have been conducted to determine its risk factors. These could include socio-demographic factors, environmental factors, behavioral factors, and health literacy. The objective of this study is to determine the different risk factors for T2DM and to study the association between health literacy and T2DM in Lebanon. Methods: A case-control study was conducted in Lebanon. Subjects were contacted by phone on randomly selected numbers. The cases and the controls were reached by the same method due to COVID-19. ARABRISK, BRIEF, Lebanese Mediterranean Diet Scale, WHOQOL-BREF and the BDS22 were included in the questionnaire. Results: 232 individuals were included in the analysis. Women versus men (adjusted OR = 0.31; 95% CI 0.127 to 0.763), age (adjusted OR = 1.06; 95% CI 1.03 to 1.10), BMI (adjusted OR = 1.16; 95% CI 1.045 to 1.291), individuals with a family history of T2DM versus individuals with no history of T2DM (adjusted OR = 2.40; 95% CI 1.051 to 5.495), and people with limited health literacy versus people with adequate health literacy (adjusted OR = 3.24; 95% CI 1.225-8.584) were associated with T2DM. Quality of life, psychological distress, and education were not significantly associated with T2DM. Discussion or Conclusion: These results introduced a new factor that could play an important role in the development of T2DM, which is the health literacy. Therefore, it is necessary to pay particular attention to this factor and to conduct additional studies concerning its association with T2DM. The association between quality of life and T2DM and psychological distress and T2DM should also be studied.
... Although the CANRISK is available in 13 other countries (languages: English, French, Chinese, Gujarati, Korean, Persian/Farsi, Punjabi, Spanish, Tagalog, Tamil, Urdu, and Vietnamese) 10 , to the best of our knowledge, these translations do not seem to have cross-cultural adaptation and validation in accordance with best international practices 14 . There are only two versions of the CANRISK adapted cross-culturally and validated, one for Chinese with appropriate psychometric properties (CHINARISK) 12 and other for the Arabic version (ARABRISK) 19 . It is also worth mentioning that the ARABRISK performed the test-retest on the same day, which is not an advisable practice according to the COSMIN guideline 14 . ...
Objective:
The aim of this study was to translate, cross-culturally adapt, and validate the Canadian Diabetes Risk Questionnaire for use in Brazilian Portuguese.
Methods:
This is a Questionnaire validity study conducted at a private university. The Brazilian version of the Canadian Diabetes Risk Questionnaire was developed by means of the processes of translation, back-translation, committee review, and pretesting. Test-retest reliability was measured using the intraclass correlation coefficient and kappa coefficient. Internal consistency was measured using Cronbach's alpha. For construct validity, the total score of the Canadian Diabetes Risk Questionnaire was correlated with the Diabetes Knowledge Scale and the Diabetes Mellitus Risk Questionnaire. Ceiling and floor effects were also evaluated in the present study.
Results:
For construct validity and floor and ceiling effect measurements, a total sample of 100 participants was used. For reliability, a subsample of 34 participants out of the total sample was used. We identified adequate values for reliability (kappa between 0.46-1.00 and ICC 0.96) and internal consistency (Cronbach's alpha 0.80). There were significant correlations between the Canadian Diabetes Risk Questionnaire and the Diabetes Mellitus Risk Questionnaire (rs=0.370, p<0.001), but not the Diabetes Knowledge Scale (rs= -0.162). No ceiling or floor effects were found.
Conclusion:
We concluded that in accordance with the best international recommendations, the Brazilian version of the Canadian Diabetes Risk Questionnaire has adequate psychometric properties.
... CANRISK has also been used in a variety of peer-reviewed scientific journal publications, such as assessing the association of walking to diabetes risk 17 and predicting postpartum dysglycemia 18 . It has also been used internationally having been translated into Arabic and entitled "ARABRISK" and validated by a group of academic researchers in Jordan and Saudi Arabia using Jordanian and Saudi Arabian populations 19,20 . Additionally, it was used to assess diabetes risk factors in hospital employees in Ethiopia 21 , and was also determined useful as an alternative to expensive invasive blood tests in rural India 22 . ...
... An Arabic version of the CANRISK was adapted and validated to enable use with Arab-speaking people in Jordan and Saudi Arabia. 18 The Arab Diabetes Risk Assessment Questionnaire (ARABRISK) represents an Arabic questionnaire designed to screen a person's risk of developing T2D or prediabetes in an Arab population. ...
The prevalence of diabetes in Jordan has been increasing. The early diagnosis of diabetes is vital to slow its progression. The Arab Risk (ARABRISK) screening tool is a self-administered questionnaire used to determine people who are at high risk for developing diabetes. This study aimed to identify people at high risk for developing type 2 diabetes by using the ARABRISK in the capital of Jordan.
A cross-sectional study was conducted with a convenience sample of people in the capital of Jordan. The ARABRISK screening tool was administered to identify the participants’ risk for developing diabetes. In addition to descriptive statistics, percentages of the ARABRISK categories were represented, and an independent samples t test was used to explore the differences between men and women. A total of 513 participants with a mean age of 51.94 (SD = 10.33) were recruited; 64.9% of the participants were men (n = 333).
The total ARABRISK score ranged from 0 to 25 with a mean score of 12.30 (SD = 4.76). Using the independent samples t test, women (mean = 13.25, SE = 0.10) had significantly higher ARABRISK total scores than men did (mean = 12.95, SE = 0.09), t(141) = −2.23, P = 0.03 in the “moderate risk” category. All of the items in the ARABRISK questionnaire were found to be good predictors of the ARABRISK total scores. Among them, age, body mass index (BMI), and high blood glucose (HBG) were the best predictors as indicated by the standardized regression coefficient (β). Older age, obesity, elevated weight circumference, absence of daily physical activity, daily consumption of fruits/vegetables, presence of high blood pressure (HBP), and HBG were significantly associated with increased odds of high ARABRISK total scores. Neither a history of gestational diabetes nor a positive family history was associated with an increased odds of high ARABRISK total scores.
By identifying risk factors in these participants, interventions and lifestyle changes can be suggested and implemented to reduce the risk and incidence of diabetes.
My thesis considers the theme of comorbidity between cardiometabolic disorders and schizophrenia by focussing on three key aspects: the nature of association between cardiometabolic disorders and schizophrenia; the potential for common underlying biological mechanisms for the comorbidity; and the prediction of cardiometabolic risk in young adults with psychosis. On the nature of association between cardiometabolic disorders and schizophrenia, using longitudinal repeat measure data from a large birth cohort, I found that disruption to glucose-insulin homeostasis through childhood/adolescence is associated with increased risk of psychosis in early-adulthood; may not be fully explained by common sociodemographic and lifestyle factors; and may be specific to it. On the mechanisms of association between cardiometabolic disorders and schizophrenia, I used a range of genetic and observational epidemiological methods to examine whether inflammation and shared genetic liability may be common underlying biological mechanisms for the comorbidity. Using birth cohort data, I show that genetic risk for type 2 diabetes is associated with psychosis-risk in adulthood, and vice versa. I also show that genetic risk for type 2 diabetes may influence psychosis risk by increasing systemic inflammation. Using summary data from large genome-wide association studies (GWAS), I show a thread of evidence for shared genetic overlap between schizophrenia, cardiometabolic and inflammatory traits. Finally, using Mendelian randomization, I show evidence supporting that inflammation may be a common cause for insulin resistance and schizophrenia. On the prediction of cardiometabolic risk in young adults with psychosis, I performed a systematic review of cardiometabolic risk prediction algorithms and explored their predictive performance in a sample of young people at risk of developing psychosis. In doing so, I show that none are likely to be suitable for this population. Then, using patient data, I developed and externally validated the Psychosis Metabolic Risk Calculator (PsyMetRiC), the first cardiometabolic risk prediction algorithm specifically tailored for young people with psychosis. Together, my work suggests that cardiometabolic disorders and schizophrenia share aetiologic mechanisms, namely inflammation and shared genetic liability. I have shown that it is possible to accurately predict cardiometabolic risk in young people with psychosis using a tool tailored for the population. Such tools can in future become valuable resources for clinicians to reduce the risk of long-term cardiometabolic morbidity and mortality in people with schizophrenia.
Objective
Cardiometabolic risk prediction algorithms are common in clinical practice. Young people with psychosis are at high‐risk for developing cardiometabolic disorders. We aimed to examine whether existing cardiometabolic risk prediction algorithms are suitable for young people with psychosis.
Methods
We conducted a systematic review and narrative synthesis of studies reporting the development and validation of cardiometabolic risk prediction algorithms for general or psychiatric populations. Furthermore, we used data from 505 participants with, or at risk of psychosis at age 18years in the ALSPAC birth cohort, to explore the performance of three algorithms (QDiabetes, QRISK3, PRIMROSE) highlighted as potentially suitable. We repeated analyses after artificially increasing participant age to the mean age of the original algorithm studies to examine the impact of age on predictive performance.
Results
We screened 7,820 results, including 110 studies. All algorithms were developed in relatively older participants, and most were at high‐risk of bias. Three studies (QDiabetes, QRISK3, PRIMROSE) featured psychiatric predictors. Age was more strongly weighted than other risk factors in each algorithm. In our exploratory analysis, calibration plots for all three algorithms implied a consistent systematic underprediction of cardiometabolic risk in the younger sample. After increasing participant age, calibration plots were markedly improved.
Conclusion
Existing cardiometabolic risk prediction algorithms cannot be recommended for young people with, or at risk of psychosis. Existing algorithms may under‐predict risk in young people, even in the face of other high‐risk features. Recalibration of existing algorithms, or a new tailored algorithm for the population is required.
Self-reported prediabetes and diabetes rates underestimate true prevalence, but mass laboratory screening is generally impractical for risk assessment and surveillance. We developed the Abnormal Glucose Risk Assessment-6 (AGRA-6) tool to address this problem.
Self-report data were obtained from the 1,887 adults (18 years or older) in the National Health and Nutrition Examination Survey (NHANES) 2005-2006 with fasting plasma glucose and oral glucose tolerance tests. We created AGRA-6 models by using logistic regression. Performance was validated with NHANES 2005-2006 data by using leave-1-out cross-validation. Standard performance characteristics (sensitivity, specificity, predictive values, area under receiver-operating characteristic curves) were assessed, as was the potential efficiency of the models to reduce laboratory testing in screening efforts.
Performance was good for all models under testing conditions. Use of the AGRA-6 in screening efforts could reduce laboratory testing by at least 30% when sensitivity is maximized and at least 52% when sensitivity and specificity are balanced.
The AGRA-6 appears to be an effective, feasible tool that uses self-reported data compatible with the Behavioral Risk Factor Surveillance System to assess population-level prevalence, identify abnormal glucose levels, optimize screening efforts, and focus interventions to reduce the prevalence of abnormal glucose levels.
Fifty-four million people in the United States have impaired fasting glucose (IFG); if it is identified, they may benefit from prevention strategies that can minimize progression to diabetes, morbidity, and mortality. We created a tool to identify those likely to have undetected hyperglycemia.
We undertook a cross-sectional analysis of existing data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 of 4,045 US adults aged 20 to 64 years who did not have a diagnosis of diabetes who had a measured fasting plasma glucose. Using characteristics that are self-reported or measured without laboratory data, we developed a logistic regression model predicting IFG and undiagnosed diabetes. Based on this model, we created TAG-IT (the Tool to Assess likelihood of fasting Glucose ImpairmenT), validated it using NHANES III, examined race and ethnicity subsets, and compared it with body mass index (BMI) alone.
Predictors in the final tool were age, sex, BMI, family history of diabetes, resting heart rate, and history of hypertension (or measured high blood pressure), which yielded an area under the curve (AUC) of 0.740, significantly better than BMI alone (AUC = 0.644).
The TAG-IT efficiently identifies those most likely to have abnormal fasting glucose and can be used as a decision aid for screening in clinical and population settings, or as a prescreening tool to help identify potential participants for research. The TAG-IT represents an improvement over BMI alone or a list of risk factors in both its utility in younger adult populations and its ability to provide clinicians and researchers with a strategy to assess the risks of combinations of factors.
Objective: To provide a practical guide to appropriate statistical analysis of a reliability study using real-time ultrasound for measuring muscle size as an example.
Design: Inter-rater and intra-rater (between-scans and between-days) reliability.
Subjects: Ten normal subjects (five male) aged 22–58 years.
Method: The cross-sectional area (CSA) of the anterior tibial muscle group was measured using real-time ultrasonography.
Main outcome measures: Intraclass correlation coefficients (ICCs) and the 95% confidence interval (CI) for the ICCs, and Bland and Altman method for assessing agreement, which includes calculation of the mean difference between measures (d), the 95% CI for d, the standard deviation of the differences (SD diff), the 95% limits of agreement and a reliability coefficient.
Results: Inter-rater reliability was high, ICC (3,1) was 0.92 with a 95% CI of 0.72 → 0.98. There was reasonable agreement between measures on the Bland and Altman test, as d was -0.63 cm², the 95% CI for d was -1.4 → 0.14 cm², the SDdiff was 1.08 cm², the 95% limits of agreement -2.73 → 1.53 cm² and the reliability coefficient was 2.4. Between-scans repeatability was high, ICCs (1,1) were 0.94 and 0.93 with 95% CIs of 0.8 → 0.99 and 0.75 → 0.98, for days 1 and 2 respectively. Measures showed good agreement on the Bland and Altman test: d for day 1 was 0.15 cm² and for day 2 it was -0.32 cm², the 95% CIs for d were -0.51 → 0.81 cm² for day 1 and -0.98 → 0.34 cm² for day 2; SDdiff was 0.93 cm² for both days, the 95% limits of agreement were -1.71 → 2.01 cm² for day 1 and -2.18 → 1.54 cm²for day 2; the reliability coefficient was 1.80 for day 1 and 1.88 for day 2. The between-days ICC (1,2) was 0.92 and the 95% CI 0.69 0.98. The d was -0.98 cm², the SDdiff was 1.25 cm² with 95% limits of agreement of -3.48 → 1.52 cm² and the reliability coefficient 2.8. The 95% CI for d(-1.88 → -0.08 cm²) and the distribution graph showed a bias towards a larger measurement on day 2.
Conclusions: The ICC and Bland and Altman tests are appropriate for analysis of reliability studies of similar design to that described, but neither test alone provides sufficient information and it is recommended that both are used.
To study the prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) and their risk factors in Jordan.
A cross-sectional study in four Jordanian communities was conducted: Sarih in the north, Sikhra in the middle of the country, Mazar in the south and Subha-Subheih in the east. Within each community, a systematic sample of households was selected. All subjects > or =25 years of age within the selected households were invited to participate in the study. A total of 2836 subjects were actually included in the study with an overall response rate of 70.5%(45% in males and 86% in females). World Health Organization criteria were adopted for the diagnosis of DM (fasting plasma glucose > or =7.8 mmol L(-1) or plasma glucose of > or =11.1 mmol L(-1), 2 h after an oral anhydrous glucose load of 75 g) and IGT (fasting plasma glucose <7.8 mmol L(-1)and plasma glucose between 7.8 mmol L(-1) and 11.1 mmol L(-1), 2 h after an oral glucose load of 75 g).
The overall prevalence of DM was 13.4%: 14.9% in males and 12.5% in females. IGT was found in 9.8% of the study population: 9.0% in males and 10.3%, in females. Factors independently related to DM using stepwise logistic regression analysis were sex, age, family history of DM, hypertension, hypercholesterolaemia (HC), and hypertriglyceridaemia (HTG).
Diabetes mellitus and IGT are common among adult Jordanians. Considering the high prevalence of this sickness makes it imperative to formulate a national plan to face this disease and its complications.
Persons with impaired glucose tolerance (IGT) are known to have an elevated risk of developing diabetes mellitus. Less is known about diabetes risk among persons with impaired fasting glucose (IFG) or with normal glucose levels.
To determine the incidence of diabetes in relation to baseline fasting and postload glucose levels and other risk factors.
Population-based cohort study conducted from October 1989 to February 1992 among 1342 nondiabetic white residents of Hoorn, the Netherlands, aged 50 to 75 years at baseline, in whom fasting plasma glucose (FPG) levels and glucose levels 2 hours after a 75-g oral glucose tolerance test were measured at baseline and at follow-up in 1996-1998.
Cumulative incidence of diabetes, defined according to the diagnostic criteria of the World Health Organization (WHO-1985 and WHO-1999) and the American Diabetes Association (ADA-1997), during a mean follow-up of 6.4 years, compared among participants with IFG, IGT, and normal glucose levels at baseline.
The cumulative incidence of diabetes was 6.1%, 8.3%, and 9.9% according to the WHO-1985, ADA, and WHO-1999 criteria, respectively. The cumulative incidence of diabetes (WHO-1999 criteria) for participants with both IFG and IGT was 64.5% compared with 4.5% for those with normal glucose levels at baseline. The odds ratios for diabetes (WHO-1999 criteria), adjusted for age, sex, and follow-up duration, were 10.0 (95% confidence interval [CI], 6.1-16.5), 10.9 (95% CI, 6.0-19.9), and 39.5 (95% CI, 17.0-92.1), respectively, for those having isolated IFG, isolated IGT, and both IFG and IGT. In addition to FPG and 2-hour postload glucose levels (P<.001 for both), the waist-hip ratio also was an important risk factor for developing diabetes (P =.002).
In this study, the cumulative incidence of diabetes was strongly related to both IFG and IGT at baseline and, in particular, to the combined presence of IFG and IGT.
Type 2 diabetes mellitus is increasingly common, primarily because of increases in the prevalence of a sedentary lifestyle and obesity. Whether type 2 diabetes can be prevented by interventions that affect the lifestyles of subjects at high risk for the disease is not known.
We randomly assigned 522 middle-aged, overweight subjects (172 men and 350 women; mean age, 55 years; mean body-mass index [weight in kilograms divided by the square of the height in meters], 31) with impaired glucose tolerance to either the intervention group or the control group. Each subject in the intervention group received individualized counseling aimed at reducing weight, total intake of fat, and intake of saturated fat and increasing intake of fiber and physical activity. An oral glucose-tolerance test was performed annually; the diagnosis of diabetes was confirmed by a second test. The mean duration of follow-up was 3.2 years.
The mean (+/-SD) amount of weight lost between base line and the end of year 1 was 4.2+/-5.1 kg in the intervention group and 0.8+/-3.7 kg in the control group; the net loss by the end of year 2 was 3.5+/-5.5 kg in the intervention group and 0.8+/-4.4 kg in the control group (P<0.001 for both comparisons between the groups). The cumulative incidence of diabetes after four years was 11 percent (95 percent confidence interval, 6 to 15 percent) in the intervention group and 23 percent (95 percent confidence interval, 17 to 29 percent) in the control group. During the trial, the risk of diabetes was reduced by 58 percent (P<0.001) in the intervention group. The reduction in the incidence of diabetes was directly associated with changes in lifestyle.
Type 2 diabetes can be prevented by changes in the lifestyles of high-risk subjects.
To evaluate screening strategies based on fasting plasma glucose (FPG), clinical information, and the oral glucose tolerance test (OGTT) for detection of diabetes or other hyperglycemic states-impaired fasting glucose (IFG) and impaired glucose tolerance-meriting clinical intervention.
We studied 8,286 African-American and white men and women without known diabetes, aged 53-75 years, who received an OGTT during the fourth exam of the Atherosclerosis Risk in Communities Study. Using a split sample technique, we estimated the diagnostic properties of various clinical detection rules derived from logistic regression modeling. Screening strategies utilizing FPG, these detection rules, and/or the OGTT were then compared in terms of both the fraction of hyperglycemia cases detected and the sample fraction receiving different screening tests and identified as screen positive.
Screening based on the IFG cut point (> or =6.1 mmol/l), followed by a clinical detection rule for those below this value, detected 86.3% of diabetic case subjects and 66.0% of all hyperglycemia cases, identifying 42% of the sample as screen positive. Applying an OGTT for those positive by the rule provides diagnostic labeling and reduces the fraction that is screen positive to 29%. Another strategy, to apply an OGTT to those with an FPG cut point between 5.6 and 6.1 mmol/l, also identifies 29% of the sample as screen positive, although it detects slightly fewer hyperglycemia cases.
Screening strategies based on FPG, complemented by clinical detection rules and/or an OGTT, are effective and practical in the detection of hyperglycemic states meriting clinical intervention.
The goal of this study was to estimate the prevalence of diabetes and the number of people of all ages with diabetes for years 2000 and 2030.
Data on diabetes prevalence by age and sex from a limited number of countries were extrapolated to all 191 World Health Organization member states and applied to United Nations' population estimates for 2000 and 2030. Urban and rural populations were considered separately for developing countries.
The prevalence of diabetes for all age-groups worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030. The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. The prevalence of diabetes is higher in men than women, but there are more women with diabetes than men. The urban population in developing countries is projected to double between 2000 and 2030. The most important demographic change to diabetes prevalence across the world appears to be the increase in the proportion of people >65 years of age.
These findings indicate that the "diabetes epidemic" will continue even if levels of obesity remain constant. Given the increasing prevalence of obesity, it is likely that these figures provide an underestimate of future diabetes prevalence.
Interventions to prevent type 2 diabetes should be directed toward individuals at increased risk for the disease. To identify such individuals without laboratory tests, we developed the Diabetes Risk Score.
A random population sample of 35- to 64-year-old men and women with no antidiabetic drug treatment at baseline were followed for 10 years. New cases of drug-treated type 2 diabetes were ascertained from the National Drug Registry. Multivariate logistic regression model coefficients were used to assign each variable category a score. The Diabetes Risk Score was composed as the sum of these individual scores. The validity of the score was tested in an independent population survey performed in 1992 with prospective follow-up for 5 years.
Age, BMI, waist circumference, history of antihypertensive drug treatment and high blood glucose, physical activity, and daily consumption of fruits, berries, or vegetables were selected as categorical variables. Complete baseline risk data were found in 4435 subjects with 182 incident cases of diabetes. The Diabetes Risk Score value varied from 0 to 20. To predict drug-treated diabetes, the score value >or=9 had sensitivity of 0.78 and 0.81, specificity of 0.77 and 0.76, and positive predictive value of 0.13 and 0.05 in the 1987 and 1992 cohorts, respectively.
The Diabetes Risk Score is a simple, fast, inexpensive, noninvasive, and reliable tool to identify individuals at high risk for type 2 diabetes.
Increased insulin resistance, which is associated with obesity, is believed to underlie the development of metabolic syndrome. It is also known to increase the risk for the development of glucose intolerance and type 2 diabetes. Both conditions are recognized as causing a high rate of cardiovascular morbidity and mortality.
To assess the prevalence of metabolic syndrome and different glucose intolerance states in healthy, overweight Arab individuals attending a primary healthcare clinic in Israel.
We randomly recruited 95 subjects attending a primary healthcare clinic who were healthy, overweight (body mass index > 27) and above the age of 40. Medical and family history was obtained and anthropometric parameters were measured. Blood chemistry and oral glucose tolerance test were performed after overnight fasting.
Twenty-seven percent of the subjects tested had undiagnosed type 2 diabetes according to WHO criteria, 42% had impaired fasting glucose and/or impaired glucose tolerance and only 31% had a normal OGTT. Metabolic syndrome was found in 48% according to criteria of the U.S. National Cholesterol Education Program, with direct correlation of this condition with BMI and insulin resistance calculated by homeostasis model assessment. Subjects with metabolic syndrome had a higher risk for abnormality in glucose metabolism, and the more metabolic syndrome components the subject had the higher was the risk for abnormal glucose metabolism. Metabolic syndrome predicted the result of OGTT with 0.67 sensitivity and 0.78 specificity. When combined with IFG, sensitivity was 0.83 and specificity 0.86 for predicting the OGTT result.
According to our initial evaluation approximately 70% of the overweight Arab population in Israel has either metabolic syndrome or abnormal glucose metabolism, indicating that they are at high risk to develop type 2 diabetes and cardiovascular morbidity and mortality. This population is likely to benefit from an intervention program.
This study aimed to determine the prevalence of type 2 diabetes mellitus (DM) and impaired fasting glycemia (IFG), identify their associated factors, determine how the prevalence of type 2 DM has changed over 10 years, and assess the awareness and state of control of diabetes in Jordan.
Data were analyzed from a cross-sectional study that included a random sample of 1121 Jordanians aged 25 years and above. A subject was deemed affected by DM if this diagnosis was known to the patient or if his or her condition complies with the American Diabetes Association definition. IFG was defined as a fasting serum glucose level of >or=6.1 mmol/l (110 mg/dl) but <7 mmol/l. HbA(1c) >7.5% was defined as "unsatisfactory" metabolic control.
The age-standardized prevalence of diabetes and IFG was 17.1% and 7.8%, respectively, with no significant differences between women and men. Of the 195 diabetic subjects, 146 (74.9%) had been previously diagnosed. More than half (54%) of those previously diagnosed were found to be with unsatisfactory glycemic control. Compared to the 1994 survey, there was a significant increase in the prevalence of diabetes by 31.5%. Increase in age, increase in body mass index, and having a family history of diabetes were associated with increased odds of diabetes and IFG. While the level of education had no effect on IFG, higher level of education was associated with a decrease in the odds of having diabetes.
The prevalence of type 2 diabetes and IFG is high in Jordan and is increasing. More than half of the patients with diabetes have unsatisfactory control. Therefore, they are likely to benefit from programs aimed at encouraging behaviors toward achieving optimum weight as well as physical activity behaviors. Physicians caring for patients with diabetes may need to adopt a more vigorous approach for diabetes control.
The prevalence of type 2 diabetes in Canada and world- wide has risen more quickly during the last 2 decades than originally forecast. Since 2005, the Public Health Agency of Canada (PHAC) has consulted with leading Canadian and international experts to develop and evaluate a strategy to address the pending diabetes epidemic. Emphasis has been placed on the prevention of type 2 diabetes among high-risk groups with impaired fasting glucose and/or impaired glucose tolerance (also referred to as prediabetes) as growing evidence demonstrates that type 2 diabetes can be prevented or delayed through lifestyle or pharmaco- logical interventions. Before such preventive interventions can be widely applied in Canada, however, practical early detection strategies must be successfully implemented and evaluated. PHAC is developing a "made-in-Canada," non laboratory-based screening questionnaire, validated against the diagnostic gold standard, to identify prediabetes and undiagnosed diabetes among middle-aged adults. This 2-stage screening approach is based on an effective Finnish model (the Finnish Diabetes Risk Score (FINDRISC)), which is being adapted to reflect Canada's multi-ethnic population. Seven provincial pilots are currently underway to field test and validate this screening approach, while also assessing effectiveness and user satisfaction. This new implementation research will help inform Canadian efforts aimed at prevent- ing type 2 diabetes.
Despite high rates of undiagnosed diabetes and prediabetes, suitable risk assessment tools for estimating personal diabetes risk in Canada are currently lacking.
We conducted a cross-sectional screening study that evaluated the accuracy and discrimination of the new Canadian Diabetes Risk Assessment Questionnaire (CANRISK) for detecting diabetes and prediabetes (dysglycemia) in 6223 adults of various ethnicities. All participants had their glycemic status confirmed with the oral glucose tolerance test (OGTT). We developed electronic and paper-based CANRISK scores using logistic regression, and then validated them against reference standard blood tests using test-set methods. We used area under the curve (AUC) summary statistics from receiver operating characteristic (ROC) analyses to compare CANRISK with other alternative risk-scoring models in terms of their ability to discern true dysglycemia.
The AUC for electronic and paper-based CANRISK scores were 0.75 (95% CI: 0.73-0.78) and 0.75 (95% CI: 0.73-0.78) respectively, as compared with 0.66 (95% CI: 0.63-0.69) for the Finnish FINDRISC score and 0.69 (95% CI: 0.66-0.72) for a simple Obesity model that included age, BMI, waist circumference and sex.
CANRISK is a statistically valid tool that may be suitable for assessing diabetes risk in Canada's multi-ethnic population. CANRISK was significantly more accurate than both the FINDRISC score and the simple Obesity model.
To estimate the global health expenditure on diabetes among people aged 20-79 years for the years 2010 and 2030.
Country-by-country expenditures for 193 countries, expressed in United States Dollars (USD) and in International Dollars (ID), were estimated based on the country's age-sex specific diabetes prevalence and population estimates, per capita health expenditures, and health expenditure ratios per person with and without diabetes. Diabetes prevalence was estimated from studies in 91 countries. Population estimates and health expenditures were from the United Nations and the World Health Organization. The health expenditure ratios were estimated based on utilization and cost data of a large health plan in the U.S. Diabetes expenditures for the year 2030 were projected by considering future changes in demographics and urbanization.
The global health expenditure on diabetes is expected to total at least USD 376 billion or ID 418 billion in 2010 and USD 490 billion or ID 561 billion in 2030. Globally, 12% of the health expenditures and USD 1330 (ID 1478) per person are anticipated to be spent on diabetes in 2010. The expenditure varies by region, age group, gender, and country's income level.
Diabetes imposes an increasing economic burden on national health care systems worldwide. More prevention efforts are needed to reduce this burden. Meanwhile, the very low expenditures per capita in poor countries indicate that more resources are required to provide basic diabetes care in such settings.
Type 2 diabetes is common, costly and often goes unrecognised for many years. When patients are diagnosed, the majority exhibit associated tissue damage or established cardiovascular risk. Evidence is accumulating that earlier detection and management of diabetes and related metabolic abnormalities may be beneficial. We aimed to develop and evaluate a score based on routinely collected information to identify people at risk of having undetected diabetes.
A population-based sample of 1077 people, aged 40 to 64 years, without known diabetes, from a single Cambridgeshire general practice, underwent clinical assessment including an oral glucose tolerance test. In a separate 12-month study, 41 practices in southern England reported clinical details of patients aged 40 to 64 years with newly diagnosed Type 2 diabetes. A notional population was created by random selection and pooling of half of each dataset. Data were entered into a regression model to produce a formula predicting the risk of diabetes. The performance of this risk score in detecting diabetes was tested in an independent, randomly selected, population-based sample.
Age, gender, body mass index, steroid and antihypertensive medication, family and smoking history contributed to the score. In the test population at 72% specificity, the sensitivity of the score was 77% and likelihood ratio 2.76. The area under the receiver-operating characteristic curve was 80%.
A simple score, using only data that are routinely collected in general practice, can help identify those at risk of diabetes. This score could contribute to efficient earlier detection through case-finding or targeted screening.
The objective of this study was to develop a simple tool for the U.S. population to calculate the probability that an individual has either undiagnosed diabetes or pre-diabetes.
We used data from the Third National Health and Nutrition Examination Survey (NHANES) and two methods (logistic regression and classification tree analysis) to build two models. We selected the classification tree model on the basis of its equivalent accuracy but greater ease of use.
The resulting tool, called the Diabetes Risk Calculator, includes questions on age, waist circumference, gestational diabetes, height, race/ethnicity, hypertension, family history, and exercise. Each terminal node specifies an individual's probability of pre-diabetes or of undiagnosed diabetes. Terminal nodes can also be used categorically to designate an individual as having a high risk for 1) undiagnosed diabetes or pre-diabetes, 2) pre-diabetes, or 3) neither undiagnosed diabetes or pre-diabetes. With these classifications, the sensitivity, specificity, positive and negative predictive values, and receiver operating characteristic area for detecting undiagnosed diabetes are 88%, 75%, 14%, 99.3%, and 0.85, respectively. For pre-diabetes or undiagnosed diabetes, the results are 75%, 65%, 49%, 85%, and 0.75, respectively. We validated the tool using v-fold cross-validation and performed an independent validation against NHANES 1999-2004 data.
The Diabetes Risk Calculator is the only currently available noninvasive screening tool designed and validated to detect both pre-diabetes and undiagnosed diabetes in the U.S. population.
Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin
- Wc Knowler
- Barrett
- E Connor
- Fowler
- Se
Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346: 393-403.