Development and Validation of a Patient Self-assessment Score for Diabetes Risk
Publication: Annals of Internal Medicine
Volume 151, Number 11
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Abstract
Background:
National guidelines disagree on who should be screened for undiagnosed diabetes. No existing diabetes risk score is highly generalizable or widely followed.
Objective:
To develop a new diabetes screening score and compare it with other available screening instruments (Centers for Disease Control and Prevention, American Diabetes Association, and U.S. Preventive Services Task Force guidelines; 2 American Diabetes Association risk questionnaires; and the Rotterdam model).
Design:
Cross-sectional data.
Setting:
NHANES (National Health and Nutrition Examination Survey) 1999 to 2004 for model development and 2005 to 2006, plus a combined cohort of 2 community studies, ARIC (Atherosclerosis Risk in Communities) Study and CHS (Cardiovascular Health Study), for validation.
Participants:
U.S. adults aged 20 years or older.
Measurements:
A risk-scoring algorithm for undiagnosed diabetes, defined as fasting plasma glucose level of 7.0 mmol/L (126 mg/dL) or greater without known diabetes, was developed in the development data set. Logistic regression was used to determine which participant characteristics were independently associated with undiagnosed diabetes. The new algorithm and other methods were evaluated by standard diagnostic and feasibility measures.
Results:
Age, sex, family history of diabetes, history of hypertension, obesity, and physical activity were associated with undiagnosed diabetes. In NHANES (ARIC/CHS), the cut-point of 5 or more points selected 35% (40%) of persons for diabetes screening and yielded a sensitivity of 79% (72%), specificity of 67% (62%), positive predictive value of 10% (10%), and positive likelihood ratio of 2.39 (1.89). In contrast, the comparison scores yielded a sensitivity of 44% to 100%, specificity of 10% to 73%, positive predictive value of 5% to 8%, and positive likelihood ratio of 1.11 to 1.98.
Limitation:
Data during pregnancy were not available.
Conclusion:
This easy-to-implement diabetes screening score seems to demonstrate improvements over existing methods. Studies are needed to evaluate it in diverse populations in real-world settings.
Primary Funding Source:
Clinical and Translational Science Center at Weill Cornell Medical College.
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Published In
Annals of Internal Medicine
Volume 151 • Number 11 • 1 December 2009
Pages: 775 - 783
History
Published online: 1 December 2009
Published in issue: 1 December 2009
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© 2009 American College of Physicians.
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Development and Validation of a Patient Self-assessment Score for Diabetes Risk. Ann Intern Med.2009;151:775-783. [Epub 1 December 2009]. doi:10.7326/0003-4819-151-11-200912010-00005
Development and Validation of a Patient Self-assessment Score for Diabetes Risk. Ann Intern Med.2009;151:775-783. [Epub 1 December 2009]. doi:10.7326/0003-4819-151-11-200912010-00005
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Diabetes Risk and Screening Instruments
Diabetes Risk and Screening Instruments
Heejung Bang et al (Ann Intern Med December 1, 2009) developed a simple risk score to identify persons at high risk of Diabetes or Pre- Diabetes. This instrument is very important in view of the trend of increased number of obese population and younger persons with diabetes or hypertension, which threatens to stop or even reverse the great advances in cardiovascular diseases prevention already achieved.
It is therefore of the highest importance to identify the younger patients, in their twenties or thirties, who are diabetics or pre- diabetics, hypertensive or pre-hypertensive, with metabolic syndrome, that could benefit with more aggressive preventive measures or appropriate medications, as well as cessation of cigarette smoking at age 30 years or earlier, which adds about 10 years of life expectancy that they would lose if they continued to smoke and do not improve their cardio-metabolic risk.
Ten years ago (Lancet, 13 March 1999), we published that the Pulse Mass Index is a simple way for the preliminary identification of young patient with a high cardiovascular risk, when their Pulse Mass Index is over 1.2 and specially if over 1.3
The Pulse Mass Index is calculated as follows: Pulse or Resting Heart Rate (after at least 2 hours fasting) multiplied by the Body Mass Index and divided by 1730 as common denominator. Normal is a Pulse Mass Index of 1.0 or less (0.7 to 1.0).
A Pulse Mass Index over 1.2 or 1.3 has a correlation with the Framingham Risk Score of 95% in people over 40 years old, but is more sensitive in younger persons, despite their Framingham RS being apparently normal because of their young age.
The practical usefulness of the Pulse Mass Index helps us to identify the persons with high risk that could need more intensive preventive measures or appropriate drugs, after confirmation with the Framingham Risk Score and other appropriate tests.
The Pulse Mass Index can also help us to identify younger patients with pre-diabetes, pre-hypertension, or metabolic syndrome that could also benefit from intensive prevention, including medication.
There is a close association of the PMI with the Metabolic Syndrome and it is also frequently elevated in overweight or obese persons with pre -diabetes, or pre-hypertensive.
The Pulse Mass Index is also the most simple and economical first clinical approach, followed by the Framingham RS for the risk evaluation in a large population of both men and women, and more so in the developing countries, where around 80% of all cardiovascular deaths occurs.
In the last few years, almost a decade after our original publication, several studies have confirmed the importance of the pulse or resting heart rate, as well as the body mass index, the two components of the Pulse Mass Index, as cardiovascular risk factors of first range. Among others the studies: BEAUTIFUL, EUROPA, QRISK, Women Health Initiative (WHI), the Framingham Heart Study and the Framingham Offspring Study.
The Pulse Mass Index is useful in two ways:
1.- For a preliminary, rapid, inexpensive, clinical evaluation of the cardiovascular risk, especially practical in younger people that could require an early prevention or medications, and
2.- To predict the potential benefit or risks of new cardiovascular, metabolic or other drugs.
Lately, we are studying the idea to improve the Pulse Mass Index to form the PULSE MASS PRESSURE PRODUCT (PMPP), an extension of both, the Pulse Mass Index and the Pulse Pressure Product.
I think that the PULSE MASS PRESSURE PRODUCT could give us as clinicians, a more exact initial evaluation of the global cardiovascular risk, of pre-diabetes, pre-hypertension and metabolic syndrome.
These patients should be screened, either with fasting plasma glucose or with GlycoHbA1c or both, and lipids profile.
They should be treated early, either with intensive lifestyle interventions, or appropriate drugs, according to the patients characteristics, to prevent cardiovascular events or complications of diabetes or hypertension in young pre-diabetics or pre-hypertensive people.
For instance, the PULSE MASS PRESSURE PRODUCT (PMPP) can be:
72 (RHR) x 24 (BMI) x 115 (SBP), which totals 198720 or round 200000 (or 200 k) as normal or basic values.
In the case of a young pre-diabetic or pre-hypertensive patient, if he had a PMPP of round 240 k (PMPP x 1.2), he could be a candidate for intensive lifestyle interventions.
If he had a PMPP of round 260k (PMPP x 1.3), he could be a serious candidate for prevention with lifestyle intervention and/or appropriate drugs.
If he had a PMPP of round 300k (PMPP x 1.5), he could be a definite candidate for treatment with appropriate drugs.
Something similar could apply for the metabolic syndrome and global cardiovascular risk.
I invite interested colleagues to evaluate this idea and contact with me to collaborate in this study.
Conflict of Interest:
None declared
When to clinically suspect Diabetes Mellitus
The prediction score for Diabetes Mellitus developed by Bang and colleagues is commendable[1].However it is less suitable for a near perfect application at a general practice clinic . Lets consider a 35 year old male with history of smoking presenting to a general practitioner for a simple upper respiratory infection. Apart from addressing his present complaint it is a moral responsibility of the clinician to quickly assess additional risk factors for chronic or occult disease.In this regard the patient may have additional symptoms which he may be ignoring and not revealing to the clinician.
Any practicing family physician or primary care physician will probably aggree that a significant number of patients who are ultimately diagnosed with diabetes have symptoms suggestive of chronic complications of diabetes or frequently associated diseases with diabetes for variable periods of time. These symptoms include the classical symptoms of hyperglycemia (increased thirst, increased frequency of urination and loss of weight), symptoms of coronary artery disease, peripheral neuropathy, retinopathy, chronic infections like dental caries, cutaneus fungal infection,recurrent urinary tract infection,etc.Should these symptoms be considered befor a decision is made about testing for diabetes? This is what conventional teaching advices us , but is backed with inadequate evidence .
It will be interesting to see these features in the baseline characteristics of the study cohort.It will also enable a practicing clinician to understand the relevance of asking for these symptoms in an patient who fails to put forth chronic symptoms as a result of mistaken self assumption.
References: 1. Heejung Bang,Alison M. Edwards,Andrew S. Bomback, Christie M. Ballantyne,David Brillon,Mark A et al. Development and Validation of a Patient Self-assessment Score for Diabetes Risk.Ann Intern Med 2009;151:775-783
Conflict of Interest:
None declared