Different type 2 diabetes risk assessments predict dissimilar numbers at high risk :

Transcription

1 Reserch Benjmin J Gry, Richrd M Brcken, Dniel Turner, Kerry Morgn, Michel Thoms, Slly P Willims, Meurig Willims, Sm Rice nd Jeffrey W Stephens on behlf of the Prosiect Sir Gâr Group Different type 2 dibetes risk ssessments predict dissimilr numbers t high risk : retrospective nlysis of dibetes risk-ssessment tools Abstrct Bckground Use of vlidted risk-ssessment tool to identify individuls t high risk of developing type 2 dibetes is currently recommended. It is under-reported, however, whether different risk tool lters the predicted risk of n individul. Aim This study explored ny differences between commonly used vlidted risk-ssessment tools for type 2 dibetes. Design nd setting Cross-sectionl nlysis of individuls who prticipted in workplce-bsed risk ssessment in Crmrthenshire, South Wles. Method Retrospective nlysis of 676 individuls (389 femles nd 287 mles) who prticipted in workplce-bsed dibetes risk-ssessment inititive. Ten-yer risk of type 2 dibetes ws predicted using the vlidted QDibetes, Leicester Risk Assessment (LRA), FINDRISC, nd Cmbridge Risk Score (CRS) lgorithms. Results Differences between the risk-ssessment tools were pprent following retrospective nlysis of individuls. CRS ctegorised the highest proportion (13.6%) of individuls t high risk followed by FINDRISC (6.6%), QDibetes (6.1%), nd, finlly, the LRA ws the most conservtive risk tool (3.1%). Following further nlysis by sex, over one-qurter of mles were ctegorised t high risk using CRS (25.4%), wheres greter percentge of femles were ctegorised s high risk using FINDRISC (7.8%). Conclusion The doption of different vlid riskssessment tool cn lter the predicted risk of n individul nd cution should be used to identify those individuls who relly re t high risk of type 2 dibetes. Keywords dibetes mellitus, type 2; generl prctice; primry helth cre; public helth; risk; risk ssessment. INTRODUCTION The number of individuls estimted to be living with dibetes in the UK is projected to rise to by the yer 23, which would see n verge increse of 31 new cses nnully. 1 The Ntionl Institute for Helth nd Cre Excellence (NICE) recently introduced guidelines to identify those individuls t high risk of developing type 2 dibetes. 2 These guidelines dvocte the use of vlidted risk-ssessment tools, equtions, or selfssessment questionnires to identify high risk individuls. 2 The guidelines further recommend using vlidted risk scores tht tke ccount of routinely collected dt in primry cre such s the QDibetes risk clcultor 3 or the Cmbridge Risk Score. 4 The guidnce lso sttes tht vlidted selfssessment questionnires cn be used to identify individuls t high risk, such s the most widely used nd vlidted exmple, FINDRISC, 5 or the Leicester Risk Assessment. 6 Comprisons hve been mde between crdiovsculr disese risk equtions, 7,8 which hve highlighted tht different lgorithm cn estimte different vlue for the -yer crdiovsculr disese BJ Gry, PhD, public helth dt coordintor/ resercher, Policy, Reserch nd Interntionl Development, Public Helth Wles, Crdiff, UK. RM Brcken, PhD, ssocite professor in exercise physiology nd biochemistry, Dibetes Reserch Group, College of Medicine; Applied Sports Technology Exercise nd Medicine (A-STEM) Reserch Centre, College of Engineering, Swnse University, Swnse, UK. D Turner, PhD, high performnce physiologist, RedBull North Americ, Snt Monic, CA, US. K Morgn, MSc, project mnger of Prosiect Sir Gâr; M Willims, MD, FRCP, consultnt physicin (retired); S Rice, PhD, FRCP, consultnt in dibetics, Hywel Dd Helth Bord, Prince Philip Hospitl, Llnelli, UK. M Thoms, MPH, FFPH, consultnt in public helth/director of public helth, Public Helth Wles, Crmrthen, UK. SP Willims, FRCP, AFOM, regionl medicl officer/occuptionl (CVD) risk of n individul. To the uthors knowledge no studies hve exmined whether doption of different vlidted risk-ssessment tool cn influence n individul s predicted risk of developing type 2 dibetes. This is significnt s those individuls predicted to be t high risk would be eligible for further clinicl investigtions. 2 The prevention of type 2 dibetes from n economic stndpoint in the UK is lso worthy considertion. In the direct nd indirect costs were 8.8 billion nd 13. billion, which re projected to rise to 15.1 billion nd 2.5 billion, respectively, by Therefore, the im of this study ws to exmine if there were ny differences between four commonly used vlidted risk-ssessment tools when pplied to the sme dtset. METHOD Study popultion All prticipnts in this study were employees of either the locl helth bord or steel workers within the Welsh region of Crmrthenshire who hd received CVD risk ssessment s prt of the estblished Prosiect Sir Gâr workplce-bsed physicin, Tt Steel Pckging Recycling, Trostre, Llnelli, UK. JW Stephens, PhD, FRCP, clinicl professor in dibetes, Dibetes Reserch Group, College of Medicine, Swnse University, Swnse, UK. Address for correspondence Benjmin J Gry, Policy, Reserch nd Interntionl Development, Public Helth Wles, Hdyn Ellis Building, Crdiff, CF24 4HQ, UK. E-mil: benjmin.gry@wles.nhs.uk Submitted: 8 December 214; Editor s response: 23 Mrch 215; finl cceptnce: 24 April 215. British Journl of Generl Prctice This is the full-length rticle (published online 6 Nov 215) of n bridged version published in print. Cite this rticle s: Br J Gen Prct 215; DOI:.3399/bjgp15X e852 British Journl of Generl Prctice, December 215

2 How this fits in Type 2 dibetes is one of the gretest public helth chllenges fcing the UK, with n estimted 31 new cses being dignosed ech yer. At present, however, there is no consensus on which risk ssessment tool to use to identify individuls t high risk of developing type 2 dibetes. This reserch compres four vlidted risk-ssessment tools nd exmines the number of individuls predicted t high risk. Use of different vlid risk-ssessment tools cn lter the predicted risk of n individul, hence cution should be tken in identifiction of who relly is t high risk of type 2 dibetes. inititive. The inititive ws introduced in 29 nd dt collection for this study took plce between 29 nd 212. All current employees over the ge of 4 yers (if white), or 25 yers (if South Asin) with no prior dignosis of CVD or dibetes were invited to prticipte in the project. This study focuses on the 676 employees who ccepted the invittion of helth ssessment, of whom 389 were femle nd 287 mle. Bseline mesurements According to stndrd opertionl policy (SOP) ll recruited individuls ttended stndrdised helth ssessment tht lsted 3 4 minutes. During the session, demogrphic (dte of birth, sex, nd postcode of residence) nd nthropometric (body mss, height, nd wist circumference) dt, systolic nd distolic blood pressure, smoking sttus, fmily nd medicl histories were ll recorded. Lifestyle questions were sked regrding dietry hbits (fruit nd vegetble intke), nd current physicl ctivity levels were ssessed by the Generl Prctice Physicl Activity Questionnire (GPPAQ 11 ). Full detils of the helth ssessment ppointment, which took plce during norml working hours t the employees workplce, hve been published extensively elsewhere. Dibetes risk prediction equtions Risk of developing type 2 dibetes ws clculted by entering the relevnt vribles s detiled in Tble 1 into the Cmbridge Risk Score, FINDRISC, Leicester Risk Assessment, nd QDibetes vlidted risk ssessments. These four riskprediction tools ll feture in the current NICE guidelines, 2 nd re either bsed on routinely collected dt (Cmbridge Risk Score, QDibetes) or from cohorts (FINDRISC, Leicester Risk Assessment). The QDibetes online lgorithm clcultes -yer percentge (%) vlue of developing type 2 dibetes, wheres the Leicester Risk Assessment nd FINDRISC model re questionnires bsed on scoring system tht ligns the individul to risk ctegory nd corresponding -yer risk of developing type 2 dibetes. The Cmbridge Risk Score is clculted using logistic regression model nd uses quintiles to express the likelihood of n individul hving undignosed dibetes. Individuls clculted in the highest-risk quintile re 22 times more likely to develop type 2 dibetes compred with the bottom-risk quintile. 12 Tble 1. Included vribles of the four vlidted risk ssessments Cmbridge Risk Score FINDRISC Leicester Risk Assessment QDibetes Age Y Y Y Y Sex Y Y Y Y Body mss index Y Y Y Y Wist circumference Y Y Ethnicity Y Y Fmily history of dibetes Y Y Y Y Smoking sttus Y Y Antihypertensive mediction Y Y Y Y Current steroid tretment Y Y Socil deprivtion Y Physicl ctivity levels Y Fruit nd vegetble intke Y History of high blood glucose Y Vribles entered into ech of the four vlidted risk ssessments. Y denotes vrible entered into risk ssessment. British Journl of Generl Prctice, December 215 e853

3 Tble 2. Bseline chrcteristics of study popultion Mles (n = 287) Femles (n = 389) All individuls (n = 676) Age, yers 49 (44 53) 49 (44 54) 49 (44 54) Height, m b 1.76 ± ± ±.4 Body mss, kg 88.6 ± ± ± 16.5 Body mss index, kg/m 2 b 28.3 ± ± ± 1.9 Wist circumference, cm.9 ± ± ± 13.2 Systolic blood pressure, mmhg b 128 ± ± ± 6 Distolic blood pressure, mmhg 85 ± 9 82 ± 9 83 ± 9 Fmily history of dibetes, first degree 69 (24.) 121 (31.1) 19 (28.1) Physiclly ctive or modertely ctive, GPPAQ 247 (86.) 24 (61.7) 487 (72.) Cmbridge Risk Score.215 (.79.37).52 (.23.16).5 ( ) FINDRISC, points 8 (6 11) 9 (6 12) 8 (6 11) Leicester Risk Assessment, points 13 (9 18) 9 (5 14) (5 15) QDibetes, % b 6.4 ± ± ± 1.9 Dt represented s men ± stndrd devition [SD]. Dt represented s medin (interqurtile rnge). b Dt represented s geometric men ± pproximte SD. Discrete vribles represented s numbers with percentges in brckets. GPPAQ = Generl Prctice Physicl Activity Questionnire. Dt nlysis The focus of the nlysis within this study ws to compre four vlidted nd routinely used dibetes risk-ssessment tools. Within the nlysis, it ws chosen to strtify the smples by ge. Sttisticl nlysis ws performed using SPSS softwre (version 19) with significnce set t P<.5. Normlity of dt ws ssessed by one-smple Kolmogorov Smirnov test. Homogeneity of vrince ws determined by Levene s sttistic nd one-wy nlysis of vrince (ANOVA) with post-hoc Bonferroni correction fctor used to locte ny differences within groups. χ 2 nlysis with set t.5 ws performed to nlyse differences between the proportions of individuls predicted t high risk. Body mss, wist circumference, nd distolic blood pressure dt re represented s men ± SD. Height, body mss index (BMI), systolic blood pressure, nd QDibetes scores did not hve norml distribution. These dtsets were consequently log trnsformed for nlysis nd represented s the geometric men nd pproximte stndrd devition. Age, FINDRISC, Leicester Risk Assessment, nd Cmbridge Risk Score dt did not hve norml distribution fter log trnsformtion, nd these dt re represented s medin nd interqurtile rnge. Kruskl Wllis nd Mnn Whitney tests were used to nlyse FINDRISC, Leicester Risk Assessment, nd Cmbridge Risk Score dt. RESULTS Bseline chrcteristics Tble 2 documents the bseline chrcteristics of the study popultion. As result of the eligibility criteri, the medin ge of the workers ws 49 yers. Both the mle nd femle cohorts of workers were found to be overweight with men BMI vlues of 28.3 ± 1.7 nd 26.6 ± 1.9 kg/m 2, respectively. The bseline chrcteristics lso demonstrte evidence of centrl obesity in the workforces, with the mle nd femle verge wist circumference vlues observed to be bove the 94 cm nd 8 cm thresholds. 13 The risk prediction ctegories for the mles nd femles were Slightly 5 Mles Femles 4 Proportion of workers t risk, % 3 2 Figure 1. Proportion of mles nd femles in ech ssocited risk quintile in the Cmbridge Risk Score. LOWEST QUINTILE Risk quintile HIGHEST QUINTILE e854 British Journl of Generl Prctice, December 215

4 Figure 2. Proportion of mles nd femles in ech ssocited risk ctegory in the FINDRISC model. 6 5 Mles Femles Proportion of workers t risk, % LOW SLIGHTLY MODERATE HIGH ELEVATED Risk ctegory Elevted, Incresed, nd Low using FINDRISC, Leicester Risk Assessment, nd QDibetes, respectively. The medin vlues of mle workers were clculted to be in the fourth quintile (second highest) nd the women in the second quintile (second lowest) when entered into the Cmbridge Risk Score. Risk prediction ctegories Figures 1 4 illustrte the proportion of sexes in ech of the risk ctegories or quintiles fter the doption of the four vlidted risk ssessments. Most mles (54.7%) were predicted in the highest two risk quintiles, wheres most femles (58.4%) were predicted in the lowest two risk quintiles when the Cmbridge Risk Score ws used (Figure 1). The FINDRISC tool predicted the highest proportion of mles (47.7%) nd femles (43.5%) in the Slightly Elevted prediction ctegory (Figure 2). The gretest numbers of mles nd femles gin were clculted in the sme ctegory when the Leicester Risk Assessment ws dopted, with proportions of 57.5% nd 44.2%, respectively, in the Mles Proportion of workers t risk, % Femles Figure 3. Proportion of mles nd femles in ech ssocited risk ctegory in the Leicester Risk Assessment. LOW INCREASED Risk ctegory MODERATE HIGH British Journl of Generl Prctice, December 215 e855

5 Figure 4. Proportion of mles nd femles in ech ssocited risk ctegory in the QDibetes model. 9 8 Proportion of workers t risk, % Mles Femles LOW INTERMEDIATE HIGH Risk ctegory Incresed risk ctegory (Figure 3). Finlly, the mles (68.6%) nd femles (84.6%) were found to hve the gretest proportions in the Low risk ctegory using the QDibetes tool (Figure 4). Individuls t high risk In terms of the proportion of individuls predicted to be t high risk by ech of the vlidted risk ssessments, the Cmbridge Risk Score ctegorised the highest proportion of ll individuls (13.6%), followed by FINDRISC (6.6%), QDibetes (6.1%), nd, finlly, the Leicester Risk Assessment, which ws the most conservtive risk tool (3.1%) (Figure 5). After further exmintion by sex nlysis, it ws found tht more mles (Figure 6) were ctegorised s high risk using either the Cmbridge Risk Score (25.4%) or QDibetes (9.8%) tools versus either the Leicester Risk Assessment (4.8%) or FINDRISC (4.9%) ssessments. A greter percentge of femles, however, were ctegorised s high risk using the FINDRISC ssessment (7.8%) compred with QDibetes (3.3%) or the Leicester Risk Assessment (1.8%) (Figure 7). In ddition, ll of the risk ssessments other thn FINDRISC predicted greter proportion of mles t high risk compred with their femle counterprts. Chnges in risk score fter ge strtifiction From the outset, it ws decided to exmine the cohorts by five predetermined ge groups (<45 yers, yers, 5 54 yers, yers, 6 yers; Tble 3). Femle predicted risk incresed from 1.8 ±.7% to 6.1 ± 2.1% in the QDibetes model where Figure 5. Proportion of individuls predicted to be t high risk of developing type 2 dibetes: ll individuls. Denotes higher proportion thn Leicester Risk Assessment. b Denotes higher proportion thn QDibetes. c Denotes higher proportion thn FINDRISC (P<.5). CRS = Cmbridge Risk Score. LRA = Leicester Risk Assessment. All individuls predicted t high risk, % c b CRS FINDRISC LRA QDibetes Mles Femles e856 British Journl of Generl Prctice, December 215

6 Figure 6. Proportion of individuls predicted to be t high risk of developing type 2 dibetes: mle individuls. Denotes higher proportion thn Leicester Risk Assessment. b Denotes higher proportion thn QDibetes. c Denotes higher proportion thn FINDRISC (P<.5). CRS = Cmbridge Risk Score. LRA = Leicester Risk Assessment. Mles predicted t high risk, % c b c 5 CRS FINDRISC LRA QDibetes Figure 7. Proportion of individuls predicted to be t high risk of developing type 2 dibetes: femle individuls. Denotes higher proportion thn Leicester Risk Assessment. b Denotes higher proportion thn QDibetes. c Denotes higher proportion thn FINDRISC (P<.5). CRS = Cmbridge Risk Score. LRA = Leicester Risk Assessment. Femles predicted t high risk, % b CRS FINDRISC LRA QDibetes risk prediction ws higher thn <45 yers in subsequent ge groups nd incresed gin in the 6 yers group compred Tble 3. Chnges in dibetes risk prediction scores following ge strtifiction <45 yers yers 5 54 yers yers 6 yers Femles n = 99 n = 9 n = 87 n = 65 n = 29 Cmbridge Risk Score.23 (.14.2).57 ( ) b.92 ( ) b,c.52 (.3.18) b.167 ( ) b,c,e FINDRISC, points 6 (4 9) 9 (6 12) b 9 (7 12) b 9 (7 12) b (7 13) b Leicester Risk 5 (2 9) 7 ( 12) 12 (8 17) b,c (8 17) b,c,d 16 (9 2) b,c,d,e Assessment, points QDibetes, % f 1.8 ± ± 1.5 b 4.7 ± 1.8 b 4.3 ± 1.5b 6.1 ± 2.1 b,c Mles n = 81 n = 88 n = 63 n = 39 n = 16 Cmbridge Risk Score.7 ( ) (.3.328) b ( ) b ( ) b,c ( ) b,c,d FINDRISC, points 6 (3 8) 9 (6 11) b 9 (6 11) b (8 12) b,c (8 12) b Leicester Risk (8 13) 11 (8 15) 15 (13 2) b,c 17 (14 2) b,c 21 (16 25) b,c,d Assessment, points QDibetes, % f 3.8 ± ± 2.3 b 7.9 ± 2.6 b. ± 3. b 11. ± 3. b Dt represented s medin nd interqurtile rnge. b Denotes significntly different from <45 yers. c Denotes significntly different from yers. d Denotes significntly different from 5 54 yers. e Denotes significntly different from yers (P<.5). f Dt represented s geometric men ± pproximte SD. with the yers group. The femle risk ctegories in the oldest ge group were moderte nd slightly elevted compred with the low risk ctegory of the <45 yers ge group in the Leicester Risk Assessment nd FINDRISC questionnires, respectively. The risk quintile of the Cmbridge Risk Score incresed from the lowest risk quintile in the <45 yers ge group to the middle quintile in the 6 yers group. The predicted -yer risk of the mle employees incresed from low (3.8 ± 1.4%) to intermedite (11. ± 3.%) risk fter doption of the QDibetes model. The risk quintiles of the mle individuls incresed from the middle quintile (<45 yers) up to the highest-risk quintile in the Cmbridge Risk Score, nd the risk ctegories incresed from low to slightly elevted in the FINDRISC model cross the ge groups. The Leicester Risk Assessment ctegory ws lredy t incresed risk in the youngest ge group of the mle cohorts nd incrementl rise in totl points scored resulted in the oldest ge group clssified in the upper limits of the moderte risk ctegory. British Journl of Generl Prctice, December 215 e857

7 DISCUSSION Summry This study exmined whether the doption of different vlidted risk-ssessment tool would lter n individul s predicted risk of type 2 dibetes. The min findings from this study demonstrted tht the risk of n individul developing type 2 dibetes ws dependent on which risk-ssessment tool ws used. It ws observed tht over one-qurter of mles were predicted to be in the highest-risk quintile when the Cmbridge Risk Score ws used. This vlue ws fivefold increse compred with the Leicester Risk Assessment nd FINDRISC questionnires, nd more thn double the mount of individuls ctegorised s high risk using the QDibetes risk ssessment. In the femle cohort, double the mount of individuls were gin ctegorised s high risk using the QDibetes tool compred with the Leicester Risk Assessment. The FINDRISC model, however, predicted the gretest proportion of femles t high risk (7.8%). Strengths nd limittions One of the min strengths of this reserch is tht the study popultion is representtive of the current working demogrphic in Crmrthenshire, South Wles, who volunteered to prticipte in workplcebsed dibetes risk ssessment. The detils of these employees would not be routinely vilble if not for the Prosiect Sir Gâr inititive nd therefore this informtion provides n insight into the current dibetes risk of the workforce in Wles. This study is lso the first to compre directly the proportion of individuls tht ws predicted to be t high risk by four vlidted nd routinely used risk ssessments. The risk ssessments were chosen in this study primrily becuse they feture in the NICE guidnce, 2 nd lso hve five common risk vribles (ge, sex, BMI, fmily history of dibetes, nd currently prescribed ntihypertensive mediction; Tble 1) tht mke direct comprisons fesible. One of the limittions to this study nd lso to the current literture is tht, unlike in vlidted CVD risk prediction lgorithms, 8 no prospective studies hve compred dibetes risk prediction models to mesure the ccurcy nd flse positive rtes of these current models. Thus, this dmission from the current literture offers suggestion for importnt future reserch. Comprison with existing literture It is cknowledged tht in the development nd vlidtion stges of some of the risk ssessment models included in this study some comprisons hve been previously mde between the risk-ssessment tools. During the vlidtion of the QDibetes model, comprisons were mde with the Cmbridge Risk Score. This vlidtion demonstrted tht the QDibetes model improved discrimintion; however, becuse the Cmbridge Risk Score does not give prediction of bsolute risk, clibrtion mesures between the two risk scores could not be determined. 3 The inclusion of ethnicity in the QDibetes model could explin these differences, with previous reserch concluding tht ethnic-specific cut points need to be estblished when using the Cmbridge Risk Score in multi-ethnic popultion. 14 Ethnic group is n importnt considertion in the FINDRISC model, which ws developed in white popultion. There is tendency for dibetes risk questionnires developed in white popultions to underperform in multi-ethnic popultions, 15 nd this observtion provided the rtionle for the Leicester Risk Assessment, which ws bsed on the FINDRISC exmple 2 nd vlidted for use in multi-ethnic popultion in the UK. 6 Interestingly, in comprison with the FINDRISC model, score of 16 on the Leicester Risk Assessment incresed the number of individuls identified with impired glucose regultion rther thn score of 9, which ws indictive of drugtreted dibetes using the FINDRISC questionnire. 2 This offers suggestion of why differences were observed in the numbers of individuls predicted to be high risk between these two risk ssessments. Other previous reserch hs estblished tht the Cmbridge Risk Score hd no dvntge in identifying dibetes risk compred with BMI lone. 16 This finding demonstrtes the importnce of wist circumference in predicting dibetes risk, especilly given tht previously evidence hs demonstrted cler ssocition between centrl obesity (wist circumference of 2 cm in mles nd 88 cm in femles) nd dibetes risk, regrdless of BMI vlues. 17 Implictions for reserch nd prctice The findings from this study rise question bout the vlidted risk ssessments currently dvocted by NICE nd the correct pproches to reduce the ever-incresing prevlence of type 2 dibetes in the UK. 2 There re three pprent options in terms of risk-ssessment tools tht cn be tken from the present observtions. First, n ggressive pproch could be tken by fvouring the Cmbridge Risk Score. Although the limittion of this model hs e858 British Journl of Generl Prctice, December 215

8 Funding This work ws prt-funded by the Europen Socil Fund (ESF) through the Europen Union s Convergence progrmme dministered by the Welsh government nd the corresponding uthor ws lso prtfunded by the St Dvid s Medicl Foundtion. Prosiect Sir Gâr received funding contributions from Tt Steel, Hywel Dd Helth Bord (Dibetes Chritble Fund nd Crmrthenshire Chritble Fund), Crmrthenshire County Council, nd the following phrmceuticl compnies: Tked, Lilly, Snofi-Aventis, Boehringer Ingelheim, Pfizer, nd AstrZenec. Ethicl pprovl Prosiect Sir Gâr nd this subsequent study were pproved by Dyfed Powys locl reserch ethics committee (reference number: 11/WA/1). Provennce Freely submitted; externlly peer reviewed. Competing interests The uthors hve declred no competing interests. Acknowledgements The uthors wish to express their grtitude to Dr Richrd Tristhm for providing his expertise regrding the primry cre/ generl prctice implictions of this rticle. The Prosiect Sir Gâr Group is: Kerry Morgn, Chris Cottrell, Vness Dvies, Liz Newbury-Dvies, Michel Thoms, Enzo M Di Bttist, Lesley Street, Fion Judd, Cindy Evns, Jo Jmes, Clire Jones, Crolyn Willims, Susn Smith, Jmes Thornton, Slly P Willims, Rhys Willims, Sm Rice, Jeffrey W Stephens, nd Meurig Willims. Discuss this rticle Contribute nd red comments bout this rticle: bjgp.org/letters been discussed, this pproch potentilly could benefit mles who develop type 2 dibetes t lower BMI vlue thn their femle counterprts. 18,19 The second method could be tking conservtive pproch by prioritising doption of the Leicester Risk Assessment, which lso llows lyperson completion. This risk tool did predict the lowest proportion of mles, femles, nd, subsequently, ll prticipnts t high risk of developing type 2 dibetes, however, which could overlook some t-risk individuls. The third, more prcticl, nd cost-effective pproch would be to use one of the two tools tht predicted ~6% of ll prticipnts t high risk, either FINDRISC or QDibetes. Interestingly, lifestyle intervention through exercise nd diet hs been proven to prevent type 2 dibetes in high-risk individuls, 2 nd hs lso been shown to be more effective thn metformin t reducing the incidence of dibetes in group of high-risk individuls with impired glucose regultion. 21 This intervention focused on weight loss of t lest 7% nd individuls prtking 15 minutes of physicl ctivity per week. 21 Impired fsting glucose (IFG) where concentrtions re 6.1 mmol/l 1 hve lso shown strong ssocitions with individuls developing type 2 dibetes compred with those individuls with fsting blood glucose below this threshold vlue. 22,23 Only the FINDRISC tool ccounts for physicl ctivity nd history of high blood glucose, both of which re positive spects to the questionnire. However s discussed previously, the FINDRISC tool does not ccount for ethnic group, which is fine if the popultion is Europid, but with lrge South Asin popultion in the UK reservtions should be given to prioritising this ssessment. Moreover, since the introduction in 211 of HbA1c s dignostic criterion for type 2 dibetes, 24 the performnce of FINDRISC hs reduced. 25 From clinicl stndpoint, given the discrepncies in the numbers of predicted high risk individuls, more prcticl pproch would be to focus more on isolted risk fctors (for exmple, dverse fmily histories, physicl inctivity, elevted wist circumference), irrespective of dibetes risk prediction vlues. There is merit for everyone to benefit from lifestyle dvice tht reinforces the benefits of regulr physicl ctivity nd blnced diet, rther thn wit for the individul to be deemed high risk. This strtegy lso hs the potentil to convert those individuls currently predicted t intermedite or incresed risk to low risk. Nevertheless, while dibetes risk ssessments remin the recommended primry tool to identify individuls t high risk, 2 the risk ssessments tht include wist circumference s risk fctor should be prioritised in primry cre nd prevention becuse of the overwhelming evidence of centrl obesity being better indictor of dibetes risk thn BMI. 17,26 A further finding ws no significnt concomitnt reltionship between ge nd chnges in risk scores, with no pprent rise in dibetes risk prediction from 5 yers old in mles nd femles. This is somewht surprising given the inclusion of ge s risk fctor nd the vrying weightiness by coefficient in ech of the dibetes risk ssessments. 3 6 This finding is importnt, however, s it provides dditionl evidence to the current trgeted ge groups s documented in current government guidelines, 2 nd potentilly offers suggestion to slightly mend this documenttion to trget those individuls ged 5 yers insted, while still providing lifestyle dvice to dults ged <5 yers old. In ddition, epidemiologicl reserch hs previously reported tht dibetes risk increses with ge, with one explntion being tht glycemic control s reflected in HbA1c scores reveled significnt increse from 5 yers onwrds. 27 Unfortuntely, it seems tht in the yers since the FINDRISC model ws introduced, nd despite new models for predicting risk of type 2 dibetes being introduced in gret numbers globlly nd nnully with n increse of focus on lyperson completion (for review, see Noble nd collegues 28 ), discrepncies remin in numbers of individuls t high risk. The chnges in dignostic criteri for dibetes, which now incorporte HbA1c vlues, lso hve been shown to reduce performnce in some of the more estblished dibetes prediction tools. Encourgingly, n emerging model hs been developed recently tht hs ccounted for these dignostic chnges involving HbA1c in its predictive cpbility. 29 Differences were observed in predicted high risk individuls using the currently dvocted risk ssessments, nd therefore cution should be ddressed when ctegorising such individuls t high risk. In primry cre, until consensus is mde on the dibetes risk prediction model of choice, more focus should be on isolted risk fctors, especilly regrding lifestyle choices nd evidence of centrl obesity irrespective of dibetes risk prediction score. Furthermore, with the chnge in dignostic criteri, it is lso importnt tht ny new risk prediction ssessments llow for these in their respective lgorithms. British Journl of Generl Prctice, December 215 e859

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