Discussion
As several studies have consistently shown, pre-diabetes can be reversed when met with targeted lifestyle interventions,6–11 underscoring the substantial potential for averting the progression to full-blown diabetes by timely identification and intervention in individuals with pre-diabetes. By capitalising on the reversibility of pre-diabetes and the cost-effectiveness of lifestyle interventions, a significant reduction in the burdens associated with T2D in terms of healthcare expenditures and immeasurable societal costs could be attained.
Recently, we developed a PRISQ using data from 6000 Qatari adults who participated in the Qatar Biobank cohort. PRISQ uses five non-invasive parameters (age, BMI, SBP, DBP and WC) and yields a score ranging from 0 to 45.16 A score above 16 indicates a moderate risk level of having pre-diabetes, while a score above 27 indicates a high-risk level.16 The sensitivity of PRISQ was 86%.16 In comparison to pre-diabetes risk scores formulated for adult populations in various international contexts, PRISQ exhibited superior discriminative capacity. As assessed by the AUC, PRISQ yielded an AUC of 80%, surpassing several analogous scores developed in disparate locales. Notably, these include risk scores from Indonesia (AUC: 62.3%),23 China (two distinct scores with AUCs of 74% and 70%)24 25 and the USA (AUC: 74%).26 Furthermore, our risk score demonstrated commendable sensitivity, quantified at 86.02%, with a designated cut-off value of 16.
In this study, we evaluated the performance of PRISQ in a real-world clinical setting by recruiting walk-in adult participants in three primary healthcare centres. Contrary to the original cohort, composed exclusively of Qatari citizens, in this investigation, we sought to ascertain the PRISQ performance across a diverse cohort, transcending ethnic boundaries.
Our results unequivocally affirm the outstanding performance of PRISQ, irrespective of participants’ ethnicity. PRISQ correctly identified more than 90% of the subjects with pre-diabetes among participants aged 40 years or above. This robust performance underscores the test’s reliability in capturing pre-diabetes in a clinical context, thus substantiating its potential as a pivotal tool in healthcare settings in Qatar to fight the T2D epidemic.
In the context of the relentless surge in the global incidence of pre-diabetes and T2D, particularly in the Middle East,27 28 a compelling imperative emerges to advance and enhance screening tools meticulously designed to enable comprehensive, population-wide screening. This need pertains notably to countries characterised by a heightened prevalence of these conditions, such as Qatar and other Gulf countries.28 29 In view of the annual conversion rate from pre-diabetes to T2D (5%–10%2), the critical significance of early diagnosis of pre-diabetes, and T2D for that matter, to formulate intervention strategies and the efficacious management of this widespread health challenge is undeniable. At a cut-off of 16, the sensitivity of PRISQ exceeded 90% in the 40+ subgroups regardless of ethnicity/race. This observation aligns with the fact that age significantly contributes to PRISQ score. Indeed, the age scores of 12 and 22 points for individuals between 36 and 55 years and those aged 55 or above, respectively. It is also noteworthy that T2D usually develops after the age of 40 years, and it is, therefore, not surprising that PRISQ performs better in the 40+ groups. We have observed a significant decline in the specificity of PRISQ, decreasing sharply from 66% in the under-40 group to 14% in the 40+ group. This steep decline is likely due to the higher prevalence of pre-diabetes in the 40+ cohort compared with the under-40 cohort (35% vs 20%). Additionally, the small sample size may contribute to this observed reduction in specificity. A wealth of evidence demonstrates the variation in diabetes prevalence among various racial and ethnic groups.30 31 Still, there is a lack of thorough knowledge of the underlying mechanics. The general view among the scientific and medical communities is that racial genetic variables have a negligible impact on the development of diabetes.32 Instead, a person’s susceptibility to pre-diabetes and T2D is more significantly influenced by non-genetic factors, which include physical characteristics, dietary habits, lifestyle decisions and more general social determinants of health like socioeconomic status, level of education, food insecurity and residential environment.33 Noteworthy is that all these non-genetic risk factors are amenable to cost-effective preventative interventions. Of particular interest is the observation that, aside from age and gender, the remaining predictors (BMI, WC, SBP and DBP) used in the computation of PRISQ could be modified, a characteristic that may elucidate the commendable performance of PRISQ across various ethnic and racial backgrounds.
The FHD exhibits a robust association with the disease’s incidence, yet the precise determinants underpinning this relationship remain incompletely elucidated.34 35 In the initial development of PRISQ, we consciously opted against incorporating FHD as a predictive variable, primarily due to the inherent challenges associated with this aspect. Many individuals may lack accurate knowledge of their family members’ medical histories,36 rendering familial history potentially unreliable.37 Moreover, situations may arise where individuals’ relatives have T2D or pre-diabetes but remain undiagnosed. Our current analysis has revealed that the differences between sensitivities of PRISQ within the 40+ age subgroups with and without FHD fail to attain statistical significance. This observation substantiates the rationale for our initial exclusion of FHD from the PRISQ model. The predictors used for PRISQ computation prove to be comprehensive and objective and can be readily ascertained by a healthcare professional in a primary healthcare setting, such as a nurse in a triage room.
Clinical importance of the study
With lifestyle interventions showing high efficiency in resolving pre-diabetes in many affected individuals, the significance of timely diagnosis of pre-diabetes cannot be overstated in the battle against the T2D epidemic sweeping the world in general and the Middle East region in particular. In this crucial endeavour, the PRISQ emerges as a beacon of hope. By relying solely on non-invasive parameters, the PRISQ tool offers a powerful means of diagnosing pre-diabetes quickly and cost-effectively. Importantly, contrary to blood tests, PRISQ is suitable for population screening in primary healthcare centres as the required parameters can all be quickly and non-invasively obtained by a nurse in the triage room before the encounter with the attending physician who is empowered to exercise discretion regarding the necessity of further recourse to confirmatory blood tests. This pragmatic approach necessitates the recognition that a nominal investment in preemptive measures to address potential FPs is financially judicious, given the far greater economic burden and clinical repercussions incurred by inadvertent oversight of TP cases. The potential of PRISQ impact extends far beyond Qatar’s borders, as it holds the potential to mitigate the worsening T2D crisis not only within the nation but also across the broader Middle East region, given the cultural, behavioural and ethnical similarities between the Middle Eastern populations, especially the nations of the GCC. The results we obtained with residents of Qatar originating from outside the Middle East countries could extend the use of PRISQ in other countries, especially from Southern, Southeastern and Western Asia. Embracing PRISQ in primary healthcare centres could be critical in preventive healthcare, promising to safeguard the health and well-being of countless individuals while relieving the strain on healthcare systems grappling with the diabetes epidemic.
The main limitation of this study was the relatively small number of participants and the lack of validation in populations outside Qatar. There is also the issue of low discordance between HbA1c and OGTT to diagnose pre-diabetes.38 39 It would have been ideal to use OGTT to confirm pre-diabetes. However, this approach would not be scientifically sound since PRISQ was developped based on HbA1c vlaues. Moreover, while we recognise that our diagnostic test may have low specificity, meaning it might produce some FPs, we are acutely aware of the potential consequences of overlooking TP results. FPs can lead to additional testing, which may incur limited additional costs, but missing TP cases can result in delayed intervention, disease progression and increased healthcare costs in the long term. Therefore, despite the limitations of our test, we prioritise sensitivity to ensure that genuine cases are not overlooked, even at the risk of some FPs. PRISQ can indeed be a starting point for further blood tests, especially OGTT, to confirm or reject the presence of pre-diabetes. We believe, however, that the strength of the study resides in the use of data from individuals from different ethnicities, indicating that PRISQ could potentially be useful in other populations.