ASSESSMENT OF THE RISK OF TYPE 2 DIABETES AMONG HEALTHY WITHOUT DIABETES IN SUDAN USING THE FINDRISC TOOL

Background and objective: Diabetes is increasingly recognized as a serious public health concern worldwide. The risk assessment of type 2 diabetes can be done through a risk questionnaire that provides an accurate, low-cost, educational and timeeffective method for this. By early identification of people at risk of developing diabetes and if it is confirmed that they are in the pre-diabetes stage, adequate care is provided to them through lifestyle interventions or even hypoglycemic drugs if needed, thus delaying or preventing their progression to diabetes. Therefore, this study aimed to assess the risk of developing type 2 diabetes (T2DM) among healthy Sudanese without diabetes in Khartoum. Methods: A cross-sectional study from Nov 2016-March 2017 comprising 122 adult participants, age (>20 yrs) visiting the garden yard located at airport street at Khartoum district without a diagnosis of T2DM was carried out. The risk of developing T2DM was assessed using the validated and widely used Finish diabetes risk score (FINDRISC) Total Risk Score of each participant was analysed and compared. Knowledge assessment tool and Anthropometric measurements were also used. Results: 122 participated in the study, the mean age of the participants was 31.55±10.122, the mean BMI was 25.718±5.813 and the mean of waist circumstances 90.2±16.63. Estimated risk of developing T2DM in 10 years of study for participants according to FINDRISC, only 3.3% have a high risk. The risk factors for the participants in the study for developing DM type 2 were 66.4% has positive family history, 44.3% were overweight or obese, has 41.8% limited physical activity and 27.9% has central obesity. The pattern of vegetables and fruits daily intake according to FINDRISC only 36.1% from participants. Significant positive correlation (r= 0.395, p=0.000) High risk score of FINDRISC is >14, Estimated age: Y=24.1+ (0.9x15) = 37.9≈38years.Significant positive correlation (r= 0.6, p=0.000) High risk score of FINDRISC is > 14, Estimated BMI: Y= 19.24+ (0.8x15) = 31 Kg/ m. Conclusion: The knowledge about diabetes risk factors, classical symptoms and common complication was not satisfactory. None of the “at high” risk had their risk further investigated. While 25% adapted health their lifestyle. Large scale studies to test the validity of FINDRISC in Sudanese population should be conducted. Development of Sudanese population specific risk score that take into count the local risk factors is warranted.


INTRODUCTION
Diabetes is increasingly recognized as a serious, worldwide public health concern 1 . In 2010 it was estimated that 285 million people are living with diabetes 2 , the number increased to 366 million in 2011 3 , then escalated to 415 million in 2015 4 . Low-and middle-income countries have the highest proportion of people with diabetes 3 . International diabetes federation (IDF) estimates that by 2040 there will be 642 million people living with diabetes worldwide 4 . In Sudan, there were 3 million cases of diabetes in 2014 5 . One of the most worrying characteristics of this rapid growth is that T2 DM is becoming more prevalent among children, adolescents, and young adults 6 ; indeed Osman et al., reported that prevalence of T2DM is now increasing among Sudanese children and adolescents 7 . This may be due to increasing prevalence of obesity, sedentary lifestyle and physical inactivity 8 . A primary concern about T2DM is that it remains clinical unapparent for long time 9 . The onset of T2DM may occur as early as 9-12 years before its clinical diagnosis 10 . Globally, 45.8% or 174. 8  are estimated to be living with undiagnosed T2DM; about 83.8% of them live in low-and middle income countries 11 . Nevertheless even those undiagnosed people are placed at increased risk for developing diabetes complications. At time of diagnosis, complications are established in 20-30% of the patients 12 . There is an intermediated stage between normoglycemia and diabetes which is pre-diabetes 13 . Approximately 5-10% of pre-diabetics per year will progress to diabetes 14 . T2DM can be delayed or even prevented in high risk subjects 15,16 which lead to delaying incidence of complications and comorbidities 19 . Life style interventions targeting weight loss and increasing physical activity and improving diet has produced a 30-60% reduction in the risk of developing T2DM 17 . Pharmacotherapy has been also used; metformin, acarbose and troglitazone with 31, 36, and 56% risk reduction respectively 18 . Various risk scores are available, the Finnish diabetes risk score has been used in this study as it received the IDF Recommendation as a simple, fast, non-invasive, inexpensive, and reliable tool to identify individuals at high risk for T2DM 19 , and it is validated in many countries with good performance 20 . This was concluded by Rowan P.C. and his colleagues after performing risk assessment followed by point of care glycosylated haemoglobin (HbA1C) test which showed positive correlation with the risk score as the risk increased the HbA1C value also increased 25 . Diabetes care represents a real challenge in Sudan for both healthcare system and patients 21-23 . According to the annual health report issued by the ministry of health for 2015, among the ten leading disease treated as outpatients diabetes was the fifth, and form the ten leading causes of hospital admissions it was the seventh 24 .
Identification of individuals at high risk for developing diabetes has been a major concern worldwide, in Community-based settings, a study conducted in Libya by Abduelkarem et al., 26 , second study in Nigeria by Alebiosu et al., 27 and third one in Saudi Arabia by Alzohairy M. and Hassan M. 28 , all of these studies used the FINDRISC as a tool for risk assessment. Likewise two studies has been conducted in India using the Indian diabetes risk score by Subramani et al., 29 in rural area of Sripuram and by Anjana et al., 30 in urban slum of Hubli. Furthermore in rural West Virginia a study has been conducted by Misra et al., [31][32][33] . There is a significant difference in the percent of individuals at high risk in rural areas compared to those in urban areas which is not surprising since urbanization leads to adapting more westernized lifestyle therefore increasing the risk of developing T2DM 34 . This study aims at assessing the risk of developing type 2 diabetes mellitus (T2DM) among healthy non-diabetic Sudanese in Khartoum city during the peroid from November 2016 to February 2017. The study was community based study divided into two phases: Phase one: cross-sectional observational study, where all participants had their risk of developing diabetes assessed and provided with verbal counseling. Phase two: educational interventional for those found at high/very high risk, their knowledge regarding diabetes was assessed, then they were provided with verbal education by feedback method with emphasis on importance of early testing for diabetes and contact information obtained, average interview time was 15-25 minutes. They were contacted after two weeks to check whether they went to investigate their risk status by doctor or not.   Table 2.  Table 3. Only 36.1% from participant's daily take vegetables and fruits while 63.9% didn't take it daily as shown in Figure 1. The estimated age at which participants are at high risk according to FINDRISC: Y=24.1+ (0.9x15) = 37.9≈38 years. Significant positive correlation (r= 0.395, p=0.000), High risk score of FINDRISC is >14.  30 and Misra et al., 31 whereas 45% and 61.8% were at high risk respectively.

Figure 1: Patterns of vegetables and fruits intake among study participants
Moderately risk was detected in 19.7% similar to Abduelkarem et al., 20% 26 , and 77% were at low/ slightly elevated risk similar proportion to findings of Alzohairy and Hassan 70.6% 28 . Majority of participants were aged less than forty five years old therefore they had less age associated risk. Additionally majority of them had neither family history nor personal history of abnormal blood glucose level, two components that are given high score in FINDRISC (5 points for each). First risk factor is the family history of diabetes either its type1 or 2. Positive family history it significantly associated with risk score, reported by 66.4% of the study participants and 4/ 4 of those found at high risk reported positive family history.  31 . In area of knowledge of high risk group about T 2 DM, family history and unhealthy diet were the most acknowledged risk factors of T2 DM. Regarding classical symptoms polyuria was the most acknowledged symptoms of diabetes, polydipsia and polyphagia were moderately known. Concerning common complications, nephropathy was well known; retinopathy and neuropathy were moderately known. One of the individuals had completely missing knowledge regarding all items assessed.

Study limitations
The small sample size that hindered the results incomparable with previous studies resulted from two factors: the first is time and resources constrain and the validity of Finnish diabetes risk score among Sudanese is not tested thus it may over or underestimate the actual risk status.

CONCLUSION
Out of the 122 individuals had their risk assessed, 3.3% were found at high risk, 19.7% were at Moderate and 77% were at low/ slightly elevated risk. The most common risk factors encountered were positive family history of diabetes 66.4%, overweight/ obese status 44.3%, limited physical activity 41.8% and central obesity 27.9%. The knowledge about diabetes risk factors, classical symptoms and common complication was not satisfactory. None of the "at high" risk had their risk further investigated. While 25% adapted health their lifestyle.

RECOMMENDATIONS
Large scale studies to test the validity of FINDRISC in Sudanese population should be conducted, development of Sudanese population specific risk score that take into count the local risk factors is waranted and diabetes awareness programs should be commenced to raise awareness about seriousness of T2 DM and most important of all is preventability of T2 DM.