p r i m a r y c a r e d i a b e t e s 1 1 ( 2 0 1 7 ) 86–93

Contents lists available at ScienceDirect

Primary Care Diabetes

journal homepage: http://www.elsevier.com/locate/pcd

Original research

A Colombian diabetes risk score for detecting

undiagnosed diabetes and impaired glucose
regulation

Noël Christopher Barengo a,b,∗ , Diana Carolina Tamayo a , Teresa Tono a ,

Jaakko Tuomilehto c,d,e,f
a Observatorio de Diabetes de Colombia, Organización para la Excelencia de la Salud, Colombia
b Department of Medical and Population Health Sciences Research, Herbert Wertheim College of Medicine, Florida
International University, Miami, USA
c Chronic Disease Prevention Unit, National Institute for Health and Welfare, Helsinki, Finland
d Department of Vascular Prevention, Danube-University Krems, Krems, Austria
e Diabetes Research Group, King Abdulaziz University, Jeddah, Saudi Arabia
f Dasman Diabetes Institute, Dasman, Kuwait

a r t i c l e i n f o a b s t r a c t

Article history: Aims: (i) To develop a diabetes mellitus risk score model for the Colombian population
Received 5 December 2015 (ColDRISC); and (ii) to evaluate the accuracy of the ColDRISC unknown Type 2 diabetes
Received in revised form mellitus
31 August 2016 Methods: Cross-sectional screening study of the 18–74 years-old population of a health-care
Accepted 17 September 2016 insurance company (n = 2060) in northern Colombia. Lifestyle habits and risk factors for
Available online 7 October 2016 diabetes mellitus were assessed by an interview using a questionnaire consisting of informa-
tion regarding sociodemographic factors, history of diabetes mellitus, tobacco consumption,
Keywords: hypertension, nutritional and physical activity habits. Anthropometric measurements and
Screening an oral glucose tolerance test were taken. The sensitivity and the specificity, receiver-
Impaired glucose regulation operating characteristic (ROC) curves, were calculated for the ColDRISC and FINDRISC.
Colombia Results: The area under the ROC curve for unknown Type 2 diabetes mellitus was 0.74 (95%
Risk score CI: 0.70–0.79) for the ColDRISC and 0.73 for the FINDRISC (95% confidence intervals [CI]
Type 2 diabetes mellitus 0.69–0.78). Using the risk score cutoff value of 4 in the ColDRISC to detect Type 2 diabetes
mellitus resulted in a sensitivity of 73% and specificity of 67%.
Conclusions: The characteristics of the ColDRISC show that it can be used as a simple, safe,
and inexpensive test to identify people at high risk for Type 2 diabetes mellitus in Colombia.
© 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

∗
Corresponding author at: Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th Street, AHC2, Miami, FL
33199, USA.
E-mail address: [email protected] (N.C. Barengo).
http://dx.doi.org/10.1016/j.pcd.2016.09.004
1751-9918/© 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
 p r i m a r y c a r e d i a b e t e s 1 1 ( 2 0 1 7 ) 86–93 87

who cannot afford to pay for health services. However, recently

1. Introduction they have started to provide services to the contributive
regime as well (people who are employed contribute monthly
The International Diabetes Federation (IDF) has estimated
fees for health-care). Mutual SER EPSS provides health-care to
that the number of adults with Type 2 diabetes mellitus in
approximately 1,300,000 people in 5 provinces. The majority of
Colombia is expected to rise from 2.14 million in 2013 to 3.34
the people registered at Mutual SER EPSS live in urban regions
million by 2035, of whom more than 95% would have had Type
(77%). All study participants were randomly selected from the
2 diabetes mellitus [1]. Furthermore, up to 10% of the adult
client database of the company.
population is at high risk to develop Type 2 diabetes mellitus
The sample size was calculated according to an estimated
in the future, since they are suffering from impaired fast-
sensitivity of 90% and specificity of 80% to detect new cases
ing glucose (IFG), impaired glucose tolerance (IGT), gestational
of Type 2 diabetes mellitus, respectively, considering a con-
diabetes, or insulin resistance [1].
fidence level of 95% and an alpha error of 5% [10]. Given an
Type 2 diabetes mellitus does not causes specific symp-
estimated response rate of 70%, the final study sample was
toms for many years at onset, which explains why between
2550 people. Given an estimated response rate of 70%, the min-
25% and 50% of the cases of Type 2 diabetes mellitus remain
imum study sample needed was 2550 people. As we obtained a
undiagnosed at any time in the community [2,3]. Plasma glu-
higher response rate as expected, we ended up with informa-
cose either fasting or 2 h after a 75 g glucose load and HbA1c
tion on 2613 participants. The study sample was calculated for
levels are recommended methods for Type 2 diabetes melli-
each municipality based on the number of people registered
tus diagnosis in the general population [4,5]. However, these
at Mutual SER EPSS. Thus, the study sample was weighted
are invasive, expensive and time consuming procedures and,
according to the number of population Mutual SER EPSS has
hence, are not suitable for mass screening. It has been shown
in each municipality with more study participants selected in
that the most cost efficient method for Type 2 diabetes mellitus
places where they have more people registered whom health-
screening in the general population is the use of a non-
care is provided to. Furthermore, to ensure that there were
invasive tool for risk stratification as the first step followed
enough participants in each age group, a stratified sampling
by a blood test for glycaemia [6]. Thus, screening for impaired
was used with 25% of the participants in age groups of 18–35
glucose regulation (IGR) should be targeted to individuals at
years, 36–45 years, 46–54 years and 55–74 years. The entry cri-
high risk of Type 2 diabetes mellitus.
teria of the study were: (i) age between 18 and 74 years; and (ii)
A European study validating existing non-laboratory-based
signed informed consent. The exclusion criteria were: (i) drug
models and assessing the variability in predictive perfor-
treatment for Type 2 diabetes mellitus or previously diagnosed
mance in European populations found that existing diabetes
diabetes; (ii) pregnancy or breast-feeding; (iii) history of cancer;
prediction models can be used to identify individuals at high
(iv) regular use of systemic corticosteroids; (vi) hemophilia;
risk of Type 2 diabetes mellitus in the general population [7].
(vii) inability to stand or communicate and (viii) living in areas
However, it is recommended to validate a given risk score
of difficult access.
before applying it to a specific population in order to assure
the sensitivity and specificity as the weight of the different
2.2. Methods
components of the score may vary in different populations
[8,9].
All measurements were performed between October 2014
Recently, a few attempts have been made to validate the
and February 2015. Lifestyle habits and risk factors for
FINDRISC in the Colombian population [10,11]. However, they
Type 2 diabetes mellitus were assessed by an interview
included only small population groups, did not define accu-
using a questionnaire consisting of information regarding
rately Type 2 diabetes mellitus and none of them weighted
sociodemographic factors, history of Type 2 diabetes mellitus,
the independent elements of the risk score for the target pop-
medical history, tobacco consumption, hypertension, nutri-
ulation [10,11].
tional and physical activity habits. The instruments applied
The aims of this study were to develop a Type 2 dia-
were designed based on the FINDRISC, Stepwise approach to
betes mellitus risk score model for the Colombian population
surveillance (STEPS) and International Physical Activity Ques-
(ColDRISC) and to compare the predictive accuracy of the new
tionnaire (IPAQ) [12–16].
ColDRISC model to the original and a modified Finnish dia-
Height and weight were measured without shoes and with
betes risk score (FINDRISC) in the Colombian population.
light clothing. BMI was calculated as weight (kg) divided by
height2 (m2 ). Waist circumference (to the nearest cm) was
measured at the approximate midpoint between the lower
2. Methods margin of the last palpable rib and the top of the iliac crest.
All participants underwent an OGTT that was carried
2.1. Material out according to the World Health Organization (WHO) rec-
ommendations [16]. The test started after 12 h fasting, and
The participants of this cross-sectional screening study were the fasting and 2-h blood samples were obtained after oral
the 18–74 years-old population of the health-care insurance ingestion of water solution with 75 g anhydrous glucose. The
company Mutual SER EPSS living in 30 municipalities in the glucose tolerance status was classified according to the Amer-
provinces of Atlántico, Bolívar, Córdoba, Magdalena and Sucre ican Diabetes Association (ADA) 2004 criteria [4]. Individuals
located in northern Colombia. Mutual SER EPSS is the health- who had fasting plasma glucose (FPG) level ≥126 mg/dl or 2 h
care insurance of the state-subsidized system, thus, people plasma glucose (2hPG) ≥200 mg/dl were classified as having
88 p r i m a r y c a r e d i a b e t e s 1 1 ( 2 0 1 7 ) 86–93

Type 2 diabetes mellitus. Those with 2hPG ≥140 mg/dl but

Table 1 – Baseline characteristics of the study sample.
<200 mg/dl, and FPG <100 mg/dl were classified as having iso-
lated IGT. Isolated IFG was defined as FPG ≥100 but <126 mg/dl, Mean SD
and 2hPG <140 mg/dl. People with 2hPG ≥140 mg/dl but Age 47,2 (15,1)
<200 mg/dl, and FPG ≥100 but <126 mg/dl were defined as com- BMI 26,55 (5,03)
Waist circumference 90 (12)
bined IGT and IFG. People with Type 2 diabetes mellitus, IGT
Fasting glucose (mg/dl) 90 (19)
or IFG were classified as having IGR.
2 h glucose (mg/dl) 122 (43)

% (n)

Sex
Men 38 (783)
Women 62 (1277)
2.3. Statistical analysis Age group
<45 years 40,9 (842)
The data was analyzed using IBM SPSS statistics version 19.0 45–54 years 27,4 (565)
for Windows. Logistic regression models were used for assess- 55–64 years 14,4 (297)
>64 years 17,3 (356)
ing the association between socio-demographic factors, risk
factors and lifestyle habits of Type 2 diabetes mellitus and Body mass index
the outcome variables. The outcome for the prognostic model < 25 kg/m2 41,6 (857)
was IGR-based on the collective results of the OGTT. The 25–30 kg/m2 34,8 (717)
>30 kg/m2 23,5 (484)
Hosmer–Lemeshow summary statistics were used to assess
the goodness-of-fit of the model. The level of statistical signif- Waist cirumference LA FINDRISC
icance was set to 0.05. <94 cm (men)/<90 cm (women) 53,8 (1108)
≥94 cm (men)/≥90 cm (women) 46,2 (952)
First, a univariate logistic regression analysis was per-
formed in order to evaluate which variables were statistically Waist cirumference FINDRISC
significantly related to the outcome variable. In a second <94 cm (men)/<80 cm (women) 36,8 (759)
94–102 cm (men)/80–88 cm (women) 23,6 (486)
step, the variables that showed statistical significance were
>102 cm (men)/>88 cm (women) 39,6 (815)
included in the multivariate models to develop the final model
of the ColDRISC. Following the methodology of the develop- 30 min daily physical activity
ment of the original FINDRISC, logistic regression was used to No 94,7 (1950)
Yes 5,3 (110
compute ˇ-coefficients for known risk factors for diabetes [10].
Coefficients (ˇ) of the model were used to assign a score value Daily fruit or vegetable intake
for each variable, and the composite diabetes risk score was No 28,2 (577)
Yes 71,8 (1468)
calculated as the sum of those scores. The diabetes risk score
value was defined using the full model, from the ˇ coefficient Use of blood pressure medication
as follows: for ˇ = 0.01–0.49, the score is 1; for ˇ = 0.50–0.9, the No 80,7 (1662)
Yes 19,3 (398)
score is 2; and for ˇ = 0,9–1,2, the score is 3. The lowest category
(reference) of each variable was given a score of 0. The total Past history of hyperglycemia (in a medical check-up, during an
diabetes risk score was calculated as the sum of the individual illness or pregnancy)
scores and varied from 0 to 9. No 97,8 (2015)
Yes 2,2 (45)
The ColDRISC was tested against the original FINDRISC [12]
and a modified FINDRISC [11]. The only difference between Family history of diabetes mellitus
the original and modified FINDRISC is that the original FIND- No 63 (1297)
Yes: grandparent, uncle, aunt or cousin 16,5 (340)
RISC uses three categories for waist circumference (men:
Yes: biological father, mother or sibling 20,5 (423)
<94 cm (0 risk points), 94–102 cm (3 risk points), >102 cm (4
Unknown Type 2 diabetes mellitus 5,1 (105)
risk points); women: <80 cm (0 risk points), 80–88 cm (3 risk
Impaired glucose regulation 27,4 (565)
points), >88 cm (4 risk points)), whereas the modified FIND-
RISC, recently renamed as the LA-FINDRISC, uses only two
categories (men: <94 cm (0 risk points), ≥94 cm (4 risk points);
women: <90 cm (0 risk points), ≥90 cm (4 risk points)) to
identify abdominal obesity in the Latin American population 2.4. Ethical considerations
[17]. The modified FINDRISC has been validated in people in
Colombia and Venezuela [11] and most recently in 521 peo- This study followed the Good Clinical Practice guidelines and
ple from a population based cross-sectional, cluster sampling the guidelines of the Helsinki Declaration. All the data have
study in Venezuela [18]. been collected using previously tested questionnaires and
The sensitivity and the specificity were assessed for methods. Besides blood samples, no invasive methods were
the ColDRISC, original and modified FINDRISC. In addition, used. The study protocol was approved by the Research Ethics
receiver-operating characteristic (ROC) curves, sensitivity, Committee of the Central Military Hospital, Bogotá, Colombia.
specificity, positive and negative predictive values were cal- All participants gave the written informed consent prior their
culated for each score for several cut-off points. participation in the study.
 p r i m a r y c a r e d i a b e t e s 1 1 ( 2 0 1 7 ) 86–93 89

Table 2 – Logistic regression models with impaired glucose regulation as the dependent variable.
Full model (n = 2060)

Beta coefficient ORa (95% CIb ) Score

Intercept −2,149

Age group
45–54 years 0,37 1,45 (1,10–1,90) 1
55–64 years 0,729 2,07 (1,51–2,85) 2
>64 years 1,118 3,06 (2,25–4,16) 3

Waist circumference
≥94 cm (men)/≥90 cm (women) 0,854 2,35 (1,90–2,90) 2

Use of blood pressure medication 0,569 1,77 (1,37–2,29) 2

Family history of diabetes mellitus 0,676 1,97 (1,55–2,50) 2

(Biological father, mother or sibling)
a
Odds ratio.
b
Confidence interval.

Using the risk score cutoff value of 3 in the ColDRISC to

3. Results identify undiagnosed diabetes resulted in a sensitivity of 86%
and a specificity of 50% (Table 3). Increasing the cutoff value of
After excluding people with incomplete data on the key vari-
the score to 4 or 5 changed the sensitivity to 73% and 52%, and
ables of the study (n = 553), the final sample for the COLDRISC
the false-positive rates to 67% and 77%, in men and women,
comprised 2060 men and women corresponding to 79% of the
respectively. The corresponding sensitivity and specificity of
total sample obtained.
the modified FINDRISC for the cut-off score of 12 was 56% and
The baseline characteristics of the study population are
77%, respectively whereas a cut-off score corresponding to 10
presented in Table 1. The prevalence of unknown Type 2 dia-
increased the sensitivity to 72% decreasing the specificity to
betes mellitus was 5.1%, and 27.4% of the participants were
60%. A 35% of the study population had a ColDRISC score of
classified as having IGR. The prevalence of central obesity was
≥4 and 33% a modified FINDRISC ≥12.
approximately 50% and a 42% of the study participants had a
body mass index (BMI) of less than 25 kg/m2 . Furthermore, the
vast majority (95%) of people did not reach the recommended 4. Discussion
half an hour physical activity per day.
In the univariate analysis (table not shown) only age, The performance of all three risk scores (ColDRISC, original
BMI, waist circumference, antihypertensive drug therapy and and modified FINDRISC) in screening for Type 2 diabetes mel-
family history of Type 2 diabetes mellitus were statistically sig- litus in Colombia was good. The risk score developed in our
nificantly associated with the outcome variable. Neither past study showed a similar performance than both the original
history of hyperglycemia, sex, physical activity or fruit and and modified FINDRISC. However, several factors may favor
vegetable intake were significantly related to IGR, thus, were the use of the ColDRISC in Colombia. However, it has to be kept
not included in the multivariate logistic regression model. in mind that the ColDRISC includes only half of the questions
When we added BMI into the model or developed another compared to the FINDRISC (eight variables). For the develop-
model with BMI instead of waist circumference, the model fit ment of the ColDRISC we decided to include one indicator of
did not improve significantly. Thus, the statistically significant obesity, waist circumference, as adding BMI to the model or the
independent predictors of IGR in the final multivariate logistic model with BMI alone did not improve the model significantly.
regression model were age, waist circumference, antihyper- The main idea of the risk score is that it is easily applicable
tensive drug therapy and family history of Type 2 diabetes in the general population without the need for calculators or
mellitus (Table 2). special equipment such as balances to define the variables of
Figs. 1 and 2 show the ROC curves for the ColDRISC, mod- the score. For the majority of the people it is much easier to
ified FINDRISC and original FINDRISC according to unknown measure their waist circumference than height, weight fol-
Type 2 diabetes mellitus (Fig. 1) and IGR (Fig. 2). The area under lowed by an algorithm to get calculated BMI. The downside of
the ROC curve for unknown Type 2 diabetes mellitus was 0.74 using waist circumference is that although it is easier to obtain
(95% CI: 0.70–0.79) for the ColDRISC and original FINDRISC (95% than BMI, measuring waist circumference has not been well
CI: 0.69–0.78), respectively 0.73 for the modified FINDRISC (95% adopted, yet, in clinical practice [19].
de CI 0.69–0.78) whereas the corresponding area under the In addition, past history of hyperglycemia was not retained
curve for IGR were 0.72 (95%: 0,69–0,74) for the ColDRISC and by the model as independent predictor of IGR contrasting the
0.70 (95% CI: 0,68–0,73) for both the modified FINDRISC and the results of the original FINDRISC where history of high blood
original FINDRISC. There was no statistically significant differ- glucose was the most powerful predictor of incident diabetes.
ence in the area under the curve of the ROC curves among the The prevalence of people who know about their past history of
three risk scores (p-value > 0.05). glucose or had their glucose tested previously was very low in
our study population. Thus, most likely there was no sufficient
90 p r i m a r y c a r e d i a b e t e s 1 1 ( 2 0 1 7 ) 86–93

1.00
0.75
Sensitivity
0.50
0.25
0.00

0.00 0.25 0.50 0.75 1.00

1-Specificity
FINDRISC. ROC area: 0.7346 CI95% (0.69320-0.77602) Modified_FINDRISC. ROC area: 0.7343 CI95% (0.69234-0.77627)

COLDRISC. ROC area: 0.7423 CI95% (0.69940-0.78529)

Fig. 1 – Receiver operating characteristics (ROC) curves for the prevalence of unknown Type 2 diabetes mellitus for the
ColDRISC, modified FINDRISC and original FINDRISC.

power to detect a possible statistically significant association next step is the implementation of the ColDRISC in the popu-
with this variable in the model. This also shows the impor- lation of Colombia as a tool to detect unknown Type 2 diabetes
tance to weight the individual components of a risk score in mellitus. Currently, there are three approaches for early detec-
a given population as their frequency differ remarkably from tion of Type 2 diabetes mellitus and IGR in the population. The
the original Finnish population for FINDRISC. The important first one consists of fasting glucose or HbA1c measurements to
1.00
0.75
Sensitivity
0.50
0.25
0.00

0.00 0.25 0.50 0.75 1.00

1-Specificity
FINDRISC. ROC area: 0.7051 CI95% (0.68073-0.72949) Modified FINDRISC. ROC area: 0.7033 CI95% (0.67893-0.72775)

COLDRISC. ROC area: 0.7176 CI95% (0.69403-0.74126)

Fig. 2 – Receiver operating characteristics (ROC) curves for the prevalence of impaired glucose regulation for the ColDRISC,
modified FINDRISC and original FINDRISC.
 p r i m a r y c a r e d i a b e t e s 1 1 ( 2 0 1 7 ) 86–93 91

Table 3 – Characteristics of the ColDRISC and the modified FINDRISC using different cutoff values for unknown Type 2
diabetes and impaired glucose regulation.
Sensitivity Specificity Positive predictive value Negative predictive value % of study sample
Unknown Type 2 diabetes mellitus
ColDRISC
Cutoff value 3 0,86 0,5 0,085 0,985 52
Cutoff value 4 0,73 0,67 0,106 0,979 35
Cutoff value 5 0,52 0,77 0,109 0,968 25

Modified FINDRISC
Cutoff value 9 0,82 0,52 0,08 0,989 58
Cutoff value 10 0,72 0,6 0,084 0,984 50
Cutoff value 12 0,56 0,77 0,096 0,971 33

Impaired glucose regulation

ColDRISC
Cutoff value 2 0,76 0,58 0,356 0,91 69
Cutoff value 3 0,57 0,73 0,577 0,759 52
Cutoff value 4 0,42 0,18 0,443 0,818 35

Modified FINDRISC
Cutoff value 8 0,78 0,5 0,36 0,877 64
Cutoff value 9 0,71 0,58 0,372 0,864 58
Cutoff value 12 0,43 0,82 0,44 0,87 33

determine explicitly IGR. The second proposed strategy uses their lifetime, and they will benefit from lifestyle interventions
demographic and clinical characteristics as well as previous [26,27,31,32].
laboratory tests to determine the likelihood for Type 2 dia- It has been shown that the most cost effective method for
betes mellitus. The last approach collects questionnaire-based Type 2 diabetes mellitus screening in the general population is
information that provides information on the presence of eti- the use of a non-invasive tool for risk stratification followed by
ological risk factors Type 2 diabetes mellitus [20]. The last two a blood test for glycaemia [33]. Furthermore, it has been sug-
strategies do not clearly determine the glycaemia and blood gested that strategies for early detection of persons with Type 2
glucose testing is necessary in all three approaches to accu- diabetes mellitus are only cost-effective when combined with
rately define whether IGR exist. However, the results from a lifestyle interventions in those identified with IGR [34–36]. In
simple first-level screening can remarkably decrease the num- addition, recent evaluation of four different screening strate-
ber of people who should to be referred for further testing gies for unknown diabetes in Colombia revealed that the most
of glycaemia and appropriately target laboratory measure- cost-effective strategy was screening by using the FINDRISC
ments to the segment of the population that has high risk followed by fasting blood glucose and OGTT if necessary [37].
of Type 2 diabetes mellitus. The second approach mentioned At the present, the evidence in regard screening and the
above is particularly suited for those with pre-existing cardio- benefits of lifestyle intervention in people at high risk have
vascular disease (CVD) and women with previous gestational not yet been established. Therefore, it is important to imple-
diabetes, while the third option is best for the general popu- ment a screening tool for Type 2 diabetes mellitus and IGR
lation including overweight or obese people. The guideline of such as the ColDRISC in order to reduce the burden of Type 2
the European Society of Cardiology and European Association diabetes mellitus as soon as possible in the current situation
for the Study of Diabetes recommends that the appropriate in the Colombian population where half of all cases of Type 2
screening strategy in the general population and people with diabetes mellitus are undetected [1,38,39].
assumed abnormalities is to start with a Type 2 diabetes mel- Naturally, our study had some limitations. The partici-
litus risk score and to ask for an OGTT or a combination of pants in our study are not from a representative sample of
HbA1c and FPG in individuals with risk score above the set the Colombian population; thus, the results may not reflect
cut-off value [21]. In patients with CVD, no diabetes risk score the proportions of IGR categories in the Colombian popula-
is needed but an OGTT is indicated if HbA1c and/or FPG are tion at large. However, the study participants were randomly
inconclusive, as people belonging to these groups may often selected from the sampling frame using the phone number
have Type 2 diabetes mellitus revealed only by elevated 2- registered at the health-care insurance company. Moreover,
h plasma glucose [22–25]. The importance to identify people the study participants was recruited geographically in order
with IGR within the Colombian population is justified by sev- to provide adequate numbers from various municipalities at
eral intervention studies that have clearly shown that Type the Colombian Atlantic coast to provide adequate statistical
2 diabetes mellitus can be prevented or at least be delayed power for developing a risk factor model. Therefore, the sam-
in people with IGT by lifestyle interventions targeting physi- ple developed for this study represents the intended target
cal activity and nutritional changes [26–30]. Thus, the optimal groups. We found that fewer variables have the same perfor-
Type 2 diabetes mellitus prevention strategy should be to iden- mance as the original or modified FINDRISC. However, it may
tify people with IGT since at least 50% of them will develop be argued that when the questionnaire is simplified, the possi-
Type 2 diabetes mellitus in 10 years and most of them during bility to explore and educate about other variables such as BMI,
nutrition and physical activity is lost. This may be valid from
92 p r i m a r y c a r e d i a b e t e s 1 1 ( 2 0 1 7 ) 86–93

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Conflict of interest
[11] P. Aschner, R. Nieto-Martinez, A. Marín, M. Rios, Evaluation
of the FINDRISC score as a screening tool for people with
The authors state that they have no conflict of interest. impaired glucose regulation in Latin America using modified
score points for waist circumference according to the
validated regional cutoff values for abdominal obesity,
Financial support Minerva Endocrinol. 37 (4) (2012) 114.
[12] J. Lindström, J. Tuomilehto, The diabetes risk score: a
practical tool to predict type 2 diabetes risk, Diabetes Care
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