June 9, 2008 — The Finnish Diabetes Risk Score (FINDRISC) was effective in identifying high-risk groups that would benefit from intensive lifestyle intervention to prevent type 2 diabetes, according to the results of a randomized controlled trial reported in the May issue of Diabetes Care.

"Intensive lifestyle intervention significantly reduced diabetes incidence among the participants in the Finnish Diabetes Prevention Study (DPS)," write Jaana Lindström, PhD, from the National Public Health Institute in Helsinki, Finland, and colleagues from the Finnish DPS Group. "We investigated whether and to what extent risk factors for type 2 diabetes and other baseline characteristics of the study participants modified the effectiveness of the lifestyle intervention."

In this study, overweight, middle-aged volunteers with impaired glucose tolerance were randomized to an intensive lifestyle intervention (n = 265) or to a control group (n =257) for a median of 4 years, during which annual oral glucose tolerance testing determined diabetes status.

Incidence rates of diabetes and hazard ratios (HRs) for the intervention vs the control group were calculated by sex and baseline tertiles of age, body mass index (BMI), waist circumference, plasma glucose concentration at fasting and 2 hours after a glucose load, fasting serum insulin and insulin resistance index, and categories of composite baseline FINDRISC. The investigators determined interactions between the intervention assignment and baseline risk factors on the risk for diabetes.

Groups in which the intervention was most effective were the oldest individuals (HRs 0.77, 0.49, and 0.36 by increasing age tertiles, respectively; P for interaction = .0130) and those with high baseline FINDRISC (HRs 1.09, 0.84, 0.34, and 0.22 by increasing risk score category, respectively; P for interaction = .0400). Other baseline characteristics or risk factors did not modify the effect of the intervention on the risk for diabetes.

"The FINDRISC may be useful in identifying high-risk groups most likely to benefit from intensive lifestyle intervention to prevent type 2 diabetes," the study authors write.

Limitations of this study include careful selection of DPS participants, limiting generalizability to other populations with differing risk profiles.

"Intensive lifestyle intervention in individuals with IGT [impaired glucose tolerance] was most effective among those with higher baseline age or a high FINDRISC," the study authors write. “To improve cost-effectiveness, the FINDRISC could be used to identify target groups for lifestyle intervention to prevent type 2 diabetes."

The DPS study has been supported by the Academy of Finland, the Juho Vainio Foundation, Ministry of Education, the Novo Nordisk Foundation, the Yrjö Jahnsson Foundation, and the Finnish Diabetes Research Foundation, and by competitive research funding from Tampere, Kuopio, and Oulu University Hospitals. The costs of publication of this article were defrayed in part by the payment of page charges, mandating that it must therefore be hereby marked "advertisement" solely to indicate this fact.

Diabetes Care. 2008;31:857-862.

Clinical Context

Study Highlights

• Participants in DPS had impaired glucose tolerance on the basis of 2 consecutive oral glucose tolerance tests, were middle-aged (40 - 64 years), and were overweight (BMI > 25 kg/m²) at baseline.
• Of 522 participants, 172 were men and 350 were women.
• In DPS, intensive lifestyle intervention significantly reduced diabetes incidence.
• The goal of this analysis was to determine whether, and to what extent, risk factors for type 2 diabetes, the composite FINDRISC, and other baseline characteristics modified the effectiveness of lifestyle intervention in reducing diabetes incidence.
• FINDRISC is a simple risk assessment tool for population screening that characterizes individuals according to their future diabetes risk. It is a paper-and-pencil screening questionnaire that takes only a few minutes to complete and does not require trained personnel or laboratory equipment.
• FINDRISC was developed and validated with 2 large, population-based cohorts. It combines the effects of 8 risk characteristics and estimates the 10-year absolute risk for type 2 diabetes.
• In DPS, participants were randomized to an intensive lifestyle intervention (n = 265) or to a control group (n = 257).
• Median duration of follow-up was 4 years; oral glucose tolerance testing was performed each year to determine diabetes status.
• Incidence rates of diabetes and HRs for the intervention vs the control group were calculated by sex and baseline tertiles of age, BMI, waist circumference, plasma glucose concentration at fasting and 2 hours after a glucose load, fasting serum insulin and insulin resistance index, and categories of composite baseline FINDRISC.
• Groups in which the intervention was most effective were the oldest individuals (HRs 0.77, 0.49, and 0.36 by increasing age tertiles; P for interaction = .0130) and those with high baseline FINDRISC (HRs: 1.09, 0.84, 0.34, and 0.22 by increasing risk score category; P for interaction = .0400).
• For participants with low baseline FINDRISC scores, the diabetes incidence rates remained virtually the same (3.6 - 4.7 cases/100 person-years) regardless of intervention.
• Participants with high baseline FINDRISC scores who received intensive lifestyle counseling had a similarly low incidence rate of diabetes (4.0 - 4.2).
• Participants with a high baseline FINDRISC who received only standard care counseling had a very high incidence rate (11.7 - 18.8), suggesting that the originally increased risk in individuals with a high FINDRISC score was completely abolished with lifestyle intervention.
• This interaction was not explained by better adherence to the intervention goals.
• With the FINDRISC as a prescreening method, the cost-efficiency of lifestyle interventions could be drastically increased, with the number needed to treat among the entire study population in the DPS reduced from 7.7 to 3.6.
• The intervention was most effective among the oldest individuals (age > 61 years), with a relative risk reduction of 64% vs that in the control group.
• Except for FINDRISC score and age, other baseline characteristics or risk factors did not modify the effect of the intervention on the risk for the development of diabetes.
• Although the incidence of diabetes increased with increasing BMI and waist circumference in both intervention and control groups, the effect of lifestyle intervention was of the same magnitude in all BMI groups.
• The investigators concluded that the FINDRISC may identify high-risk groups most likely to benefit from intensive lifestyle intervention to prevent type 2 diabetes and that use of the FINDRISC to identify target groups for lifestyle intervention could improve cost effectiveness.

Pearls for Practice

• FINDRISC may identify high-risk groups most likely to benefit from intensive lifestyle intervention to prevent type 2 diabetes. By using the FINDRISC as a prescreening method, the cost-efficiency of lifestyle interventions could be drastically increased.
• Intensive lifestyle intervention was most effective among the oldest individuals (age > 61 years), with a relative risk reduction of 64% vs that in the control group. Except for FINDRISC score and age, other baseline characteristics or risk factors did not modify the effect of the intervention on the risk for the development of diabetes.

CME Test