INTRODUCTION
Diabetes is a chronic disease that affects the endocrine system and is normally characterized by a hyperglycaemic state [1]. In turn, chronic hyperglycaemia may result in a deficiency in insulin secretion and action [1,2]. Diabetes has seen a high prevalence worldwide in recent years, with an estimated 422 million people living with the disease in 2014. Also, future perspectives have been reported an exponential growth of this disease, which may reach 700 million people within 20 years [3,4]. In Portugal, the latest epidemiological reports from 2018 demonstrated that the type 2 diabetes (T2D) was responsible for approximately 4% of deaths in Portuguese population and is still responsible for spending 0.8 of the country’s gross domestic product (GDP) for its control [5]. Worldwide, the spending on the treatment of T2D in 2015 was approximately US$ 1.3 trillion, and this cost is also growing exponentially, as it is expected to reach US$ 2.5 trillion by 2030 [5,6].
Diabetes disease is mainly classified into different types, type 1 diabetes (T1D), T2D and gestational diabetes (GD) [7]. Hence, the T1D is predominantly characterized as an autoimmune disease, in which there is an increase of glucose in the bloodstream due to a dysfunction of pancreatic beta (β) cells, resultant of the autoimmunity aggression by T cells [8,9]. The T2D diagnosis has two specific factors, namely the endocrine system dysfunction caused by the onset of insulin resistance, expressed by a peripheral insulin resistance, as well as a progressive failure of pancreatic insulin secretion and the body’s insufficient ability to produce enough insulin to suppress its needs [4,10]. The GD was diagnosed when a woman, with no previous history of T2D, registers uncontrolled glucose values in the bloodstream during pregnancy. This dysregulation is driven by insulin resistance promoted by the release of hormones that influence its action, hormones such as growth hormone, corticotrophin-releasing hormone or lactogen [11,12].
The T2D is considered the most prevalent type of diabetes, and it is estimated that one in two adults has this type of diabetes, although, in many cases, the disease is not diagnosed [3,4]. The T2D is currently one of the most leading causes of death worldwide, with 6.7 million deaths, and a growing trend that points to a 5% increase in premature deaths [4]. This type of diabetes is currently a disease of great concern due to its high prevalence (> 90% of cases of diabetes) with an exponential growth trend, making it one of the main public health problems [13]. The growth of T2D is mainly due to the increasing prevalence of risk factors associated with this type of diabetes. Waist circumference (WC), body mass index (BMI), gender, ethnicity, physical activity (PA) rates, smoking, eating habits, family history, hypertension, and treatments using medications, such as β-blockers and diuretics, are factors that have been identified over time that increase the risk of T2D developing [14,15]. Screening through non-clinical means at an early stage has a high relevance in the control and prevention of this metabolic disease. Applying non-invasive methods such as the American Diabetes Association (ADA) Risk Test questionnaire [16], and/or the Finnish Diabetes Risk Score questionnaire (FINDRISC) [17] allows simple and rapid assessment, enabling instant alerts to individuals at risk of developing the disease. With this, high risk individuals may seek clinical evaluation for the diagnosis of diabetes and primary changes in lifestyles and habits.
Specifically, the FINDRISC is a risk score test, created by Lindström & Toumilehto [17], with the aim of tracking cases at high risk of developing T2D and thus being an effective tool in disease prevention. The FINDRISC questionnaire assigns a risk score at the end of the test based on the answers given to each of the questions regarding risk factors [18]. Each question is related to a risk factor associated with T2D. The FINDRISC questions to estimate the global risk of developing T2D, BMI, WC, sedentary lifestyle, consumption of vegetables or fruits, use of medication to control blood pressure, episodes of hyperglycaemia and a family history of diabetes. The Finnish national diabetes prevention program used the FINDRISC test for large-scale screening to warn and try to control the course of the disease [19]. This study shows that the use of this test is a very useful tool, as it allows screening the risk of T2D in many individuals, making viable an early and rapid intervention, with clear benefits for their health. Other studies corroborate this idea, having concluded that the use of this tool contributes to a primary prevention of the disease in the general population, being able to reach many individuals due to its easy and quick application [20,21]. Dantas et al. [22] confirmed a greater effectiveness of the FINDRISC questionnaire as a screening tool for T2D. In this regard, FINDRISC allows to identify and track individuals at high risk of developing T2D, being a valid and effective strategy for primary prevention, as well as enabling early action on modifiable risk factors for the development of the disease. Two other studies were carried out in Portugal using this same tool. The first, Valente & Azevedo [23]examined the T2D risk in patients registered in Amarante Health Center (HC), reporting that 1 in 8 users of this HC had a high risk of developing the disease. In another study, Viveiros et al. [24] revealed that the application of the FINDRISC questionnaire found that 1 in 4 study participants had a high risk of developing T2D in a 10-year period. Thus, the results of different studies show the high importance of this type of questionnaire in identifying individuals at greater risk of developing T2D, making laboratory screening more efficient and effective, as well as identifying cases of the disease that may not be diagnosed. Thus, both studies demonstrated that FINDRISC can be applied for an early intervention and, thus, contain the onset of the disease [23,24]. This study intends to update previously carried out previous epidemiological studies in higher education student [25,26]. However, this reality has been fundamental in hospital or HC contexts, i.e., in primary care, with work contexts being little studied, therefore populations at risk who do not attend health services [22–24]. More specifically, the higher education is little studied in this area, however the increase in ageing workforce justifies the premature diagnosis of with metabolic health problem during working life since this can improve the quality and average life expectancy after retirement [3,4].
Thus, this study aimed to predict the risk of developing T2D in the community of Polytechnic Institute of Bragança (IPB), understand which T2D risk factors have a greatest impact on this disease, and raise the awareness of the IPB population through screening for T2D problems. We hypothesized that the older age group (staff group) has a higher risk of developing T2D than the younger age group (students). Also, we hypothesize that overweight and obesity represent the most prevalent risk factors among the IPB academic community. As well, we expected that the practice of physical activity is inversely proportional to the T2D risk score.
METHODS
Research Design and Sample
This was an observational, cross-sectional, and prospective study that aimed to estimate the risk level for T2D in the academic community of the Polytechnic Institute of Bragança (IPB). The eligible sample comprised a total number of 10,556 individuals from the IPB community. Of these, only 3021 individuals participated in the study, of which 1759 were female (58.23% with an average age of 23.4 ± 8.7 years) and 1262 were male (41.77% with an average age of 24.2 ± 8.9 years). This study was approved by the Ethics Committee of the IPB on May 31st, 2021, with reference number 43/2021 and an informed consent was completed by all participants at the time of their participation.
Data Collection
Selection Criteria
The sample was selected from cross-sectional, observational, and prospective research conducted in IPB community. For individuals to be eligible to be part of the sample, they could not have any of the exclusion criteria defined for the study. Therefore, they had to be students, teachers, or non-teaching staff of the IPB and not have a confirmed diagnosis of T2D. The exclusion criteria: i) not to be a student/staff/researcher of the IPB; ii) individual with a confirmed diagnosis of type 1 or type 2 diabetes (T1D or T2D). From this, research sample included 2716 students (21.40 ± 4.23 years) and 1667 were staff members (44.01 ± 11.73 years). After ensuring the validity of the participation of each of the potential subjects, the sample was selected as shown in Figure 1.
FINDRISC Score
The diabetes risk assessment questionnaire used in the National Programme for Diabetes Prevention and Control (PNPCD) [21] of the Directorate-General for Health (DGS) from Portugal was used in this study, adapted from the questionnaire developed by researchers from Finland, known as the Finnish Diabetes Risk Score (FINDRISC) [20]. This questionnaire allows for a wide-ranging screening due to its ease of application and for being a non-evasive tool. This tool assigns a risk score which dictates the probability, for those who answer the questionnaire, of developing T2D over a 10-year period. The FINDRISC’s survey items were blood pressure, age, waist circumference, BMI, exercise, food, usage of antihypertensive medication, history of elevated blood glucose, and family history of diabetes mellitus [20,21]. The questionnaire comprises five risk intervals [21]: i) low risk (<7 points), ii) mild risk (7–11 points), iii) moderate risk (12–14 points), iv) high risk (15–20 points), v) very high risk (>20 points) [17,18]. Using the score obtained from the questionnaire, it was possible to divide the subjects who had an increased risk of developing T2D and those who did not have an increased risk of developing T2D. A score of 9 points was considered the cut-off value, where subjects with a risk score of less than or equal to 9 points were considered to be in the group with no increased risk (SR) of developing T2D and subjects with scores above 9 points were considered to be in the group with an increased risk (R) of developing T2D [14,15].
Sociodemographic variables
The sociodemographic variables were selected according to previous epidemiological reports [22–24], specifically: sex (male, female or undefined), marital status (i.e. single, divorced, married or widowed), education (i.e. primary, secondary, basic or higher) and professional activity at the Higher Education institution under study.
T2D risk factors
T2D risk factors were assessed as independent variables. The risk result is obtained by adding the score recorded in each of the answers regarding the different risk factors included in the questionnaire: age, BMI, WC, PA, fruit and vegetable consumption, hypertension medication, history of hyperglycaemia and family history. Of these factors, the history of hyperglycaemia and family history are the factors with the greatest impact on the final estimation of the risk of T2D, contributing with a maximum score of 5 points for each one of those factors. On the other hand, fruit and vegetable consumption is the factor with the lowest impact, with a maximum score of 1 point. The FINDRISC questionnaire established a cut-off value of 9 points to classify respondents as at-risk or non-risk [17]. Additionally, the consumption of cigarettes, alcoholic beverages and the practice of PA (i.e., more than 30 minutes per day, including activities of daily living) and physical exercise practice (i.e., sedentary - 0/1 session per week; active – more than 2 sessions per week). PA and exercise were defined by ACSM standards [27]. Participants were also asked about their personal history of cardiovascular disease (i.e., cerebrovascular disease, coronary heart disease, peripheral vascular disease, diabetic foot, retinopathy, nephropathy, neuropathy or other).
Anthropometric Measures
The WC and body mass were measured by a flexible measuring tape and a Tanita MC 780-PMA® bioimpedance scale (Tanita Corporation, Tokyo, Japan) respectively, as well as a folding screen for greater privacy in the measurement process with minimal clothing. The average of three measurements was used to calculate body mass, height, and WC to the closest 0.1 International Units (IU). The WC (cm) was measured at the junction of the lower border of the lower perceptible rib and the top of the iliac crest. For the WC measurements, the following gender-specific criteria were taken into account: WC ≥ 88 cm for women and WC ≥ 102 cm for males [28]. The measurement was taken three times by the same researcher, and the average was chosen for further examination. The Intra-class correlation Coefficient (ICC) revealed an almost perfect agreement (ICC = 0.90). BMI was calculated by dividing weight (kg) by the square of height (m2) [15,17].
Procedures
The procedures were structured based on previous Portuguese studies that used the same questionnaire for their studies [22,24]. In a preparatory phase, with the purpose of making the IPB community aware of the study, an email was prepared with a brief description including the variables and the aims of the study, which was addressed to each of the directors of the different schools from IPB and people responsible for the research laboratories, as well as central and social services of the institution. On this basis, the risk group and the no-risk group were defined. The questionnaire was applied by a digital format from OutSystems® platform. To share the questionnaire, two simple access modes were created to make the access process faster and more intuitive. A QR Code was created by the researchers with direct access to the questionnaire, and also a short link.
Then, the information about the study was disseminated to the respective IPB communities (students and staff) through institutional email addresses. To distribute the questionnaires to students and teaching staff of the IPB, the research team visited the classrooms of the different schools of the institution and the workstations of the staff and researchers where they explained the aims of the study and asked for their collaboration in completing the questionnaire.
Before answering the questionnaire, participants were asked to give their informed consent to participate in the study, which was provided at the beginning of the questionnaire, and so that the results could be used in the present investigation. After completing the informed consent, the participants should answer whether they have T1D or T2D. If they answered that they did not have either type of diabetes, they moved on to the part of the questionnaire concerning the assessment of the risk of developing T2D. After completing all the questions of the questionnaire, the specific risk level for developing in the next 10 years and BMI level was automatically calculated by the software, giving each participant a final outcome.
Statistical Analysis
An exploratory analysis was performed to verify the normal distribution of variables. The data of quantitative variables were reported through the mean as a measure of central tendency and the standard deviation as a measure of dispersion. The data of qualitative variables were expressed through the absolute and relative frequency. The significance value adopted to determine the existence of statistically significant differences for the tests performed was p < 0.05.
The chi-square (X2) test or Fisher’s exact test was applied whenever to explore the association between the independent variables under study with the presence or absence of risk of developing T2D [29,30]. The Cramer`s V test was also performed to understand the strength of the association of each variable with the presence of risk for T2D. The Cramers’ V test is divided into five degrees of intensity of association, negligible (0.00–0.10), weak (0.10–0.20), moderate (0.20–0.40), relatively strong (0.40–0.60), strong (0.60–0.80) and very strong (0.80–1.00) [30]. To understand the meaning of the association of variables, the analysis of adjusted residues was performed. JASP (JASP Team, 2019; jasp-stats. org) and IMB SPSS 26 (Armonk, NY: IBM Corp) for MacOS® software were used for data processing and analysis.
RESULTS
Sample Characterization
Table 1 showed significant differences reported between students and staff. Staff members were the highest percentage of subjects with risk factors associated with T2D disease, considering only the risk factors that were significantly associated with the risk of developing this disease (p < 0.05 to p < 0.001). The risk factor “family history of diabetes” was the only risk factor that was more present in the students than staff group. The variables height and PA did not show statistically significant differences between the groups studied.
Figure 2 shows that approximately 96 per cent of the students had a low or slight risk of developing T2D over a 10- year period. This value was clearly higher than that observed in the staff group, where the percentage of participants in this ranges was approximately 84 per cent. In the student group, the moderate risk range is only 3%, and in the high risk range, approximately 1%. In the group of employees, the values was appreciably higher, with approximately 15% of participants in the moderate risk range and approximately 5% in the high-risk range. Considering the total sample (students and employees), about 5% had an increased risk of developing T2D in the next 10 years.
Association of Socio-Demographic Variables and Risk Variables from the FINDRISC Questionnaire with the Risk of Developing T2D
In one hand, the variables marital status, level of PA, level of education and number of alcoholic beverages showed a significant association with the risk of T2D (p < 0.05). On the other hand, the variables gender, smoking habit, and consumption of alcoholic beverages showed no association with the risk of T2D. Analyzing the variables in Table 2, for the variable civil status (X2 = 168.5; p < 0.001), it is possible to observe that married and divorced participants are positively associated with the risk of developing T2D. For the variable level of education (X2 = 47.1; p < 0.001), it is observed that only the study participants who had secondary education were associated with the group of individuals with no risk of developing T2D.
In Table 3, no association was found between the risk of developing T2D and any of the variables analyzed, including PA, smoking habits, consumption of alcoholic beverages, and number of alcoholic beverages.
Table 4 shows that participants under 45 years old were more likely to have no T2D risk. Regarding WC, participants with lower WC (men < 94 cm and women < 80 cm), in both genders, obtained statistically significant associations (X2 = 1034.5; p < 0.001) with no risk of developing T2D. Individuals with a BMI below 25 kg/m2 was people without risk of developing T2D, whereas individuals with a higher BMI are at risk of developing the disease.
In Table 5, it is evident that all variables, except for the consumption of vegetables/fruit, show the existence of a significant positive association between the variables that were identified as risk factors for T2D in the FINDRISC questionnaire, and the risk of developing T2D (p < 0.05). A significant association between PA practice and having no risk of developing T2D was observed (X2 = 70.2; p < 0.001). In turn, participants who answered negatively to the same question were faced with a significant association with being at risk of developing T2D.
The study found a positive association between taking medication for hypertension and previous episodes of hyperglycemia and the risk of developing T2D. Participants who responded positively to the questions on taking medication for hypertension and on occurrences of previous hyperglycaemia states were associated with the risk of developing this disease, while those who answered with no were associated with having no risk of developing the disease.
Cramers’v Test for Socio-Demographic Variables and the Risk Variables of the FINDRISC Questionnaire
Except for gender, smoking habit, alcohol consumption and vegetable consumption, all factors show a significant association (p < 0.05) with the risk of developing T2D. However, the variable WC and BMI, showed the strongest association with the variable, referring to WC being closer to 1 than to 0 (Table 6).
On the other hand, the variable with the lowest Cramer’s v value was the practice of PA. Thus, being the variable with the weakest association among the risk variables. Therefore, overall, the WC is the variable that recorded a stronger association, while the variable “number of alcoholic beverages” is the one that showed a weaker association.
DISCUSSION
This study aimed to predict the risk of developing T2D in a higher education community of Bragança, North-Eastern Portugal. It was observed that the older group (staff members) had a higher risk of developing T2D than the younger group (students). Among the academic community of the IPB, overweight and obesity were the most prevalent risk factors. Additionally, the practice of PA was inversely proportional to the T2D risk score. These results confirm the findings for the preponderance of BMI and WC as risk factors for T2D.
Based on the analysis of the results, the present study revealed that the risk of developing T2D in the IPB population is about 10%. That is, 1 in 10 individuals in this population had a real risk of developing the disease. In comparison with previous results that used the same screening methodology and the same risk assessment questionnaire, the results of the present study differ from previous investigations carried out in Portugal. In an investigation by Dantas et al. [22], approximately 49% of the study sample was at risk of developing T2D in 10 years. In another research carried out by Viveiros et al. [24] the values found were like those of the work of Dantas et al. [22], with 42% of participants in this study having a moderate to very high risk of developing T2D. The study carried out by Valente & Azevedo [23], considered as one of the first studies carried out in Portugal using the FINDRISC questionnaire, obtained significantly higher values than all the above-mentioned studies, concluding that approximately 70% of participants had a moderate to very high risk of developing T2D over a 10-year period.
The differences between the values presented in previous works and the present investigation can be partially explained by two factors: the age of the individuals under study and the institution where the data was collected. More recently, a research conducted by Aris et al. [26] in 2020 in Malaysia, studied a group of university students from Kebangsaan University. This study applied the FINDRISC questionnaire to understand the risk of this population developing T2D, and they concluded that 5.6% of respondents were at moderate risk of developing T2D and 0.3% at high risk. These values show some similarity with the results of the present research, especially when compared with the results described in the group of students where approximately 3% of the participants were at moderate risk of developing T2D and 1% at high risk. In addition to these similarities, it is still possible to observe that the mean risk score of both investigations match, with the investigation carried out by Aris et al. [26] recording a mean risk score of 5.23 points and the present investigation a mean risk score of 5.04 points.
Current research analyzed the association between risk factors and socio-demographic factors with the level of risk of developing T2D over a 10-year period. The analysis of the results showed that, in relation to the socio-demographic variables, only the variables “gender”, “smoking habits” and “alcohol consumption” were not associated with the risk of developing T2D. These results contradict the current literature, which states that smoking habits [31] and alcohol consumption [32] affect an individual's risk of developing T2D. Smoking habits increase the risk of developing T2D, and, on the other hand, the moderate consumption of alcoholic beverages seems to be associated with a slight reduction of this same risk. The results in relation to alcohol consumption contradict the literature, in the sense that they may be due to the fact that most of the respondents are of a younger age group and although they consume alcohol regularly, they are associated with a low risk of developing T2D, leading us to believe that alcohol consumption does not contribute positively to the higher risk of T2D [33].
Looking at the risk factors included in the FINDRISC questionnaire, contrary to what would be expected, one of the variables considered as a risk variable did not show a significant association with the risk of T2D. This variable was the “consumption of vegetables/fruit”, which may also help to explain its reduced contribution to the calculation of the final risk, adding only one point for those who do not regularly consume vegetables/fruit. All the remaining variables obtained a significant association with the risk of T2D. The other variables that were shown to be associated with T2D follow the same logic as those described above and in the literature. The variables WC and BMI were the ones that showed the strongest positive association with the risk of T2D. A stronger association for these two variables was expected, since they are directly linked to higher levels of body adiposity which, in turn, may contribute to the etiological process of peripheral resistance to insulin action and T2D. In fact, a subject in a state of obesity has a greater amount of free fatty acids in the body which are stored in different organs in the form of fat, resulting in an increased state of reactive oxygen species production, oxidative stress, and chronic inflammation. This pro-inflammatory state plays an important role in the development of insulin resistance, the main cause of T2D development [34].
This research can be considered as a reference point for the reality of young people in Portugal regarding T2D, due to the high sample size of young people and the existence of a huge sample diversity among them, considering that most young people diverge from the different regions of the country. Thus, it is possible to predict that in Portugal, young people aged between 18 and 25 years old are at low risk of developing T2D, thus anticipating that 4 out of every 100 young people in Portugal are at risk of developing T2D over a 10-year period. The results of the present study are in line with the literature that considers obesity a public health problem with exponential growth with high prevalence worldwide and with great influence on T2D disease [35]. This exponential increase in the risk of developing diabetes is worrying, which is why the definition of exercise-based strategies and the promotion of active lifestyles are fundamental to reducing the prevalence of all the components of metabolic syndrome, in this specific case T2D [15].
Practical Applications, Future Perspectives and Study Limitations
This research aims to raise awareness about a growing public health issue worldwide, including in Portugal. By using the FINDRISC [17] questionnaire through an online application, the study helped inform and alert participants about their individual risk of developing T2D over a 10-year period. In fact, as the workforce ages and retirement is postponed, individuals are exposed to longer periods of sedentary work, stress, and potentially unhealthy lifestyle habits, which are risk factors for developing conditions like T2D. This can be particularly relevant if proper health and wellness programs are not in place to support employees in maintaining healthy lifestyles and physically active as they age [35].
However, it should be noted that the questionnaire was applied during the COVID-19 pandemic. This limitation meant that the study took longer, as it was necessary to comply with all the health regulations imposed. Consequently, the questionnaire was administered room by room in each of the IPB's schools and services, which made it impossible to collect other types of data that could complement the research since this study could not impact on the running of teaching activities or the IPB's support services. Therefore, in order to reach the largest number of subjects, only body mass, body circumference and WC values were collected.
Another limitation is that it was not possible to quantify the number of packets of cigarettes consumed by each participant each year, which could have been an important variable for understanding the real impact of smoking on the onset and control of T2D, as was observed in relation to the number of alcoholic drinks [31,32]. The questionnaire used for this study, FINDRIC [24] is assumed as a limitation of the study. Although this same questionnaire is integrated in the national program for the prevention and control of diabetes, it always evidences subjective nature as it is always dependent on the answers of each participant, which participants, which may not fully correspond to reality.
CONCLUSIONS
Older individuals (members of staff) had a higher risk of developing T2D than younger ones (sudents). BMI and WC were higher associated with the risk of developing T2D in the IPB population. In general, the risk of developing T2D within the IPB community was considered low, however the concern should be centered on the greater risk of developing T2D among older people. Thus, it may be important to implement strategies in the work context to promote the practice of PA in middle-age and older adults, in a way to control and prevent T2D risk factors.
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