India is grappling with a dual burden as the presence of communicable diseases continue to afflict her populace and lifestyle disorders like Hypertension and Diabetes are expediting to make their mark as well, both in urban and rural areas. 14 The societal burden of Type 2 Diabetes Mellitus (T2DM) has increased in the past decades due to population ageing and increasing prevalence of underlying risk factors, such as obesity, increased sedentary activity and unhealthy diet. 3

T2DM is associated with a two- to four-fold increased risk of developing cardiovascular disease (CVD) and micro-vascular complications, which may be present even before diagnosis. It is, therefore, important to detect people with an increased risk of T2DM at an early stage. To facilitate targeted prevention of T2DM, many risk assessment models have been developed to identify people at high risk of developing T2DM or with undiagnosed T2DM. 2 Many of these models included similar predictors such as age, sex, Body Mass Index, waist circumference, blood pressure and family history of T2DM. 7

Longitudinal studies have shown that obesity is the preeminent risk factor  and one of the most powerful predictor of Type 2 diabetes development.1,5 Several studies indicate that waist circumference or waist-to-hip ratio, which reflect visceral (abdominal) fat, may be better indicators of the risk of developing Type 2 diabetes than body mass index. 1

Physical activity levels have decreased over recent decades in many populations, and this has also been a major contributor to the current global rise of obesity. Reportedly physical inactivity has found to be an independent predictor of Type 2 diabetes in men and women, as stated in both cross-sectional and longitudinal studies.8 Furthermore evidence from laboratory and epidemiologic studies in recent years have propounded that decreased sleep duration and/or quality may adversely affect glucose regulation and increase the risk of  type 2 diabetes mellitus.

Medical students life is enervating and grueling owing to fulfill their academic requirements, toting to physical inactivity and altered sleep pattern. Substantial studies focusing on diet, sleep and physical activity among Indian medical students are meager.12 Therefore the current study was undertaken to screen the risk of diabetes and enforcing lifestyle interventions among medical undergraduates.

This cross-sectional study was conducted among students of PES Institute of Medical Sciences & Research (PESIMSR), Kuppam, Andhra Pradesh. The study was conducted over a period of 6 months from September 2023 to February 2024.

Sample size calculation: Sample size was calculated  based on the findings by Meghachandra et al (2019), using the formula 4pq/d² , where prevalence (p) = 77% who were having low diabetes risk ,  q = 23% , absolute precision 6.9%. A sample size of 143 was obtained, which was rounded off to 150.

Sampling method: Simple Random sampling.  150 students were selected randomly among the medical students studying from first year to final year MBBS part II.

Inclusion criteria: Those who were willing to participate in the study

Exclusion criteria: Those who had Juvenile (Type 1) diabetic

Method of collection of data and study tool:

Data was collected using a pre-designed structured questionnaire for socio-demographic and other details. Followed by Indian Diabetic Risk score (IDRS) a validated questionnaire was used to assess the diabetes risk among the students.¹³ IDRS assesses the risk by various paramaters like age, abdominal obesity, physical activity, family history of diabetes.^{19, 18}

Each variable has a scoring ranging from 0 to 30,  with a maximum score of 100 depending upon the responses from participants. After the final scoring they were categorized into low, moderate and high risk. Participant with an IDRS of <30 was categorized as low risk, 30 – 59 as medium risk and > 60 as high risk for diabetes.

After explaining the purpose of study to the participants, written informed consent was obtained. Participants were interviewed for the details regarding general data & IDRS assessment including anthropometric measurements were noted using bathroom weighing scale for weight, stadiometer for height and measuring (inch) tape for waist & hip circumference. Observations were noted in the study Profarma.

Statistical Analysis of data:

Data was entered into MS Excel version 16 and analyzed using SPSS version 23. Descriptive statistics were expressed as percentages and mean, median, standard deviation and 95% confidence interval were calculated.  Inferential statistics were done by tests of significance like Mann Whitney U test, student t test and paired t-test etc, where p<0.05 were considered to be statistically significant.

Data was collected using a validated Indian Diabetic Risk score (IDRS) along with socio-demographic factors, detailed information regarding their family history of diabetes & exercise, and other factors.

STRUCTURED COMBINED INTERVENTION

After preliminary data analysis, students were categorized into low, moderate and high risk groups as per the IDRS assessment method. Students with low risk were provided with general preventive education material in relation to Diabetes for future usage. We applied structured combined interventional method for moderate and high risk students.  Specific health educational material in the form of literature, audio-visual clips, journals and individual case studies related to Diabetes were provided to the students under risk categories to improve their cognitive knowledge in initial three weeks. Under combined interventional methods students were motivated to bring behavioral changes in their diet, physical activity and sleep patterns.

Students were requested to limit consumption of high calorie junk,  processed foods and beverages, not more than twice a week and non-vegetarian food once a week. Mess in charge personnel were directed to include fiber , protein rich food fresh fruits and sprouts at least in one meal per day. They were also instructed to limit the serving of fried foods twice a week

Students were motivated to initiate physical activities twice a day at least 20 minutes each both in the morning and evening. Activities like cycling, running, skipping and other physical exercises were promoted in the morning session. Walking, yoga & meditation, sports and dance activities were chosen by students in the evening session. Electronic gadgets like smart watches were used to monitor these physical activities.

These students were requested to follow minimum of 8 hrs sleep in night. On weekly basis student counseling sessions were conducted under Motivational Interview Technique to sustain these behavioral changes permanently in their lifestyle. Guidelines from National and international health organizations were provided. Interactive sessions with chronic diabetic patients were also arranged.

Table 1: Socio Demographic characteristics of study participants (N=150)

Mean age among study population is found to be 20.72 + 1.54 years, males and females were  67(44.7%) and  83(55.3%) respectively. . Majority were Hindu by religion 120(80.0%). Based on BG Prasad classification, 111(74.0%) belonged to Class I.

Table 2: Indian Diabetes Risk Score among study participants (N=150)

The above table shows risk score among participants, 107 (71.3%) had low risk, 42(28.0%) had moderate risk and high risk was reported in only 1(0.7%) participant.

Table 3: Anthropometry among participants (N=150)

The above table shows anthropometry observations of BMI and WHR. In BMI, 21(14.0%) were underweight, 58(38.7%) were normal and 71(47.3%) had increased BMI; whereas 77(51.3%) had abnormal WHR.

Table 4 : Association of diabetes risk with participants’ characteristics   (N=150)

Note: *Mann Whitney U test, **Student t test, p value of <0.05 considered as statistically significant

Table 4 shows association of risk of diabetes with characteristics of study participants, where all the factors like Family

H/o of   DM, BMI, WHR and Physical activity were found to statistically significant.

Table 5: Structured Combined Intervention among Moderate- to High risk participants

The frequency of intake related to high calorie & processed food decreased from 6.81 + 2.03 to 2.09 ­­­+ 1.37 per week after intervention. Consumption of protein & fibre rich foods increased from 2.77 + 1.98 to 5.19 + 1.59 per week . The mean physical activity period of study subjects increased from 18.01 + 1.11 to 55 + 3.75 min per day. The average BMI which was 24.65 + 4.33 before intervention reduced to 21.58 + 3.75. The WHR of study subjects also decreased notably from 0.98 + 0.94 to 0.91 + 0.88. The duration of sleep was also markedly enhanced from average 5.09 ­­­+ 1.37 to 7.15 + 1.03 hours per day. The application of Motivational Interview Techniques resulted in remarkable improvements across all study parameters.

Our study findings had low risk 71.3%) and moderate to high risk in 28.7% these  study findings almost correlates with study done by Mongjam et al which reports low risk in 77% and moderate to high risk 23%.  8 Also, studies by Gopala Krishnan et al (1.9%) and Bhatia et al (1%) also reveals similar results in high risk group.9,4

Mongjam study revealed   BMI < 23 in  54.1% and  BMI > 23 in  45.9% which almost corresponds to our study reports which was 52.7% and 47.3% respectively. 7 48.7% had normal and 51.3% had increased Waist-Hip ratio  reported in this study. On contrary  a study by Tejaswini among medical students  also had 62.5% normal and 37.5% had abnormal WHR.20  Another study by Komal quotes 28% and 72% had low and moderate to high risk WHR among the study participants.2

The current study shows significant association between, Body Mass Index, Family History, Physical activity and IDR Score, which coincides to the studies done by Gopalakrishnan et al and Chowdry et al.9, 6

In the current study, post intervention including intake of healthy (fruits,vegetables) & unhealthy (fat rich) foods,  physical activity, BMI, WHR and sleep was found to be statistically significant which coincides with study by Anjela et al which also reports similar findings with respect to healthy and unhealthy diet and physical activity.16 Another study by Greaves also mentioned post interventional changes in achieving weight loss(BMI), reduction in waist circumference and increase in physical activity minutes which correlates with our study. 10 Another study by Mahadevan focused on sleep abnormalities and diabetes risk also showed significant association with metabolism as well.17

This current study the application of Indian Diabetes Risk Score to identify undiagnosed and at risk diabetic subjects among medical undergraduates. We found out that, 107 (71.3%) had low risk, 42(28.0%) had moderate risk and high risk was reported in only 1(0.7%) participant. There was a statistically significant association between Family H/o of   DM, BMI, WHR and Physical activity with that of the risk score. 43(28.7%) Participants belonging to moderate to high risk score underwent Structured Combined Intervention along with motivational interview technique for 4 months. This method focused to achieve lifestyle changes among the risk group. Post intervention appreciable results were noticed and all the parameter were also found to be significant statistically.

Strengths

Promoting awareness and education on diabetes risk at an early age will motivate the young generation to adopt healthy life style involving healthy diet, physical activity and sleep pattern.

Limitations

This study was conducted in a small group and short time period, thus results cannot be generalized. To bring desired healthy life style modification and sustained behavioral change life long, extended or prolonged monitoring is required.

ACKNOWLEDGEMENTS

We are grateful to all the participants who dedicated their time to take part in this study. We also thank the Dean and Principal, PESIMSR, Chittoor; Head of the Department - Community Medicine for giving us the platform to conduct this study.

Funding: No funding sources

Conflict of interest: None declared

1. Alberti KG, Zimmet P, Shaw J. International diabetes federation: A consensus on type 2 diabetes prevention. Diabetic Medicine. 2007 Apr 26;24(5):451–63. doi:10.1111/j.1464-5491.2007.02157.x.
2. Anand K, Jain S, Chopra H, Kumar A, Singh G. Indian Diabetes Risk Score (IDRS): An effective tool to screen undiagnosed diabetes. Indian J Comm Health. 2022;34(1):130-135. https://doi.org/10.47203/IJCH.2022.v34i01.024
3. Beulens J, Rutters F, Rydén L, Schnell O, Mellbin L, Hart H, et al. Risk and management of pre-diabetes. European Journal of Preventive Cardiology. 2019;26(2):47–54. doi:10.1177/2047487319880041.
4. Bhatia T, Maitreyi O, Vimisha D, Sonalika B, Gerhard F, Vaidehi L, et al, Type 2 Diabetes Mellitus : Risk evaluation and advice in undergraduate students in Mumbai. Int J Pharm Sci Invent. 2014:3:37-40. doi:10.4103/ijem.ijem_623_18.
5. Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care. 1994;17(9):961–9. doi:10.2337/diacare.17.9.961
6. Chowdhury R, Mukherjee A, Lahiri SK. A Study on distribution and determinants of Indian Diabetic Risk Score (IDRS) among rural population of West Bengal. National J Med Res. 2012;2(3):282-6.
7. Collins GS, Mallett S, Omar O, et al. Developing risk prediction models for type 2 diabetes: A systematic review of methodology and reporting. BMC Med 2011;9: 103.
8. Dunstan DW, Salmon J, Owen N, Armstrong T, Zimmet PZ, Welborn TA, et al. Physical activity and television viewing in relation to risk of undiagnosed abnormal glucose metabolism in adults. Diabetes Care. 2004;27(11):2603–9. doi:10.2337/diacare.27.11.2603
9. GopalaKrishnan S, Rama R, Muthulakshmi M. Assessing the risk of developing type 2 Diabetes Mellitus among medical students in Chennai using Indian Diabetic Risk Score. Int J Med Public Health. 2017;4:2366-72.
10. Greaves CJ, Middlebrooke A, O’Loughlin L, Holland S, Piper J, Steele A, et al. Motivational interviewing for modifying diabetes risk: A randomised controlled trial. British Journal of General Practice. 2008 Aug 1;58(553):535–40. doi:10.3399/bjgp08x319648
11. Knutson KL. Role of sleep duration and quality in the risk and severity of type 2 diabetes mellitus. Archives of Internal Medicine. 2006 Sept 18;166(16):1768. doi:10.1001/archinte.166.16.1768.
12. Mangla V, Singh M, Pangtey R, Garg S. Risk assessment of diabetes using the Indian Diabetes Risk Score: A study on young medical students from Northern India. Indian Journal of Endocrinology and Metabolism. 2019;23(1):86. doi:10.4103/ijem.ijem_623_18 .
13. Mohan V, Deepa R, Deepa M, Somannavar S, Datta M. A simplified Indian Diabetes Risk Score for screening for undiagnosed diabetic subjects. J Assoc Physicians India. Sep 2005;53:759-763.
14. Nallapu SS, Bharani KY. Appraisal of responsiveness concerning two epidemiologically discrete diseases among rural and urban families of Guntur district. Journal of Pharmaceutical and Biomedical Sciences. 2012; 23(23):1 - 4.
15. Ohlson LO, Larsson B, Svardsudd K, Welin L, Eriksson H, Wilhelmsen L, et al. The influence of body fat distribution on the incidence of diabetes mellitus. Diabetes. 1985 1;34(10):1055–8. doi:10.2337/diabetes.34.10.1055. 
16. P fammatter A, Spring B, Saligram N, Davé R, Gowda A, Blais L, et al. MHealth intervention to improve diabetes risk behaviors in India: A prospective, Parallel Group Cohort Study. Journal of Medical Internet Research. 2016 Aug 5;18(8). doi:10.2196/jmir.5712.
17. Roopa M, Deepa M, Indulekha K, Mohan V. Prevalence of sleep abnormalities and their association with metabolic syndrome among Asian Indians: Chennai Urban Rural Epidemiology Study (cures − 67). Journal of Diabetes Science and Technology. 2010 Nov;4(6):1524–31. doi:10.1177/193229681000400630
18. Rowett Institute of Nutrition and Health [homepage on the Internet]. Aberdeen: University of Aberdeen; [cited 2012 Aug 12]. Body composition.[About 6 screens]. Available from: http:/www.rowett.ac.uk/ edu_web/sec_pup/body_comp.pdf.
19. Sigal RJ, Kenny GP, Wasserman DH, Sceppa CC, White RD. Physical Activity/Exercise and Type 2 Diabetes. Diabetes Care 2006; 29:1433-38.
20. V B T. Evaluation of risk of type 2 diabetes mellitus in medical students using indian diabetes risk score (IDRS). International Journal of Physiology. 2020;8(4):77-79. doi:10.37506/ijop.v8i4.1714.