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Cited by 41Diabetes, Cardiovascular Risks, and LipoproteinsDiabetes Management and ResearchHealth Promotion and Cardiovascular Prevention

A Novel Testing Model for Opportunistic Screening of Pre-Diabetes and Diabetes among U.S. Adults

Open access
Zhang, Yurong, Hu, Gang, Zhang, Lu, Mayo, Rachel, Chen, Liwei·2015·PLOS ONE
DOI 10.1371/journal.pone.0120382PMC PMC4366186
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Abstract

OBJECTIVE: The study aim was to evaluate the performance of a novel simultaneous testing model, based on the Finnish Diabetes Risk Score (FINDRISC) and HbA1c, in detecting undiagnosed diabetes and pre-diabetes in Americans. RESEARCH DESIGN AND METHODS: This cross-sectional analysis included 3,886 men and women (≥ 20 years) without known diabetes from the U.S. National Health and Nutrition Examination Survey (NHANES) 2005-2010. The FINDRISC was developed based on eight variables (age, BMI, waist circumference, use of antihypertensive drug, history of high blood glucose, family history of diabetes, daily physical activity and fruit & vegetable intake). The sensitivity, specificity, and the receiver operating characteristic (ROC) curve of the testing model were calculated for undiagnosed diabetes and pre-diabetes, determined by oral glucose tolerance test (OGTT). RESULTS: The prevalence of undiagnosed diabetes was 7.0% and 43.1% for pre-diabetes (27.7% for isolated impaired fasting glucose (IFG), 5.1% for impaired glucose tolerance (IGT), and 10.3% for having both IFG and IGT). The sensitivity and specificity of using the HbA1c alone was 24.2% and 99.6% for diabetes (cutoff of ≥6.5%), and 35.2% and 86.4% for pre-diabetes (cutoff of ≥5.7%). The sensitivity and specificity of using the FINDRISC alone (cutoff of ≥9) was 79.1% and 48.6% for diabetes and 60.2% and 61.4% for pre-diabetes. Using the simultaneous testing model with a combination of FINDRISC and HbA1c improved the sensitivity to 84.2% for diabetes and 74.2% for pre-diabetes. The specificity for the simultaneous testing model was 48.4% of diabetes and 53.0% for pre-diabetes. CONCLUSIONS: This simultaneous testing model is a practical and valid tool in diabetes screening in the general U.S. population.

AI snapshot

Written from the paper’s full text.

TL;DR

A cross-sectional NHANES 2005–2010 analysis tested a simultaneous screening model combining the Finnish Diabetes Risk Score (FINDRISC) and HbA1c to detect undiagnosed diabetes and pre-diabetes in U.S. adults. The combined model improved sensitivity over either test alone, supporting its use for opportunistic screening.

Key findings

  • Among 3,886 adults ≥20 years without known diabetes, the abstract reports undiagnosed diabetes prevalence of 7.0% and pre-diabetes prevalence of 43.1% (27.7% isolated IFG, 5.1% IGT, 10.3% IFG+IGT); Table 1 lists 5.3% undiagnosed diabetes and 41.0% pre-diabetes.
  • HbA1c alone had low sensitivity: 24.2% for diabetes at ≥6.5% (specificity 99.6%) and 35.2% for pre-diabetes at ≥5.7% (specificity 86.4%).
  • FINDRISC alone at cutoff ≥9 had sensitivity/specificity of 79.1%/51.4% for undiagnosed diabetes and 60.2%/61.4% for pre-diabetes in the results text; the abstract reports 48.6% specificity for diabetes.
  • The simultaneous model (positive if either test positive) improved sensitivity to 84.2% for diabetes and 74.2% for pre-diabetes, with specificity 48.4% and 53.0%, respectively; AUC was 0.80 for diabetes and 0.70 for pre-diabetes.

Methods

  • Cross-sectional analysis of U.S. NHANES 2005–2010; included 3,886 men and women aged ≥20 years without self-reported diabetes who attended morning examination sessions and fasted ≥9 hours. Exclusions included missing HbA1c, FPG, or OGTT data and self-reported diabetes.
  • FINDRISC was calculated from eight variables (age, BMI, waist circumference, antihypertensive drug use, history of high blood glucose, family history of diabetes, daily physical activity, and fruit/vegetable intake). HbA1c was measured by high-performance liquid chromatography.
  • Diabetes and pre-diabetes were defined by 2013 ADA criteria using FPG and 2-hour plasma glucose from OGTT. Weighted analyses calculated sensitivity, specificity, predictive values, ROC curves, and AUC; optimal FINDRISC cutoff was chosen by shortest distance on the ROC curve, with sensitivity analyses restricted to adults ≥45 years.

Limitations

  • Stated: each laboratory test (HbA1c, FPG, OGTT) was measured only once in NHANES 2005–2010, though the authors argue misclassification would be small because HbA1c has low day-to-day variation (<2%) and OGTT is the gold standard.
  • Stated: the study did not investigate different HbA1c cutoff values, and further study is warranted to evaluate cost-effectiveness of the screening model.
  • Evident from the text: the cross-sectional design cannot assess whether screening improves long-term diabetes complications, mortality, or cost outcomes; the model was not externally validated in independent populations.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1371/journal.pone.0120382

Cites

50 of 50 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

13 of 35 cited sources checked · 5 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    FINDRISC is a valid and reliable tool to identify undiagnosed diabetes and pre-diabetes in the general U.S. population in both men and women with different races/ethnicities.

    “In addition, our group recently evaluated the validity of FINDRISC in the general U.S. population and found it is a valid and reliable tool to identify undiagnosed diabetes and pre-diabetes in both men and women with different races/ethnicities [26].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [26] L Zhang, 2014, Evaluation of Finnish Diabetes Risk Score in screening undiagnosed diabetes and prediabetes among U.S. adults by gender and race: NHANES 1999–2010, PLoS One source
  • Premisecitation

    Even lowering the cutoff value to 5.3% resulted in a sensitivity of only 78% among individuals with at least one risk factor in an Australian national population study.

    “Even lowering the cutoff value to 5.3%, resulted in a sensitivity of only 78% among individuals with at least one risk factor in a study conducted in Australia national population [38].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [38] S Colagiuri, 2004, Screening for type 2 diabetes and impaired glucose metabolism: the Australian experience, Diabetes Care source
  • Premisecitation

    Our previous study indicated that the FINDRISC score is a valid tool in detecting both undiagnosed diabetes and pre-diabetes in U.S. men and women with different race/ethnicities.

    “In addition, our previous study has indicated that FINDRISC score is a valid tool in detecting both undiagnosed diabetes and pre-diabetes in U.S. men and women with different race/ethnicities [26].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [26] L Zhang, 2014, Evaluation of Finnish Diabetes Risk Score in screening undiagnosed diabetes and prediabetes among U.S. adults by gender and race: NHANES 1999–2010, PLoS One source
  • Premisecitation

    The sensitivity of using HbA1c alone in detecting diabetes is unacceptably low, ranging from 63.2% at a cutoff of 6.1% to 28.3% at a cutoff of 7.0% in different populations.

    “However, the sensitivity of using HbA1c alone in detecting diabetes is unacceptably low, ranged from 63.2% at a cutoff value of 6.1% to 28.3% at a cutoff value of 7.0% in different populations [15,16].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [15] C Buell, 2007, Utility of A1C for diabetes screening in the 1999 2004 NHANES population, Diabetes Care source
    • cites [16] CL Rohlfing, 2000, Use of GHb (HbA1c) in screening for undiagnosed diabetes in the U.S. population, Diabetes Care source

      Table 2 reports exactly 63.2% sensitivity at an HbA1c cutoff of 6.1% and 28.3% at 7.0%. These are different cutoffs in the same representative U.S. sample, not results from different populations. The Conclusions describe HbA1c as sensitive and specific for detecting undiagnosed diabetes, rather than calling its sensitivity unacceptably low. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
  • Premisecitation

    Lowering the HbA1c cutoff value from 6.5% to 5.6% substantially increased sensitivity from 42.3% to 83.4% in the U.S. population.

    “For HbA1c, studies have shown that lowering the cutoff value from 6.5% to 5.6% substantially increased the sensitivity from 42.3% to 83.4% in U.S. population [16].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [16] CL Rohlfing, 2000, Use of GHb (HbA1c) in screening for undiagnosed diabetes in the U.S. population, Diabetes Care source

      Table 2 (page not provided) reports sensitivity of 83.4% at an HbA1c cutoff of 5.6% in a representative U.S. population sample. At 6.5%, however, it reports 42.8%, not the claimed 42.3%. (LLM, conf=0.94)

      Experimental — accuracy not yet measured
  • May combine two claims. 8
  • Classified as probably not a substantial claim. 9
  • The quote only partly states this claim. 2

  • May combine two claims.

    Premisecitation

    Glycosylated hemoglobin reflects long-term glycemic control and is a more accurate and stable measure than fasting plasma glucose.

    “Glycosylated hemoglobin reflects long-term glycemic control and is a more accurate and stable measure than FPG levels [13,14].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [13] DE Goldstein, 2003, Tests of glycemia in diabetes, Diabetes Care source

      The ‘Glycated hemoglobin testing’ and ‘Standardization of GHb’ sections describe glycosylated hemoglobin as a measure of glycemia over preceding weeks and months, supporting the long-term-control claim. The copy does not establish that it is more accurate or a more stable measure than fasting plasma glucose; its description of stable hemoglobin components does not make that comparison. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [14] CL Rohlfing, 2002, Defining the relationship between plasma glucose and HbA(1c): analysis of glucose profiles and HbA(1c) in the Diabetes Control and Complications Trial, Diabetes Care source

  • Classified as probably not a substantial claim.

    Premisecitation

    Most professional organizations recommended a two-stage strategy, starting with first-stage selection of people at higher risk by a questionnaire or risk score and followed by second-stage testing for conventional biomarkers such as FPG, HbA1c, or OGTT.

    “Most of them recommended a two-stage strategy, starting with the first-stage of selection of people at higher risk by a questionnaire or risk score and followed by the second-stage of testing for conventional biomarkers such as FPG, HbA1c, or OGTT [12,39].”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [12] N Waugh, 2007, Screening for type 2 diabetes: literature review and economic modelling, Health Technology Assessment source

      Chapter 3, “Screening tests” describes two-stage screening: selecting people at higher risk, then testing glucose levels. “Stage 1 - selection by risk factors” discusses questionnaires, and “Stage 2 - glucose testing” lists FPG, HbA1c and glucose tolerance tests. These passages do not establish that most professional organizations recommended this strategy; the chapter describes how organized screening would work, not the prevalence of that recommendation among organizations. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
    • cites [39] A Abbasi, 2012, Prediction models for risk of developing type 2 diabetes: systematic literature search and independent external validation study, BMJ source

      The Introduction (page not supplied) says European guidelines and the International Diabetes Federation recommend a questionnaire or risk score to identify people at high risk; it describes a different screening recommendation from the American Diabetes Association. The paper discusses models incorporating biomarkers, but our copy does not say that most professional organizations recommend the claimed two-stage sequence or subsequent FPG, HbA1c, or OGTT testing. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    FINDRISC is the most commonly evaluated diabetes risk score worldwide and has been recommended as the best available risk assessment tool for clinical practice by a systematic review.

    “Moreover, FINDRISC is the most commonly evaluated diabetes risk score worldwide [17,18,19,20,21,22,23,24,25] and has been recommended as the best available risk assessment tool for use in the clinical practice by a systematic review [11].”
    Quote in the paperSubstantial claim3 of 10 sources checked
    • cites [17] M Franciosi, 2005, Use of the diabetes risk score for opportunistic screening of undiagnosed diabetes and impaired glucose tolerance: the IGLOO (Impaired Glucose Tolerance and Long-Term Outcomes Observational) study, Diabetes Care source
    • cites [18] A Bergmann, 2007, A simplified Finnish diabetes risk score to predict type 2 diabetes risk and disease evolution in a German population, Horm Metab Res source
    • cites [19] K Makrilakis, 2011, Validation of the Finnish diabetes risk score (FINDRISC) questionnaire for screening for undiagnosed type 2 diabetes, dysglycaemia and the metabolic syndrome in Greece, Diabet Med source
    • cites [20] F Soriguer, 2012, Validation of the FINDRISC (FINnish Diabetes RIsk SCore) for prediction of the risk of type 2 diabetes in a population of southern Spain, Pizarra Study. Med Clin (Barc) source
    • cites [21] MI Hellgren, 2012, Feasibility of the FINDRISC questionnaire to identify individuals with impaired glucose tolerance in Swedish primary care. A cross-sectional population-based study, Diabet Med source
    • cites [22] G Winkler, 2013, Prevalence of undiagnosed abnormal glucose tolerance in adult patients cared for by general practitioners in Hungary. Results of a risk-stratified screening based on FINDRISC questionnaire, Med Sci Monit source

      The Methods and Discussion describe this Hungarian FINDRISC evaluation and mention evaluations in other countries. They do not establish that FINDRISC is the most commonly evaluated diabetes risk score worldwide. The systematic-review recommendation is attributed to a different citation, [11], not to this paper. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [23] JW Lin, 2009, Cross-sectional validation of diabetes risk scores for predicting diabetes, metabolic syndrome, and chronic kidney disease in Taiwanese, Diabetes Care source
    • cites [24] T Tankova, 2011, Evaluation of the Finnish Diabetes Risk Score as a screening tool for impaired fasting glucose, impaired glucose tolerance and undetected diabetes, Diabetes Res Clin Pract source
    • cites [25] H Garcia-Alcala, 2012, Frequency of diabetes, impaired fasting glucose, and glucose intolerance in high-risk groups identified by a FINDRISC survey in Puebla City, Mexico, Diabetes Metab Syndr Obes source

      The Introduction says FINDRISC has been widely used and validated in different countries and epidemiologic studies, supporting its broad evaluation. It does not establish that FINDRISC is the most commonly evaluated diabetes risk score worldwide. The separate systematic-review recommendation is attributed to citation [11], not this paper. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [11] PE Schwarz, 2009, Tools for predicting the risk of type 2 diabetes in daily practice, Horm Metab Res source

  • May combine two claims.

    Premisecitation

    Early intervention is critical to improve the progression of complications and reduce the long-term cost of diabetes.

    “Early intervention has been shown to be critical to improve the progression of the complications and reduce the cost of the disease in the long term [7].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [7] KG Alberti, 2007, International Diabetes Federation: a consensus on Type 2 diabetes prevention, Diabet Med source

      The IDF strategy for diabetes prevention section says early detection and intervention can reduce the incidence of diabetes and its complications. The Health economics section describes economic benefits as potential and says long-term cost savings from avoided complications are not yet established by follow-up data. The claim overstates the evidence by presenting a reduction in long-term costs as demonstrated. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • The quote only partly states this claim.

    Findingown data

    The prevalence of pre-diabetes among U.S. adults aged 20 years or older without known diabetes in NHANES 2005-2010 was 43.1%.

    “The prevalence of undiagnosed diabetes was 7.0% and 43.1% for pre-diabetes (27.7% for isolated impaired fasting glucose (IFG), 5.1% for impaired glucose tolerance (IGT), and 10.3% for having both IFG and IGT).”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    The prevalence of impaired glucose tolerance among U.S. adults aged 20 years or older without known diabetes in NHANES 2005-2010 was 5.1%.

    “The prevalence of undiagnosed diabetes was 7.0% and 43.1% for pre-diabetes (27.7% for isolated impaired fasting glucose (IFG), 5.1% for impaired glucose tolerance (IGT), and 10.3% for having both IFG and IGT).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    More females were found in the impaired glucose tolerance group than in the impaired fasting glucose group.

    “More females were found in the IGT group than in the IFG group (63.2% vs. 33.7%; P < 0.001).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Using two tests sequentially will generally increase specificity but reduce sensitivity, resulting in a substantial number of individuals with diabetes being unidentified.

    “Moreover, using two tests sequentially will generally increase the specificity but reduce the sensitivity, which will result in a substantial number of individuals with diabetes unidentified.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Sequential testing generally increases specificity and positive predictive value and decreases sensitivity and negative predictive value.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The test model was evaluated for diabetes and pre-diabetes, including isolated IFG, isolated IGT, and IFG+IGT.

    “Second, the 75-g glucose OGTT test was used as the reference standard for diagnosing and the test model was evaluated for diabetes and pre-diabetes, including isolated IFG, isolated IGT, and IFG+IGT.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Each laboratory test (HbA1c, FPG, and OGTT) was only tested for once in NHANES 2005-2010.

    “Our study is limited in that each laboratory test (i.e. HbA1c, FPG, and OGTT) was only tested for once in NHANES 2005–2010.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The simultaneous testing model combining FINDRISC and HbA1c is a practical and sufficient tool for diabetes screening in the U.S. population.

    “However, using the simultaneous testing model with combination of FINDRISC and HbA1c improved the sensitivity to 74.18% to identify pre-diabetes and to 84.17% to identify undiagnosed diabetes, suggesting it is a practical and sufficient tool in diabetes screening in the U.S. population.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The analyses were weighted to account for the complex survey design of NHANES.

    “The analyses were weighted to account for the complex survey design of NHANES.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The optimal cutoff values for HbA1c have been intensively reported in previous studies and discussed in several review papers.

    “The optimal cutoff values for HbA1c has been intensively reported in previous studies and discussed in several review papers [4,14,15,38,41,42,43,44,45].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [4] CD Saudek, 2008, A new look at screening and diagnosing diabetes mellitus, J Clin Endocrinol Metab source
    • cites [14] CL Rohlfing, 2002, Defining the relationship between plasma glucose and HbA(1c): analysis of glucose profiles and HbA(1c) in the Diabetes Control and Complications Trial, Diabetes Care source
    • cites [15] C Buell, 2007, Utility of A1C for diabetes screening in the 1999 2004 NHANES population, Diabetes Care source

  • May combine two claims.

    Interpretationown data

    The simultaneous testing model is a practical and valid tool for diabetes screening in the general U.S. population.

    “This simultaneous testing model is a practical and valid tool in diabetes screening in the general U.S. population.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Sensitivity analyses were performed by restricting analyses to only individuals aged 45 years or above.

    “Sensitivity analyses were performed by restricting analyses to only individuals aged 45 years or above.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Lowering the cutoff value will result in a larger number of false positives, which would be costly but inefficient and put a huge burden on the health care system.

    “However, such an approach will result in a larger number of false positives (people who are considered as having positive rests but do not actually have the disease) which would be costly but inefficient, and put a huge burden on the health care system.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    There is no doubt that adding FINDRISC will improve the sensitivity at any given HbA1c value.

    “Therefore, there is no doubt that adding FINDRISC will improve the sensitivity at any given HbA1c value.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Lowering the cutoff values of a given test will result in an increase in sensitivity.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Tests in series have been advocated in T2D by professional organizations such as ADA and AACE.

    “Tests in series have been advocated in T2D by a few of professional organizations such as ADA and American Association of Clinical Endocrinologists (AACE) (Table 3).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [30] Y Handelsman, 2011, American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan, Endocr Pract source
    • cites [31] 2014, Diagnosis and classification of diabetes mellitus, Diabetes Care

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisereasoning

    FINDRISC is simple, non-invasive, and includes modifiable diabetes risk factors such as diet, physical activity, and body weight.

    “Among all the diabetes risk scores (questionnaires) we reviewed, we selected the Finnish Diabetes Risk Score (FINDRISC) because it is: 1) simple (could be administrated by a lay person); 2) non-invasive (no blood draw required); and 3) includes modifiable diabetes risk factor such as diet, physical activity, and body weight.”
    Quote in the paperSubstantial claim
19 of 19

  • The paper relies on this without support.

    No studies have been carried out to evaluate whether adding a simple risk score to HbA1c would improve sensitivity in identifying undiagnosed diabetes and pre-diabetes in the general U.S. population.

    “However, no studies have been carried out to evaluate whether adding a simple risk score to HbA1C, a clinical routing non-fasting biomarker, would improve the sensitivity in identifying undiagnosed diabetes and pre-diabetes in general U.S. population.”

  • The paper relies on this without support.

    There is no global consensus on the screening strategy and test for detection of diabetes.

    “There is no global consensus on the screening strategy and test for detection of diabetes.”

  • The paper relies on this without support.

    Approximately 30% of people with diabetes in the U.S. are undiagnosed, and the average lag between onset and diagnosis is 7 years.

    “In addition, approximately 30% of people with diabetes in the U.S. are undiagnosed, and the average lag between onset and diagnosis is 7 years.”

  • The paper relies on this without support.

    Fasting plasma glucose has a large random variation, only reflects current glycemic status, and requires people to fast for at least 8 hours before the test.

    “Fasting plasma glucose (FPG) has been a commonly used tool in screening diabetes, but it has a large random variation, only reflects current glycemic status, and requires people to fast for at least 8 hours before the test.”

  • The paper relies on this without support.

    HbA1c has practical advantages over fasting plasma glucose and oral glucose tolerance test and is not affected by short-term lifestyle changes.

    “HbA1c, a non-fasting test, has the practical advantages over FPG and OGTT and is not affected by short-term lifestyle changes (day-to-day variation less than 2%).”

  • The paper relies on this without support.

    Postprandial hyperglycemia is one of the earliest biomarkers for disease progression from the perspective of the natural history of T2D.

    “From the perspective of natural history of T2D, postprandial hyperglycemia is one of the earliest biomarkers for disease progression.”

  • The paper relies on this without support.

    IGT indicates a critical window of early effective intervention, as shown by several RCTs across different populations and racial groups.

    “Therefore, IGT indicates a critical window of early effective intervention and this has been shown by several RCTs across different populations and racial groups.”

  • The paper relies on this without support.

    Simultaneous testing generally increases sensitivity and negative predictive value and decreases specificity and positive predictive value.

    “In the case of simultaneous testing, the sensitivity and the negative predictive value are generally increased and the specificity and positive predictive values decreased.”

  • The paper relies on this without support.

    Sequential testing generally increases specificity and positive predictive value and decreases sensitivity and negative predictive value.

    “On the other hand, if sequential testing is applied, the specificity and positive predictive value are generally increased and the sensitivity and negative predicted value decreased.”

  • The paper relies on this without support.

    There is no evidence from RCTs to show that universal screening of asymptomatic individuals will be effective or cost-effective in improving diabetic complications or mortality.

    “The rationale for such a recommendation is that there is no evidence from RCT to show that universal screening of asymptomatic individuals will be effective or cost-effective in improving diabetic complications or mortality.”

  • The paper relies on this without support.

    The selected FINDRISC score was developed based on an individual’s information on eight questions that do not require any laboratory tests.

    “Third, the selected FINDRISC score was developed based on individual’s information on eight questions that do not require any laboratory tests.”

  • The paper relies on this without support.

    The HbA1C test does not require fasting and can be conducted at any time of the day.

    “Moreover, the HbA1C test does not require fasting and can be conducted at any time of the day.”

  • The paper relies on this without support.

    OGTT is the best reliable test for diabetes and has been considered as the “gold standard” test in evaluating other tests.

    “OGTT is still the best reliable test for diabetes and has been considered as “gold standard” test in evaluating other tests.”

  • The paper relies on this without support.

    HbA1c has a very small day-to-day variation (<2%).

    “HbA1c, on the other hand, has a very small day-to-day variation (<2%).”

  • The paper relies on this without support.

    Lowering the cutoff values of a given test will result in an increase in sensitivity.

    “It’s well known that lower the cutoff values of a given test will result in an increase in sensitivity.”
15 of 15

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Claimed 78.7% sensitivity for HbA1c alone comes from a combined test

    Minor

    The discussion describes 78.7% as the sensitivity of HbA1c alone, but the corresponding Table 4 row specifies HbA1c and a risk factor. The table note identifies "And" as sequential testing.

  • Claimed 16.7% diabetes sensitivity misstates the table entry

    Minor

    The discussion attributes a 16.7% sensitivity to detecting diabetes at an HbA1c cutoff of 6.1%. Table 4 instead lists 16.7% under pre-diabetes, at a cutoff of 6.0%.

  • Overall 2-hour glucose mean conflicts with subgroup means

    Minor

    Using the table's subgroup percentages and 2-hour glucose means gives an overall mean of about 113.3 mg/dl, not 166.87 mg/dl. The reported overall mean therefore cannot be reconciled with the table's own subgroup data.

  • Abstract gives a different FINDRISC specificity for diabetes

    Minor

    At a FINDRISC cutoff of 9, the abstract reports 48.6% specificity for diabetes, whereas Table 2 and the Results text report 51.4%.

4 of 4

Cites

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1 of the 51 references couldn’t be matched to a known paper.

Cited by

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Related

Authors
Zhang, Y., Hu, G., Zhang, L., Mayo, R., & Chen, L.
Affiliations
  • First Affiliated Hospital of Xi'an Jiaotong University (CN)
  • Pennington Biomedical Research Center (US)
  • Louisiana State University Health Sciences Center New Orleans (US)
  • Clemson University (US)
Corresponding author
Chen, Liwei
ORCID
Venue
PLOS ONE
Publisher
Public Library of Science (PLoS)
Published
2015-03-19
Volume
10
Issue
3
Pages
e0120382
ISSN
1932-6203 (ISSN-L)
DOI
10.1371/journal.pone.0120382
PMC
PMC4366186
OpenAlex
W2025825915
Semantic Scholar
6fbb6a010c87518b39a6d263f40a2c7bf3ddbe66
Cited by
41
References
51
Citations by year
2025: 2 · 2024: 2 · 2023: 7 · 2022: 3 · 2021: 2 · 2020: 4 · 2019: 5 · 2018: 6 · 2017: 3 · 2016: 5 · 2015: 1 · 2014: 1
FWCI
3.80
Type
journal article
Language
en
Open access
Licence
Locations
  • PLoS ONE (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (submittedVersion, cc-by)
  • PubMed Central (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • eScholarship (California Digital Library) (submittedVersion)
Funders
  • Clemson University
  • Natural Science Foundation of Shaanxi Province
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
Keywords
diabetes screening, prediabetes, FINDRISC, HbA1c, undiagnosed diabetes, impaired fasting glucose, impaired glucose tolerance, oral glucose tolerance test, risk prediction model, sensitivity and specificity, NHANES
MeSH terms
Adult, Aged, Cross-Sectional Studies, Diabetes Mellitus, Female, Glycated Hemoglobin, Humans, Male, Mass Screening, Middle Aged, Nutrition Surveys, Prediabetic State, ROC Curve, Sensitivity and Specificity, United States, Models, Statistical, Prevalence, Risk Assessment

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-14.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-14.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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