The study was initiated after the approval from institutional ethics committee (IEC) conducted at diabetic clinic, Department of Physiotherapy, Kasturba Hospital, Manipal, Dr. TMA Pai Hospital, Udupi, community centers in Udupi and various Health check-up camps. The study was approved by the Institutional Ethics Committee, Kasturba Hospital, Manipal, Karnataka, India. The convenient study sampling design was used.

In the current study, we included asymptomatic and undiagnosed participants for T2DM whose age ranged between 30yrs–65yrs. Participants with the history of any previous neurological conditions and were pregnant at the time of assessment were excluded. Participants were explained the purpose of the study by principal investigator, those who were willing to take part in the study, written informed consent was obtained. RBS was measured using Accu-check Performa nano-glucometer. Blood pressure was measured in high sitting position, with back straight, feet touching the ground and arm at the level of heart stabilized on hard surface using digital sphygmomanometer Omron (HEM-7121). Both glucometer and digital sphygmomanometer were calibrated periodically.

Along with demographic details of the participants’ anthropometric measurements like height, weight, waist circumference was noted. Height was measured stadiometer and weight was measured using health sense personal scale (PS 130). Waist circumference was measured using an inch tape in horizontal plane, at the level of iliac crest at the end of normal expiration.

Risk for the development of diabetes mellitus was assessed using the IDRS and the participants were categorized as high risk if the score ≥60, moderate risk score 30–50 and low risk score <30. The participants level of physical activity was assessed using GPAQ questionnaire, and the overall energy expenditure using GPAQ data was calculated in the form of MET minute/wk. level of physical activity was further classified based on MET minute/week into four groups as Sedentary (0–600 MET-min/wk), minimally active (600–1200 MET-min/wk), active (1200–6000 MET-min/wk) and highly active (≥6000 MET-min/wk).

Data was analyzed using Statistical Package for the Social Sciences (SPSS) version 15. A test for normality was done. Normally distributed data were represented as a mean and standard deviation. The level of significance was kept at p≤0.05.

A total of 27,000 participants were screened, based on inclusion and exclusion criteria 23,960 participants were included in the study. The average age of the participants was 49.06 ± 14.44, the mean body mass index (BMI) was 28.8 kg/m². The demographic characteristics of the study participants are mentioned in table 1. The average RBS, BP and IDRS score is mentioned in table 2.

In the present study, the risk stratification for the development of type 2 diabetes was done based on IDRS under which 6.9% were under lower risk category, 24.9% were under moderate risk category, and 68.2% were under higher risk category table 3. Using GPAQ, level of physical activity was estimated of the study participants. Based on MET value participants were classified as sedentary, minimally active, very active and highly active. 14% of the participants were under sedentary lifestyle category, 27.6% participants were minimally active, 53.7% participants were very active, and 4.6% were highly active. 8.0% of the participants below 35 yrs of age, 15.5% participants between 35–49 yrs and 18.1% participants above 49 years fall under sedentary and minimally active PA levels and 7.8% and 14.7% of the male participants and 6.2%, and 12.9% of the female participants fall under sedentary and minimally active level of physical activity category respectively table 4. Significant correlation was found between IDRS score and level of physical activity Rs 0.04 table 5.

Simplified Indian diabetes risk Score is a tool that can be used for identifying the risk of T2DM in future. It includes both the modifiable and non-modifiable risk factors which contribute to predicting the risk of T2DM. In the present study, we have used simplified Indian diabetes risk Score for identifying newly detected high-risk participants in the Udupi population.

In the current study, based on IDRS risk stratification 68.2% participants have a higher risk of developing T2DM in Udupi population. Similar findings were reported in the study conducted in urban Pondicherry, [12] urban slum in Pune [13] and the rural areas of Tamil Nadu [14] with 31.2%, 36.55% and 18.66% of the population having a higher risk score respectively. The difference in the risk prevalence between the current study and the one with Pondicherry and Pune may be due to lifestyle and environmental variation and dietary modification of the population.

A study conducted in Southern Indian population in coastal Karnataka found out that using an IDRS score, 62.2% of people living with undiagnosed diabetes in that population could be detected with a specificity of 73.7%.[15] A similar study was conducted using IDRS to Distinguish T2DM from Non-T2DM in which an IDRS of less than 60 was optimal for identifying non-T2DM and ≥60 for identifying T2DM with a sensitivity and specificity of 79.9% and 83.8%.[16] A study was done in Srilanka using IDRS to screen undiagnosed diabetes wherein the study concluded the screening tool as a simple, low-cost and a non-invasive tool for stepwise community level screening.[17]

PA has beneficial effects on glucose metabolism with an increase in PA levels there can be an increase in peripheral insulin sensitivity which in turn increases muscle glucose uptake. In the present study, 14% and 27.6% of the participants fall under sedentary and minimally active PA levels of which 7.8% and 14.7% of the male participants and 6.2% and 12.9% of the female participants fall under the same PA levels. A similar study was performed which found that physical inactivity was 67.3% and 71.0% for males and females, but the study included young population. [18]

In a meta-analysis which included low versus high PA, leisure time activity, occupational activity, walking and cardiorespiratory fitness, showed a significant statistical reduction in most of the activities and these were associated with 25–40% reduction in the relative risk of T2DM, while walking, occupational activity and cardiorespiratory fitness was associated with 15%, 15% and 55% decrease in the relative risk of T2DM, respectively. Besides, participants with increased PA levels or those into high PA levels over time had a 36% and 41% and subsequently had a lower risk of T2DM. [19] Lower PA levels in the present study can be associated with other risk factors, including BMI and the waist circumference on the higher side and participants above 49 years of age were minimally active in most of the PA domains including occupational PA or recreational PA thus showed more of a sedentary lifestyle.

The present study concludes that based on IDRS risk stratification 68.2% participants have a higher risk of developing T2DM in future. Regarding physical activity levels, 14% and 27.6% of the participants included in the study falls under sedentary and minimally active.

We would like to acknowledge World Diabetes Foundation ‘Diabetic Foot Care: Stepping Ahead’ — WDF: 15–941.

We would like to acknowledge Centre for Diabetic Foot Care and Research.

Conflict of interest: All the authors declare that there is no potential conflict of interest present in this study.