Non-communicable diseases (NCDs), including heart disease, stroke, cancer, diabetes, and chronic lung disease, are the leading cause of death worldwide, responsible for 74% of all deaths worldwide [1]. As of March 2023, the World Health Organization (WHO) estimates that about 422 million people worldwide have diabetes, and the International Diabetes Federation (IDF) estimates that 783 million people will have diabetes in 2045, which is 12.2% of the global population [2,3]. The number of people with diabetes is increasing in all regions of the world, but the rate is much faster in developed countries. In 2021, IDF reported that 10.8% of adults in Indonesia had diabetes, which is 19,465,102 people, placing it among the top 10 countries with the highest prevalence of diabetes and it will increase to 16.09% in 2045 [4]. Diabetes was also one of the top three causes of death in Indonesia.

Diabetes is a chronic, metabolic disease characterized by elevated blood glucose levels. The most common type of diabetes was type 2 diabetes, accounting for roughly 90% of all diabetes cases. Type 2 diabetes mellitus (T2DM) is a leading public health concern globally and affects more than 80% of all diabetes cases in most countries [3]. According to the Indonesian Basic Health Research in 2018, the prevalence of T2DM was 10.9% of the population ≥15 years old [5]. The majority of these patients with T2DM also have acute or chronic complications, which are associated with several potentially life-threatening microvascular and macrovascular complications, such as heart failure, coronary artery disease, and chronic kidney diseases [6]. Due to these complications, diabetes poses risks of decreased quality of life and a high economic burden. In 2017, global health expenditure on diabetes was estimated to be USD 727 billion and is expected to grow to a projected USD 825 billion by 2030 [7,8].

Obesity or excessive weight gain is identified as the most important and significant risk factor in the development and progression of type 2 diabetes mellitus (T2DM) [9]. The Centers for Disease Control and Prevention report that women with a body mass index (BMI) of 30 kg/m² have a 28 times greater risk of developing diabetes than do women of normal weight and the risk of diabetes is 93 times greater if the BMI is 35 kg/m² [10]. Screening for diabetes is indicated in all patients with obesity. The body adiposity index (BAI) has proven to be a valuable tool in estimating the risk of a patient developing T2DM in a Brazilian population [11]. A study in Turkey shows that obesity is a significant determinant of poor metabolic control in T2DM patients and highlights the importance of preventing and managing obesity to improve healthcare in T2DM patients [12]. As a result, clinicians must understand obesity treatment in diabetic patients because modest weight loss of 3–5% of initial body weight improves glucose intolerance and A1C, slows diabetes complications, reduces the need for glucose-lowering agents, and prevents the progression of prediabetes to type 2 diabetes [13].

Screening tests for type 2 diabetes include questionnaire risk assessments, biochemical tests, and a combination. To make the diagnosis, screening tests are frequently followed by diagnostic testing, fasting plasma glucose (FPG), and oral glucose tolerance test (OGTT) using standard criteria [14]. The Canadian Diabetes Risk Questionnaire or CANRISK is one of the screening tools that can be used. CANRISK is a questionnaire-based screening tool that has been validated in Canada to assess risk factors for type 2 diabetes using a variety of tests. CANRISK is an updated version of the FINDRISC questionnaire, where the questions on the CANRISK questionnaire are more diverse to represent diabetes risk factors better, and some new questions have been added. CANRISK is a low-cost assessment tool that has been found to improve the efficiency and effectiveness of targeted diabetes prevention for people who are at moderate or high risk of acquiring type 2 diabetes mellitus [15,16].

Children, adolescents, and adults who are overweight or obese and have additional risk factors for diabetes should be screened for prediabetes and type 2 diabetes using risk factor assessment or a validated technique [17]. The CANRISK questionnaire is used in this study as a risk assessment tool. CANRISK is a good tool for assessing diabetes risk in a multi-ethnic Canadian population. BMI is one of the parameters that can be used to estimate the risk of obesity or overweight. In the next ten years, CANRISK will be able to detect the risk of diabetes mellitus. Furthermore, when compared to AusDrisk and FINDRISC, CANRISK is the most recent questionnaire and includes all type 2 diabetes mellitus risk variables.

Screening for risk factors with questionnaires and diagnostics is highly recommended because it can reduce mortality and is highly beneficial for people at high risk of developing diabetes mellitus. Therefore, this study aims to identify the likelihood of individuals with overweight or obesity developing type 2 diabetes mellitus in the next ten years in Surabaya, Indonesia.

The research was carried out at a primary healthcare center in Surabaya, Indonesia from April to November 2020. The primary healthcare centers were chosen from among 63 in Surabaya based on the highest number of patients who were overweight or obese. A minimum sample size of 97 was sought to represent the population. Participants were recruited if they met the following criteria: 17 years or older, had a BMI above the normal range (overweight and obesity), had never been diagnosed with diabetes mellitus, and were not taking anti-diabetic medications. Participant were excluded if they had been pregnant and had other medical conditions that could have harmed their health.

The Human Research Ethics Committee has approved the study protocol (No.05/LE/2020). Participants were first asked to complete a consent form, demographic information, and the CANRISK questionnaire. The participants’ height and weight were then measured to calculate their BMI. BMI was calculated as weight in kilograms divided by height in meters squared. The waist circumference of each participant was also measured.

The demographic profiles of the participants were identified using descriptive analysis. Age, sex, level of education, history of hypertension, medication being taken, and family history of diabetes mellitus were among the demographic data collected. Before analysis, the data’s normality was assessed. A chi-square analysis was performed to determine the proportion of each risk factor variable compared to the total score risk category. IBM SPSS version 22.0 was used to analyze all data.

There were 161 patients in primary healthcare centers with abnormal BMI scores, and only 140 patients met the inclusion criteria. Of those who met the inclusion criteria, 121 (75.1%) respondents agreed to participate in this study. After gaining consent, the researcher informed the prospective respondents about the study’s aim and objective. Respondents eligible to participate were asked to fill out the consent form as well as the demographic data sheet and questionnaire. The study has been approved by the Public Health Agency of Canada (Ref: HC2020–0259) to translate and adapt the CANRISK questionnaires to be used in this study.

Table 1 were demographic characteristics of participants. Table 1 shows that most of the participants were below or equal to 44 years old (61.2%) with a median of 40 years old. Most of the participants were female (63.6%) and had senior high school education levels (60.3%). All of the participants never had a history of diabetes (100%) and most of the participants had no and did not know of a family history of diabetes (48.8%). Of 66.1% of them had no chronic diseases.

Table 1 . Demographic characteristics of participants (n=121).

Characteristics	n (%)
Age (median)	40.3 [78]**
≤44 years	74 (61.2)
45–54 years	26 (21.5)
55–64 years	12 (9.9)
65–74 years	9 (7.4)
Sex
Male	44 (36.4)
Female	77 (63.6)
Level of education
No school	2 (1.7)
Elementary	11 (9.1)
Junior high school	16 (13.2)
Senior high school	73 (60.3)
Diploma	5 (4.1)
Undergradute/master/doctoral	14 (11.6)
History of diabetes mellitus
Never	121 (100)
Family history of diabetes mellitus
No or I do not know	59 (48.8)
Mother	20 (16.5)
Father	19 (15.7)
Others	13 (10.7)
Brothers/sisters	5 (4.1)
Mother & father	3 (2.5)
Mother & brothers/sisters	2 (1.7)
Had chronic diseases
No	80 (66.1)
Hypertension	17 (14.0)

Based on the BMI value, most BMI categories were in the overweight category, namely 31 (70.5%) for males and 40 (51.9) for females (Table 2). The CANRISK’s waist circumference of females was in the highest category >88 cm, approximately 60 (77.9%) and 94 to 102 cm for males, accounting for 17 (38.6%). In terms of physical activity, it was found that 52.1% of participants did not engage in physical activity daily. Regarding the regular consumption of fruit or vegetables daily, 52.9% of participants did consume fruit or vegetables every day. Of 69.4% and 94.2% respondents had no or did not know about the history of high blood pressure and the history of high blood sugar.

Table 2 . Questionnaire CANRISK items (n=121).

Variable	Categories	n (%)
Age group	≤44 years	74 (61.2)
	45–54 years	26 (21.5)
	55–64 years	12 (9.9)
	65–74 years	9 (7.4)
Sex	Male	4 (36.4)
	Female	77 (63.6)
BMI
Male	Overweight (25–29)	31 (70.5)
	Obesity, non-morbid (30–34)	10 (22.7)
	Obesity, morbid (≥35)	3 (6.8)
Female	Overweight (25–29)	40 (51.9)
	Obesity, non-morbid (30–34)	27 (35.1)
	Obesity, morbid (≥35)	10 (13.0)
Waist circumference	98,67 [144-78]*
Male	<94 cm	12 (27.3)
	94–102 cm	17 (38.6)
	>102 cm	15 (34.1)
Female	<80 cm	1 (1.3)
	80-88 cm	16 (20.8)
	>88 cm	60 (77.9)
Daily physical activity ≥30 minutes	Yes	58 (47.9)
	No	63 (52.1)
Eat vegetables and fruits	Everyday	64 (52.9)
	Not every day	57 (47.1)
History of high blood pressure	Yes	37 (30.6)
	No or I do not know	84 (69.4)
History of high blood sugar	Yes	7 (5.8)
	No or I do not know	114 (94.2)
History of giving birth to a large baby weighing 4,1 kg or more	Yes	9 (7.4)
	No or I do not know or irrelevant	112 (92.6)
Family history of diabetes mellitus	Mother	20 (16.5)
	Father	19 (15.7)
	Others	13 (10.7)
	Mother and Father	5 (4.1)
	Brothers or sisters	3 (2.5)
	Mothers and brothers or sisters	2 (1.7)
	Child	0 (0.0)
	No or I do not know	59 (48.8)
Ethnicity	East Asia (Indonesia, China, Vietnam, Filipina, Korea, etc.)	121 (100.0)
Level of education	Incomplete senior high school or less	36 (29.8)
	Senior high School graduate	66 (54.5)
	College (not graduated)	2 (1.7)
	College (graduated)	17 (14.0)

*Median [max-min]..

Based on the CANRISK questionnaire results (Table 3), most of the respondents (62.8%) were classified as having a high risk of developing type 2 diabetes mellitus over the next ten years. While 28.1% of the respondents classified had moderate risk and 9.1% had a low risk of developing T2DM in the next ten years.

Table 3 . CANRISK total score category (n=121).

Total score	n (%)
<21 (low risk)	11 (9.1)
21–32 (middle risk)	34 (28.1)
≥33 (high risk)	76 (62.8)

This study found a significant difference between each age group (p=0.000), between male and female respondents (p=0.000), history of high blood pressure (p=0.006), and education level (p=0.002) in the risk of developing type 2 diabetes based on the CANRISK questionnaire (Table 4).

Table 4 . Level risk of developing type 2 diabetes.

Variable	Level of T2DM risk			Total	p-value
	Low	Middle	High
	n (%)	n (%)	n (%)
Age					0.000*
≤44 years	11 (9.1)	29 (24.0)	34 (28.1)	74 (61.1)
45–54 years	0 (0.0)	4 (3.3)	22 (18.1)	26 (21.4)
55–64 years	0 (0.0)	1 (0.8)	11 (9.1)	12 (9.9)
65–74 years	0 (0.0)	0 (0.0)	9 (7.4)	9 (7.4)
Sex					0.000*
Male	10 (8.3)	17 (14.0)	17 (14.0)	44 (36.4)
Female	0 (0.0)	20 (16.5)	57 (47.1)	77 (63.6)
BMI					0.351
Overweight	11 (9.1)	26 (21.5)	34 (28.1)	71 (58.7)
Obesity, non morbid	0 (0.0)	8 (6.6)	29 (24.0)	37 (30.6)
Obesity, morbid	0 (0.0)	0 (0.0)	13 (10.7)	13 (10.7)
Waist circumference					0.184
<80 cm	0 (0.0)	1 (0.8)	0 (0.0)	1 (0.8)
80–88 cm	2 (1.7)	9 (7.4)	8 (6.6)	19 (15.7)
89–93 cm	5 (4.1)	5 (4.1)	9 (7.4)	19 (15.7)
94–102 cm	2 (1.7)	13 (10.7)	27 (22.3)	42 (34.7)
>102 cm	2 (1.7)	6 (5.0)	32 (26.4)	40 (33.1)
Daily physical activity					0.625
Yes	4 (3.3)	19 (15.7)	35 (28.9)	58 (47.9)
No	6 (5.0)	18 (14.9)	39 (32.2)	63 (52.1)
Eat vegetables and fruits					0.203
Everyday	3 (2.5)	21 (17.4)	40 (33.1)	64 (52.9)
Not everyday	7 (5.8)	16 (13.2)	34 (28.1)	57 (47.1)
History of high blood pressure					0.006*
Yes	1 (0.8)	6 (5.0)	30 (24.8)	37 (30.6)
No or do not know	9 (7.4)	31 (25.6)	44 (36.4)	84 (69.4)
History of high blood sugar					0.111
Yes	0 (0.0)	0 (0.0)	7 (5.8)	7 (5.8)
No or do not know	10 (8.3)	37 (30.6)	67 (55.4)	114 (94.2)
Family history of DM					0.564
Yes	3 (2.5)	25 (20.7)	34 (28.1)	62 (51.2)
No	7 (5.8)	12 (9.9)	40 (33.1)	59 (48.8)
Level education					0.002*
Incomplete senior high school or less	0 (0.0)	3 (2.5)	33 (27.3)	36 (29.8)
Senior high school	9 (7.4)	26 (21.5)	31 (25.6)	66 (54.5)
Incomplete university graduate	0 (0.0)	1 (0.8)	1 (0.8)	2 (1.6)
University graduate	2 (1.6)	4 (3.3)	11 (9.1)	17 (14.0)

*Significant at the 0.05 level (2-tailed)..

Several factors and conditions were significant for the development of type 2 diabetes, such as a sedentary lifestyle, physical inactivity, smoking, and alcohol consumption [18]. Certain factors, such as hypertension, ethnicity, blood sugar levels, and a history of giving birth to a baby weighing more than four kilograms, were also considered risk factors for developing type 2 diabetes and included as the risk factors in the CANRISK questionnaires. Each question’s score is totaled and classified into three categories: low, medium, and high risk for developing type 2 diabetes in the next ten years.

Obesity is caused by excessive adipose tissue, which is one of the most serious risks of type 2 diabetes by disrupting the body’s metabolic balance. The accumulation of an excessive amount of body fat can cause type 2 diabetes, and the risk of type 2 diabetes increases linearly with an increase in body mass index (BMI) [19]. Accordingly, the worldwide increase in the prevalence of obesity has led to the concomitant increase in the prevalence of type 2 diabetes. A previous study also reported that obesity is strongly associated with T2DM, especially in higher body mass index categories [20].

The goal of diabetes screening is to identify people with undiagnosed diabetes, as well as those at risk for developing diabetes. The CANRISK questionnaire is a tool that helps people assess their risk of developing type 2 diabetes or prediabetes. This study found that most of the participants had a high risk of developing type 2 diabetes over the next ten years. This highlights the need for early intervention and preventive measures to reduce the risk and manage the progression of the disease. Lifestyle intervention programs promoting healthy diets, physical activity, and modest body weight reductions can prevent or delay the onset of diabetes among these high-risk populations [21].

This study also found that sex had a significant difference between risk factor categories and risk categories based on the CANRISK questionnaire, in which females were more at high risk of developing T2DM because most of them were overweight and had a waist circumference of more than 88 cm. Worldwide, an estimated 17.7 million more men than women have diabetes mellitus. This study finding is in line with the previous studies which reported that women with a body mass index of 30 kg/m² have a 28 times greater risk of developing diabetes than women of normal weight [10]. Women who have a waist circumference of 80–88 cm are also at higher risk of type 2 diabetes [22].

Obesity, hypertension, and diabetes are closely linked and often occur together. This study finds that hypertension is one of the risk factors that had significant differences with the level of T2DM based on the CANRISK questionnaire. Hypertension is twice as frequent in patients with diabetes compared with those who do not have diabetes. Moreover, patients with hypertension often exhibit insulin resistance and are at greater risk of diabetes developing than normotensive individuals [23]. Hypertensive individuals are at a considerably higher risk of diabetes than those with normal blood pressure, therefore the detection and management of high blood pressure is an essential component of the clinical management of people with risk of diabetes [24].

Education level also plays a critical role in understanding and utilizing tools like the CANRISK questionnaire for assessing the risk of type 2 diabetes. In this study, education level was significantly associated with the risk categories identified by the CANRISK questionnaire. Individuals with higher education levels are generally more likely to comprehend health information and apply it effectively, leading to better awareness and management of diabetes risk factors. Conversely, those with lower education levels may face challenges in understanding the questionnaire or recognizing the importance of the identified risks, potentially limiting the effectiveness of screening efforts. A previous study reported that individuals with higher education were more likely to engage in preventive behavior such as maintaining a healthy diet and regular physical activity, both of which are crucial for mitigating diabetes risk [25]. To maximize the utility of the CANRISK questionnaire, efforts should focus on improving health literacy among individuals with lower education levels. Tailored interventions, such as simplified educational materials or guided assistance during screenings, can bridge this gap. Addressing education-related disparities in diabetes risk assessment is essential for equitable and effective prevention strategies.

Respondents with moderate and high risk can be advised to improve their lifestyle and increase the frequency of exercise to reduce or even normalize BMI and abdominal circumference. History of hypertension can be modified by choosing foods with low salt intake. In addition, the level of education can be increased if it is still possible to carry out formal education. However, if not, education can be obtained informally, especially in this technological era, where access to information can be easily obtained. Respondents with moderate risk are advised to consult with health workers regarding their risk of type 2 DM, while respondents with high risk are advised to consult with health workers and check blood sugar.

Type 2 diabetes risk assessment studies remain limited in Indonesia, particularly when the CANRISK questionnaire is used as a risk assessment tool. Furthermore, this study’s findings can help prevent the high-risk population from developing type 2 diabetes. However, more study is required to determine the role of healthcare professionals in the population, including pharmacists. Pharmacists as well as health promotors can participate in health screening to identify the risk of developing type 2 diabetes mellitus and it may reduce the barriers to medication adherence.

Based on the results, it is known that (62.8%) were classified as having a high risk of developing type 2 diabetes mellitus over the next ten years. While 28.1% of the respondents classified had moderate risk and 9.1% had a low risk of developing T2DM in the next ten years. Various risk factors such as age, sex, history of high blood pressure, and education level were significant differences between risk factor categories and risk categories based on the CANRISK questionnaire. There was no significant difference between the risk factor categories and the risk category of developing type 2 diabetes based on the CANRISK questionnaire for physical activity, fruit or vegetable consumption, history of high blood sugar levels, and family history of diabetes mellitus. Further research is needed to understand why some factors showed no significant differences in risk categories. Engaging families and communities in awareness initiatives and advocating for supportive public health policy can also help reduce the risk of type 2 diabetes.

All data related to this study was kept under the supervision of the research team.

This manuscript has not been published or presented elsewhere in part or in entirety and is not under consideration by another journal. The study was approved by the Human Research Ethics Committee of the Faculty of Pharmacy Universitas Airlangga, Surabaya, Indonesia (No.05/LE/2020).

Informed consent was obtained from all the individuals participated in this study.

Ethical approval was obtained, and all procedures performed in this study were by the ethical standards of the Human Research Ethics Committee.

No potential conflict of interest relevant to this article was reported.

This study was supported by the Indonesian Ministry of Education and Culture (DRPM – PDUPT 2019-2021).

The authors would like to thank the Faculty of Pharmacy, Universitas Airlangga, and the Lembaga Penelitian dan Pengabdian Masyarakat (LPPM) Universitas Airlangga for the support and facilities provided during the study (DRPM PDUPT: 2019–2021). We also thank the research assistants involved in this study: Ms. Yenni Desilia Indahsari and Ms. Edlia Fadilah.