The International Diabetes Federation estimates that there has been an increase in the number of people with diabetes by 21% between 2013 and 20191,2. The number of people with diabetes is estimated to be 463 million in 2019 and will increase to 700 million by 2045. It is estimated that 50.1% of people with diabetes are still undetected3. In addition, people with prediabetes as a high-risk group for developing diabetes usually go undetected clinically4. Improper and late intervention in this group will cause prediabetes to develop progressively into type 2 diabetes mellitus within 2-3 years, which in 70% of patients will remain throughout their lives5. Diabetes mellitus will burden patients, families, and the health care system6.

A systematic review and meta-analysis have discovered that lifestyle change interventions such as exercise, weight loss, and dietary management can prevent prediabetes and even slow the progression of type 2 diabetes7. Identification of individuals with prediabetes in the population is essential. However, prediabetes is difficult to trace because it is asymptomatic. Therefore, an instrument is needed to identify individuals with a high risk of developing type 2 diabetes so that lifestyle change interventions can be more targeted8.

The Finnish diabetes risk score (FINDRISC) is an instrument in the form of a questionnaire aimed at identifying individuals with a high risk of developing diabetes9. The question items in this instrument are a set of the main risk factors for type 2 diabetes. Initially, this instrument was developed to detect the risk of diabetes in the next ten years in the Caucasian population. However, this instrument has been translated, adapted, and validated over time so it can be applied to other populations, such as Asian populations10-12. Several other studies have also compared the performance of the original version of FINDRISC with the simplified version of FINDRISC13,14.

A study showed that FINDRISC could screen individuals at high risk of developing type 2 diabetes and that lifestyle intervention for these individuals effectively treats their obesity, one of the risk factors for type 2 diabetes15. In addition to its ability to identify individuals at high risk of developing diabetes, several studies have also evaluated the ability of FINDRISC to detect individuals with undiagnosed type 2 diabetes, the presence of impaired glucose tolerance, and the risk of developing metabolic syndrome16-18. Individuals with higher FINDRISC are also associated with a decreased quality of life19.

No studies precisely quantify the development of research trends toward the FINDRISC instrument. Bibliometric analysis can be used for this purpose and has been widely used in many disciplines to observe research trends on a particular topic, population, or region. It can also be used to identify the potential for future research development. Therefore, this study aimed to identify the utilization of the FINDRISC using bibliometric analysis.

Bibliometric analysis was performed by conducting a literature search on PubMed and Scopus with the keywords: "FINDRISC" AND "Diabetes". A total of 249 articles were obtained and analyzed based on the number of publications per year, journals that publish the articles, number of publications by author and year of publication, number of publications based on affiliation and year of publication, number of publications by country of origin and year of publication, number of keywords per year, number of citations per year, types of articles, specific topics, and theme mapping. The data visualization was obtained from the Scopus database with the VOSviewer and Biblioshiny applications.

Data analysis and visualization

The data in the Scopus database are visualized automatically. In contrast, we used VOSviewer and Biblioshiny to show data from the PubMed database. Only four of the 11 figures in this article are obtained from Scopus, notably Figures 1,2,8, and 9. We used VOSviewer/Biblioshiny to visualize the rest of the data from PubMed.

From the literature search on PubMed and Scopus, the same 249 articles were obtained, with the annual distribution shown in Figure 1. Despite the increase in the number of publications, the number of publications on the topic of FINDRISC in patients with diabetes mellitus is still very few per year, where every year, only less than 35 articles are published. The highest number of published articles, 34 articles, was in 2020.

Figure1. Number of articles on the topics of FINDRISC and diabetes for the period 2005-2021.

A bibliometric analysis of the number of publications related to the utilization of FINDRISC in patients with diabetes revealed an increasing trend since 2005. The overview of publication productivity based on country clusters showed that those researchers from European countries still dominate publications. This situation is likely because the FINDRISC instrument was first developed in a population at high risk of developing diabetes in Finland20,21. In 2003, a new Diabetes Risk Screening program was started in Finland, with the development of an instrument called the Diabetes Risk Score instrument. Furthermore, the first publication discussing this topic was in 200522. This finding is in line with the Word Cloud analysis (Figure 10), which shows that the word "Finland" is the word with the highest frequency of occurrence.

Figure 2 shows the journals that published articles related to FINDRISC and diabetes from 2005-2021. PLoS One was the journal that published the most articles on this topic in 2016. In 2021, Diabetes Research and Clinical Practice and Primary Care Diabetes published three articles on FINDRISC and diabetes. Research topics regarding FINDRISC and diabetes still have the potential to be explored, as evidenced by PLoS One publishing many articles related to FINDRISC and diabetes.

Figure 3 displays the authors of articles related to FINDRISC and diabetes based on the year of publication and the number of publications. There are eight clusters of authors of articles that are also related to each other. The number of relationships between authors is 344. The authors with yellow circles are included in the latest publication cluster, although the number of published articles is still limited. Tuomilehto was the author with the most publications around 2012-2016, followed by Lindstrom at the same time range.

Figure 4 displays the number of articles by institutional affiliation of the author and year of publication. There are 10 relations between institutions to which the authors are affiliated, and these institutions are divided into three clusters based on the year of publication. Research in 2018 was conducted mainly by the Diabetes Research Group, Dasman Diabetes Institute, and the Department of Chronic Disease. The institution that conducted the most extended years of research was the National Institute for Health.

Figure2. Number of published articles related to FINDRISC and diabetes by journal.

Figure3. Number of publications on the topics of FINDRISC and diabetes for the period 2005-2021 by author and year of publication.

Figure4. Number of articles with FINDRISC and diabetes topics in publications for the period 2005-2021 by author affiliation and year of publication.

Figure 5 shows the number of articles by country of origin of the author and year of publication. There are five clusters of countries involved based on the year of publication, with 111 relationships with each other. Recent publications have been by authors from Saudi Arabia, Brazil, Venezuela, Greece, Belgium, and Colombia, although the number of publications is still relatively small. Most publications were by authors from Finland in 2015. This is understandable because FINDRISC originates from Finland.

Figure5. Mapping of publications with FINDRISC and Diabetes topics for the period 2005-2021 by country of origin of author and year of publication.

Figure 6 shows the keywords used by the authors. There are five clusters of these keywords based on the year of publication with 199 relationships with each other. The keyword "diabetes" appeared in 2017 and is almost the same as "type 2 diabetes," which appeared in 2015.

Figure6. Mapping of keywords related to FINDRISC and Diabetes topics in publications for the period 2005-2021 based on keyword type and year of publication.

Since 2015, articles have been published by researchers from countries in the Americas and Asia. Even though the number of articles is still relatively small, the researchers who research the topic of FINDRISC seem to be intensely related and interact with each other through citations. The lack of publications regarding the utilization of FINDRISC in Asian populations provides an opportunity to conduct a comparative analysis of the validity of the FINDRISC screening instrument in Asian populations. The different characteristics of populations with diabetes mellitus in Europe and Asia are very important to understand by clinicians and policymakers for the prevention of risk factors and management of diabetes. Compared to the European population, the incidence of diabetes in the Asian population is dominated by young people with insulin resistance due to excessive accumulation of body fat and abdominal obesity23.

Figure 7 exhibits a mapping of citations by author and year of publication. There are six clusters based on the year of publication with 115 relationships between authors. The article by Tuomilehto was most cited in 2014, while the most cited articles published in 2020 were those by Cardon and Iotova. Figure 8 shows the types of published articles, most of which are research articles (92.8%). While Figure 9 displays the subject areas of the research, most of which are medicine (58.4%).

Figure7. Mapping of citations related to FINDRISC and Diabetes topics in publications for the period 2005-2021 by author and year of publication.

Figure8. Types of articles on the topics of FINDRISC and Diabetes in publications for the period 2005-2021.

Figure9. Subject areas of research with the topics of FINDRISC and Diabetes in publications for the period 2005-2021.

The overview of the types of published articles reveals that most of the documents in this bibliometric analysis are original papers or research articles. The number of review articles was found to be less than 5%. It indicates an opportunity to conduct a systematic literature review, scoping review, or meta-analysis method to examine the validity and performance of FINDRISC as an instrument for screening various populations at risk of developing diabetes or having prediabetes. In addition, the existing publications that test the validity of FINDRISC in the new population mainly used a cross-sectional design, and there are still few publications that used prospective data24.

Figure 10 shows the most frequently occurring words in publications about FINDRISC and diabetes. "Finland" is the most mentioned word in the publications. Figure 11 is a mapping of themes based on articles found in publications for 2005-2021. The theme clusters can be seen from the color difference. The cluster in gray is the cluster of most discussed themes in research on FINDRISC and diabetes, which include: consensus, diet restriction, clinical effectiveness, Spain, questionnaire, glucose blood level, and others.

Figure10. Word Cloud in research related to FINDRISC and Diabetes in publications for the period 2005-2021.

Figure11. Mapping of themes of research with the topics of FINDRISC and Diabetes in publications for the period 2005-2021.

It seems that the research themes related to FINDRISC are not only limited to immediate diabetes risk factors such as diet restriction, glucose blood level, cardiovascular risk, and lifestyle modification but also intersect with broader themes such as disease course, mortality, morbidity, and costs. Several themes that were also discussed, such as screening tests, high-risk patients, and clinical effectiveness, indicate that the FINDRISC instrument has the potential to be studied further at the clinical level and community level, and it is possible for this instrument to be used to screen for other metabolic disorders such as metabolic syndrome. In addition, the attempt to include FINDRISC in the practice guidelines for primary medical care has become a growing theme25. A cost-effectiveness analysis is necessary for the evaluation26.

On the other hand, although nearly 60% of the subject areas of research on FINDRISC and diabetes are medicine, research from other subject areas such as biochemistry, nursing, dentistry, agriculture, pharmacology, and others provides opportunities for collaborative research on this topic in the future. Various reports on the results of studies related to FINDRISC are still popular and exciting to publish. This is indicated by articles on this topic continuously published by reputable and prestigious journals such as PLoS One, BMC Public Health, and Primary Care Diabetes.

One limitation of this study is that the only databases used were PubMed and Scopus. Scopus will repeat the number of articles based on contributing authors from different countries in one article, so some articles may be counted multiple times if the contributing authors are from several countries27. Nevertheless, this is sufficient to serve as a basis for evaluating the utilization of FINDRISC in diabetes screening and identifying research gaps and future research opportunities. Opportunities to conduct research using Indonesia's FINDRISC instrument are still ample. This instrument can be one of the government's considerations, especially in measures for the early detection of diabetes, for example, in the integrated post guidance for non-communicable diseases (Pos Binaan Terpadu; Posbindu) and the Healthy Campus program initiated by the Ministry of Health of the Republic of Indonesia.

Despite the increase in publications, the number of publications on FINDRISC in patients with diabetes mellitus per year is still relatively small, with 92.8% of publications being primary studies. The publications are still dominated by those of researchers from countries in the European region, and these researchers intensely relate to each other and interact with each other through citations. Research themes related to FINDRISC are not limited to diabetes risk factors.

We want to thank all those who have helped us in the data collection process and the process of writing this article. Also, thanks to the Office of Research and Publication, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.

DAP was the first to propose this research concept. Then, DAP and MRR collect and analyze data. In addition to being the corresponding author, BA also ensures that the final draft of the manuscript complies with the guidelines of the intended journal. ZZ contributes to data visualization. SR support in budgeting. All authors provided feedback from the initial draft to the final manuscript and approved the overall process.

None.

The authors declare no conflict of interest.

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