Building resilience and reversing frailty: a randomised controlled trial of a primary care intervention for older adults.

BACKGROUND: There is a need for effective primary care interventions that help older people combat frailty and build resilience. OBJECTIVE: To study the effectiveness of an optimised exercise and dietary protein intervention. DESIGN: Multicentre, randomised-controlled, parallel-arm trial. SETTING: Six primary care practices, Ireland. METHODS: Six general practitioners enrolled adults aged 65+ with Clinical Frailty Scale score ≤5 from December 2020 to May 2021. Participants were randomised to intervention or usual care with allocation concealed until enrolment. Intervention comprised a 3-month home-based exercise regime, emphasising strength, and dietary protein guidance (1.2 g/kg/day). Effectiveness was measured by comparing frailty levels, based on the SHARE-Frailty Instrument, on an intention-to-treat basis. Secondary outcomes included bone mass, muscle mass and biological age measured by bioelectrical impedance analysis. Ease of intervention and perceived health benefit were measured on Likert scales. RESULTS: Of the 359 adults screened, 197 were eligible and 168 enrolled; 156 (92.9%) attended follow-up (mean age 77.1; 67.3% women; 79 intervention, 77 control). At baseline, 17.7% of intervention and 16.9% of control participants were frail by SHARE-FI. At follow-up, 6.3 and 18.2% were frail, respectively. The odds ratio of being frail between intervention and control groups post-intervention was 0.23 (95% confidence interval: 0.07-0.72; P = 0.011), adjusting for age, gender and site. Absolute risk reduction was 11.9% (CI: 0.8%-22.9%). Number needed to treat was 8.4. Grip strength (P < 0.001) and bone mass (P = 0.040) improved significantly. 66.2% found the intervention easy, 69.0% reported feeling better. CONCLUSION: A combination of exercises and dietary protein significantly reduced frailty and improved self-reported health.

Testing the feasibility of a primary-care exercise intervention to prevent and reverse early frailty and build resilience in community-dwelling older adults.

Background: Resistance exercises have been shown to prevent and reverse frailty but their application in clinical practice is low. We wished to test the feasibility of an optimised exercise intervention for mild or pre-frailty in a primary-care setting and inform the design of a definitive randomised control trial. Methods: The intervention was co-designed with eighteen older adults in two group workshops, informed by systematic review and meta-analysis. Eligible patients aged 65+, mildly frail or less, presenting to an Irish primary-care centre over 6 months from January 2020 were invited to participate. They were offered an exercise guide and educational discussion. Demographics, health indicators and frailty scores were recorded. Feasibility was assessed using the Bowen model for acceptability; participation; demand; implementation; practicality; adaptation; integration; expansion; and limited-efficacy. Half of the randomly selected participants were telephoned after one month, and all the participants were called after two to measure effects on adherence. Findings: 94 of 107 eligible people (88%) participated (average age 77, 59 women (63%)). Only 15% had previously considered resistance exercises. The intervention satisfied all Bowen feasibility criteria. At one month, 65% of participants were exercising. At two months, adherence amongst those previously called was higher: 78%. 87% described exercises as 'very easy' or 'somewhat easy'. 66% felt 'much better' or 'slightly better'. Interpretation: Frailty intervention uptake and adherence were high. A single telephone call appeared to help increase adherence. Participants reported meaningful physical and mental health benefits. Funding: Roman Romero-Ortuno is funded by a grant from Science Foundation Ireland (SFI), grant number 18/FRL/6188.

Involving older people in co-designing an intervention to reverse frailty and build resilience.

BACKGROUND: An essential consideration in health research is to conduct research with members of the public rather than for them. Public and patient involvement (PPI) of older people in research can improve enrolment, relevance and impact. However, few studies with PPI in frailty research have been identified. PPI has fallen during the Covid-19 pandemic. OBJECTIVE: We aimed to involve older people in co-designing a randomised control trial (RCT) intervention to reverse frailty and build resilience. We also wished to encourage wider use of PPI with older people by outlining our approach. METHODS: Involvement of older people was undertaken in three stages. Eighteen over 65-year-olds helped co-design an exercise intervention in two group discussions using the Socratic education method. Ninety-four contributed intervention feedback in one-on-one telephone interviews over nine months. Ten contributors helped optimise the intervention in three online workshops. Multidisciplinary team input and systematic review supported co-design. RESULTS: Eleven home-based resistance exercises were co-designed by group discussion contributors (mean age 75, 61% female). Frailty intervention format, gender balance and GP follow-up were shaped in telephone interviews (mean age 77, 63% female). Dietary guidance and patient communication were co-designed in workshops (mean age 71, 60% females). Technology proved no barrier to PPI. The co-designed frailty intervention is being evaluated in a definitive RCT. CONCLUSIONS: We enabled meaningful the involvement of 112 older people in the co-design of an intervention to reverse frailty and build resilience in diverse ways. Inclusive involvement can be achieved during a pandemic. Feedback enhanced intervention feasibility for real-world primary-care.

Our research paper describes how we involved 112 older adults in the co-design of an intervention aiming to reverse frailty and build resilience. Involving participants in research can improve its feasibility and impact. However, there have been few studies involving older people in frailty research and involvement has fallen further during the Covid-19 pandemic. Involvement of older people was undertaken in three stages. Eighteen over 65-year-olds helped co-design an exercise intervention in two group discussions. Ninety-four older adults contributed intervention feedback in one-on-one telephone interviews over nine months. Ten contributors helped optimise the intervention in three online workshops. The co-designed intervention involved resistance exercises and dietary guidance and will be tested in a full randomised control trial. We enabled the meaningful involvement of 112 older people in our research in diverse ways. Inclusive involvement can be achieved during a pandemic.

Hypertension Pharmacological Treatment in Adults: A World Health Organization Guideline Executive Summary.

Hypertension is a major cause of cardiovascular disease and deaths worldwide especially in low- and middle-income countries. Despite the availability of safe, well-tolerated, and cost-effective blood pressure (BP)-lowering therapies, <14% of adults with hypertension have BP controlled to a systolic/diastolic BP <140/90 mm Hg. We report new hypertension treatment guidelines, developed in accordance with the World Health Organization Handbook for Guideline Development. Overviews of reviews of the evidence were conducted and summary tables were developed according to the Grading of Recommendations, Assessment, Development, and Evaluations approach. In these guidelines, the World Health Organization provides the most current and relevant evidence-based guidance for the pharmacological treatment of nonpregnant adults with hypertension. The recommendations pertain to adults with an accurate diagnosis of hypertension who have already received lifestyle modification counseling. The guidelines recommend BP threshold to initiate pharmacological therapy, BP treatment targets, intervals for follow-up visits, and best use of health care workers in the management of hypertension. The guidelines provide guidance for choice of monotherapy or dual therapy, treatment with single pill combination medications, and use of treatment algorithms for hypertension management. Strength of the recommendations was guided by the quality of the underlying evidence; the tradeoffs between desirable and undesirable effects; patient's values, resource considerations and cost-effectiveness; health equity; acceptability, and feasibility consideration of different treatment options. The goal of the guideline is to facilitate standard approaches to pharmacological treatment and management of hypertension which, if widely implemented, will increase the hypertension control rate world-wide.

Systematic Coronary Risk Evaluation (SCORE): JACC Focus Seminar 4/8.

Clinical estimation of the combined effect of several risk factors is unreliable and this resulted in the development of a number of risk estimation systems to guide clinical practice. Here, after defining general principles of risk estimation, the authors describe the evolution of the European Society of Cardiology's (ESC) Systematic COronary Risk Evaluation (SCORE) risk estimation system and some learnings from the data. They move on to describe the establishment of the ESC's Cardiovascular Risk Collaboration and outline its proposed research directions. First among these is the evolution of SCORE 2, which provides updated, calibrated risk estimates for total cardiovascular events for low, moderate, high, and very high-risk regions of Europe. The authors conclude by considering that the future of risk estimation may be to express risk as years of exposure to a cardiovascular risk factor profile rather than risk over a fixed time period, such as 10 years, and how advances in genetics may permit individualized lifetime risk estimation from childhood on.

Primary care interventions to address physical frailty among community-dwelling adults aged 60 years or older: A meta-analysis.

INTRODUCTION: The best interventions to address frailty among older adults have not yet been fully defined, and the diversity of interventions and outcome measures makes this process challenging. Consequently, there is a lack of guidance for clinicians and researchers regarding which interventions are most likely to help older persons remain robust and independent. This paper uses meta-analysis to assess effectiveness of primary care interventions for physical frailty among community-dwelling adults aged 60+ and provides an up-to-date synthesis of literature in this area. METHODS: PubMed, CINAHL, Cochrane Register of Controlled Trials, and PEDro databases were searched, and RCTs, controlled pilot studies, or trials with similar study designs addressing frailty in the primary care setting among persons aged 60+ were chosen. Study data was abstracted following PRISMA guidelines, then meta-analysis was performed using the random effects model. RESULTS: 31 studies with a total of 4794 participants were analysed. Interventions using predominantly resistance-based exercise and nutrition supplementation seemed to improve frailty status versus control (RR = 0.62 (CI 0.48-0.79), I2 = 0%). Exercise plus nutrition education also reduced frailty (RR = 0.69 (CI 0.58-0.82), I2 = 0%). Exercise alone seemed effective in reducing frailty (RR = 0.63 (CI 0.47-0.84), I2 = 0%) and improving physical performance (RR = 0.43 (CI 0.18-0.67), I2 = 0%). Exercise alone also appeared superior to control in improving gait speed (SMD = 0.36 (CI 0.10-0.61, I2 = 74%), leg strength (SMD = 0.61 (CI 0.09-1.13), I2 = 87%), and grip strength (Mean Difference = 1.08 (CI 0.02-2.15), I2 = 71%) though a high degree of heterogeneity was observed. Comprehensive geriatric assessment (RR = 0.77 (CI 0.64-0.93), I2 = 0%) also seemed superior to control in reducing frailty. CONCLUSION: Exercise alone or with nutrition supplementation or education, and comprehensive geriatric assessment, may reduce physical frailty. Individual-level factors and health systems resource availability will likely determine configuration of future interventions.

Protocol for a randomised controlled trial of a primary care intervention to Reverse Frailty and Enhance Resilience through Exercise and dietary protein Education (REFEREE) in community-dwelling adults aged 65 and over.

Introduction: Resistance exercises and dietary protein have been shown to reverse frailty, yet they are not commonly offered in clinical practice. We aim to measure changes in health outcomes, including physical frailty status (SHARE-FI), clinical frailty status (CFS) and muscle mass, as a result of an optimised exercise and dietary intervention versus usual care in a primary care (PC) setting. The intervention has been derived from our systematic review and meta-analysis findings and optimised through patient and public involvement and multidisciplinary team input. Methods: This study is a multicentre randomised controlled parallel arm trial with a three month follow up. 210 eligible people aged 65 and over, no more than mildly frail, will be recruited in seven PC practices in Ireland and randomly assigned to 'intervention' or 'usual care'. Intervention participants will be provided a leaflet with strength exercises, protein dietary guidance and educational discussion. Baseline measurements will include demographics, health indicators, comorbidities, malnutrition universal screening tool (MUST), frailty status (SHARE-FI, CFS) and muscle mass (bioelectrical impedance). Primary outcome will be frailty status measured by SHARE-FI at three months. Secondary outcomes include CFS, muscle mass, in-patient hospitalisation, long term care admission, and subjective ease of intervention and difference to general health. Statistical analysis will be undertaken by an independent statistician. Discussion: The diversity of tested frailty interventions and lack of clear guidance may contribute to low implementation rates. The REFEREE trial focusses on an optimised intervention for a syndrome that poses growing individual and societal challenges. It is hoped results can encourage mainstream adoption of interventions to reverse clinical frailty and build resilience in primary care. Trial registration: ClinicalTrials.gov ID NCT04628754; registered on 13 November 2020.

What are the mechanisms that support healthcare professionals to adopt assisted decision-making practice? A rapid realist review.

BACKGROUND: The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) establishes a right to legal capacity for all people, including those with support needs. People with disabilities have a legal right to be given the appropriate supports to make informed decisions in all aspects of their lives, including health. In Ireland, the Assisted Decision-Making (Capacity) Act (2015) ratifies the Convention and has established a legal framework for Assisted Decision Making (ADM). The main provisions of the Act are not yet implemented. Codes of Practice to guide health and social care professionals are currently being developed. Internationally, concerns are expressed that ADM implementation is poorly understood. Using realist synthesis, this study aims to identify Programme Theory (PT) that will inform ADM implementation in healthcare. METHODS: A Rapid Realist Review using collaborative methods was chosen to appraise relevant literature and engage knowledge users from Irish health and social care. The review was led by an expert panel of relevant stakeholders that developed the research question which asks, 'what mechanisms enable healthcare professionals to adopt ADM into practice?' To ensure the PT was inclusive of local contextual influences, five reference panels were conducted with healthcare professionals, family carers and people with dementia. PT was refined and tested iteratively through knowledge synthesis informed by forty-seven primary studies, reference panel discussions and expert panel refinement and consensus. RESULTS: The review has developed an explanatory PT on ADM implementation in healthcare practice. The review identified four implementation domains as significant. These are Personalisation of Health & ADM Service Provision, Culture & Leadership, Environmental & Social Re-structuring and Education, Training & Enablement. Each domain is presented as an explanatory PT statement using realist convention that identifies context, mechanism and outcome configurations. CONCLUSIONS: This realist review makes a unique contribution to this field. The PT can be applied by policymakers to inform intervention development and implementation strategy. It informs the imminent policy and practice developments in Ireland and has relevance for other worldwide healthcare systems dealing with similar legislative changes in line with UNCRPD.

Enabling public, patient and practitioner involvement in co-designing frailty pathways in the acute care setting.

BACKGROUND: Although not an inevitable part of ageing, frailty is an increasingly common condition in older people. Frail older patients are particularly vulnerable to the adverse effects of hospitalisation, including deconditioning, immobility and loss of independence (Chong et al, J Am Med Dir Assoc 18:638.e7-638.e11, 2017). The 'Systematic Approach to improving care for Frail older patients' (SAFE) study co-designed, with public and patient representatives, quality improvement initiatives aimed at enhancing the delivery of care to frail older patients within an acute hospital setting. This paper describes quality improvement initiatives which resulted from a co-design process aiming to improve service delivery in the acute setting for frail older people. These improvement initiatives were aligned to five priority areas identified by patients and public representatives. METHODS: The co-design work was supported by four pillars of effective and meaningful public and patient representative (PPR) involvement in health research (Bombard et al, Implement Sci 13:98, 2018; Black et al, J Health Serv Res Policy 23:158-67, 2018). These pillars were: research environment and receptive contexts; expectations and role clarity; support for participation and inclusive representation and; commitment to the value of co-learning involving institutional leadership. RESULTS: Five priority areas were identified by the co-design team for targeted quality improvement initiatives: Collaboration along the integrated care continuum; continence care; improved mobility; access to food and hydration and improved patient information. These priority areas and the responding quality improvement initiatives are discussed in relation to patient-centred outcomes for enhanced care delivery for frail older people in an acute hospital setting. CONCLUSIONS: The co-design approach to quality improvement places patient-centred outcomes such as dignity, identity, respectful communication as well as independence as key drivers for implementation. Enhanced inter-personal communication was consistently emphasised by the co-design team and much of the quality improvement initiatives target more effective, respectful and clear communication between healthcare personnel and patients. Measurement and evaluation of these patient-centred outcomes, while challenging, should be prioritised in the implementation of quality improvement initiatives. Adequate resourcing and administrative commitment pose the greatest challenges to the sustainability of the interventions developed along the SAFE pathways. The inclusion of organisational leadership in the co-design and implementation teams is a critical factor in the success of interventions targeting service delivery and quality improvement.

Using geographic information systems to map older people's emergency department attendance for future health planning.

OBJECTIVES: This study aimed to assess the pattern of use of EDs, factors contributing to the visits, geographical distribution and outcomes in people aged 65 years or older to a large hospital in Dublin. METHODS: A retrospective analysis of 2 years of data from an urban university teaching hospital ED in the southern part of Dublin was reviewed for the period 2014-2015 (n=103 022) to capture the records of attenders. All ED presentations by individuals 65 years and older were extracted for analysis. Address-matched records were analysed using QGIS, a geographic information systems (GIS) analysis and visualisation tool to determine straight-line distances travelled to the ED by age. RESULTS: Of the 49 538 non-duplicate presentations in the main database, 49.9% of the total are women and 49.1% are men. A subset comprised of 40 801 had address-matched records. When mapped, the data showed a distinct clustering of addresses around the hospital site but this clustering shows different patterns based on age cohort. Average distances travelled to ED are shorter for people 65 and older compared with younger patients. Average distances travelled for those aged 65-74 was 21 km (n=4177 presentations); for the age group 75-84, 18 km (n=2518 presentations) and 13 km for those aged 85 and older (n=2104 presentations). This is validated by statistical tests on the clustered data. Self-referral rates of about 60% were recorded for each age group, although this varied slightly, not significantly, with age. CONCLUSIONS: Health planning at a regional level should account for the significant number of older patients attending EDs. The use of GIS for health planning in particular can assist hospitals to improve their understanding of the origin of the cohort of older ED patients.

Determinants of coronary artery disease risk factor management across three world regions.

BACKGROUND: The SUrvey of Risk Factors (SURF) indicated poor control of risk factors in subjects with established coronary heart disease (CHD). The present study aimed to investigate determinants of risk factor management in patients with CHD. METHODS AND RESULTS: SURF recruited 9987 consecutive patients with CHD from Europe, Asia and the Middle East between 2012 and 2013. Risk factor management was summarised as a Cardiovascular Health Index Score (CHIS) based on six risk factor targets (non-smoker/ex-smoker, body mass index <30, adequate exercise, controlled blood pressure, controlled low-density lipoprotein and controlled glucose). Logistic regression models assessed the associations between determinants (age, sex, family history, cardiac rehabilitation, previous hospital admission and diabetes) and achievement of moderate CHIS (≥3 risk factors controlled). The results are presented as OR with corresponding 95% CI. A moderate CHIS was less likely to be reached by women (OR 0.90, 95% CI 0.69 to 1.00), those aged <55 years old (OR 0.62, 95% CI 0.53 to 0.76) and those with diabetes (OR 0.41, 95% CI 0.37 to 0.46). Attendance in cardiac rehabilitation was associated with better CHIS achievements (OR 1.62, 95% CI 1.42 to 1.87). Younger Asian and European patients had poorer risk factor management, whereas for patients from the Middle East age was not significantly associated with risk factor management. The availability and applicability of cardiac rehabilitation varied by region. CONCLUSIONS: Overall, risk factor management was poorer in women, those younger than 55 years old, those with diabetes and those who did not participate in a cardiac rehabilitation. Determinants of cardiovascular risk factor management differed by region.

Delaying and reversing frailty: a systematic review of primary care interventions.

BACKGROUND: Recommendations for routine frailty screening in general practice are increasing as frailty prevalence grows. In England, frailty identification became a contractual requirement in 2017. However, there is little guidance on the most effective and practical interventions once frailty has been identified. AIM: To assess the comparative effectiveness and ease of implementation of frailty interventions in primary care. DESIGN AND SETTING: A systematic review of frailty interventions in primary care. METHOD: Scientific databases were searched from inception to May 2017 for randomised controlled trials or cohort studies with control groups on primary care frailty interventions. Screening methods, interventions, and outcomes were analysed in included studies. Effectiveness was scored in terms of change of frailty status or frailty indicators and ease of implementation in terms of human resources, marginal costs, and time requirements. RESULTS: A total of 925 studies satisfied search criteria and 46 were included. There were 15 690 participants (median study size was 160 participants). Studies reflected a broad heterogeneity. There were 17 different frailty screening methods. Of the frailty interventions, 23 involved physical activity and other interventions involved health education, nutrition supplementation, home visits, hormone supplementation, and counselling. A significant improvement of frailty status was demonstrated in 71% (n = 10) of studies and of frailty indicators in 69% (n=22) of studies where measured. Interventions with both muscle strength training and protein supplementation were consistently placed highest for effectiveness and ease of implementation. CONCLUSION: A combination of muscle strength training and protein supplementation was the most effective intervention to delay or reverse frailty and the easiest to implement in primary care. A map of interventions was created that can be used to inform choices for managing frailty.

Undertaking a Collaborative Rapid Realist Review to Investigate What Works in the Successful Implementation of a Frail Older Person's Pathway.

We addressed the research question "what factors enable the successful development and implementation of a frail older person's pathway within the acute setting". A rapid realist review (RRR) was conducted by adopting the RAMESES standards. We began with a sample of 232 articles via database searches supplemented with 94 additional records including inputs from a twitter chat and a hospital site visit. Our final sample consisted of 18 documents. Following review and consensus by an expert panel we identified a conceptual model of context-mechanism-(resources)-outcomes. There was overall agreement frailty should be identified at the front door of the acute hospital. Significant challenges identified related to organisational boundaries both within the acute setting and externally, the need to shift outcomes to patient orientated ones, to support staff to sustain the pathway by providing ongoing education and by providing role clarity. RRRs can support research such as the systematic approach to improving care for frail older adults (SAFE) study by producing accounts of what works based on a wide range of sources and innovative engagement with stakeholders. It is evident from our provisional model that numerous factors need to combine and interact to enable and sustain a successful frail older person's pathway.

The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person's pathway.

Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people's acute admissions. Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation. Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.

An evaluation of the performance of SCORE Sweden 2015 in estimating cardiovascular risk: The Northern Sweden MONICA Study 1999-2014.

BACKGROUND: Risk prediction models for cardiovascular death are important for providing advice on lifestyle and in decision-making regarding primary preventive drug treatment. The latest Swedish version of the Systematic COronary Risk Evaluation (SCORE 2015) has yet not been tested in the population. OBJECTIVE: The objective of this study was to estimate the prevalence of high and very high risk of fatal cardiovascular disease (CVD) of the current population according to 2015 SCORE Sweden and to evaluate the predictive accuracy of the 2003 Swedish version of SCORE (2003 SCORE Sweden) and 2015 SCORE Sweden in a population with declining CVD mortality. METHODS: We estimated the high and very high risk group for cardiovascular death for individuals 40-65 years of age in the 2014 Northern Sweden MONICA population survey excluding subjects with known diabetes or previous CVD (n = 813). Using the 1999 MONICA survey (n = 3347) followed up for 10 years for CVD mortality, we assessed the calibration of both 2003 and 2015 SCORE Sweden. RESULTS: In 2014 2.6% of the population was considered at high or very high risk for fatal CVD, 95% were men and 76% were in the age group 60-65 years. Including subjects with a single markedly elevated risk factor, known diabetes or CVD, 12% of the population was at high or very high risk. During 10 years of follow-up of the 1999 cohort, 34 CVD deaths (24 men and 10 women) occurred. The 2003 SCORE overestimated the risk of death from CVD (ratio predicted/observed 2.3, P < 0.001) whereas the 2015 SCORE slightly overestimated the number of deaths (predicted/observed 1.3, P = 0.12). The 2015 SCORE predicted more accurately than the 2003 SCORE the number of deaths in the different risk and age categories. CONCLUSION: The 2015 SCORE Sweden more adequately than 2003 SCORE Sweden predicts the number of deaths. In 2014, the proportion of high-risk individuals is small in northern Sweden. The main use of 2015 SCORE Sweden would therefore be as an educational tool between the physician and people without diabetes or CVD in a consultation regarding cardiovascular risk.