Dr.

Dharmendra Panchal
Dr. Sanjeev Phatak
Dr. Banshi Saboo
 WHAT IS BLUE INDEX ??

• BLUE INDEX has been coined to represent the

overall health of the patient with type 2 diabetes,
not only sugar control.
• Blue index consists of 2 parts: Diabetes Health Score and
Complications score
• The Diabetes Health Score enlists 10 parameters (A to J) of
importance in diabetes care each, which are graded on a 6
point(zero though 5) scale. The minimum possible score is zero,
and the maximum possible score is 50.
• The (K)Complications score (KS) consists of Cardio-Cerebral score
(C), Retino-Renal score(M), and Foot complications(F).
• The Blue Index is expressed as “DHS/KS (C_R_F_)”
• The choice of the name Blue is inspired by the colour of the
International Diabetes Federation logo, Unite for Diabetes.
 10 ITEMS
• A: A1C • F: FOLLOW UP
• B: BLOOD PRESSURE • G: GENERAL HEALTH
• C: CHOLESTEROL • H: HABITS
• D: DIET • I: INFECTION
• E: EXERCISE PREVENTION
• J: JEOPARDY OF
DIABETES
MANGEMENT

K: Komplications
Score 5 4 3 2 1 0 Score
A. Average blood sugar - hba1c
A1c At or below target 0.1-0.5% more than target 0.6-1% more than target 1.1-2.0 % more than target 2.1-4.0% off target >4.0% off target
A. Blood pressure (BP)
SBP 0-10 mmHg above target or 11-20 mmHg above target or 21-40 mmHg above target or >40 mmHg above target or
Normotensive At target with medicine
DBP 0-5 mmHg above target 6-10 mmHg above target 11-20 mmHg above target >20 mmHg above target
A. Cholesterol TG, LDL, non HDL
TG > 500 or
C No dyslipidemia All 3 at target with medicine One of the 3 above target Two of the 3 above target All 3 above target LDL > 190 or
Non HDL > 220
A. Diet*
D Fully adherent Mostly adherent Partially adherent Mostly non-adherent Totally non adherent Not willing
A. Exercise** ; aerobic/yoga- meditation /resistance
E Fully adherent Mostly adherent Partially adherent Mostly non - adherent Totally non-adherent Not willing
A. Follow up***: clinical, lab, SMBG
F Fully adherent Mostly adherent Partially adherent Mostly non adherent Totally non adherent Not willing or not able
General health*** Obesity, respiratory disease/OSA, mental stress/disease, malignancy, liver dysfunction/NAFLD, bone/joint problems, thyroid disorder, anemia
≥5/8 or ≥1 advanced disease*
G 0/8 1/8 2/8 3/8 4/8
condition
A. Habits****
Light smoker (<10) light Moderate smoker (10-20) Heavy (>20)
H Never Ex smoker Not willing
tobacco (<5) Tobacco (5-10) Tobacco ( >10)
A. Infection*****

Fully vaccinated and taking Partial vaccinated Not vaccinated Vaccinated (fully/partial)
Recurrent
I all precautions Taking precautions No precautions Precautions ± Recurrent severe
Non-severe
No infections No infections No infections Occasional infections

A. Jeopardy of Diabetes Management*****

Probable ADR Probable ADR
No ADR Documented ADR Documented severe ADR ADR / Hypo that needs
J LEVEL 1 LEVEL 1
No hypo LEVEL 2 LEVEL 3 hoospitalisation
Asymptomatic Symptomatic

Maximum Score: 50
A: Average Blood Glucose
5 4 3 2 1 0 FINAL SCORE
1.1-2.0 %
At or below 0.1-0.5% more 0.6-1% more 2.1-4.0% off >4.0% off
A1C more than
target than target than target target target
target

Target HbA1C is individualised as per clinical decision

 TARGET HbA1c
HbA1c <6.5 6.5-7.0 7.0-7.5 7.5-8.0 8.0-8.5
Age <35 35-65 >65
CKD (e GFR) >45 30-45 30-15 <15 or On RRT
>0.676, >0.676, Non-
NFS <-1.455 -1.45 – 0.676 Compansated Compansated
LVD (EF%) >50 35-50 35-15 <15
Absent
or Present, Present, Present,
ASCVD
Present, NYHA 2-3 NYHA 2-3 NYHA 4
NYHA 1
Hypo Risk Low Intermediate High High
Cognitive Mild to
impairment No Moderate Severe
Patient
Good Intermediate Poor Poor
efforts
Resource Enough Intermediate Poor Poor
 B: BLOOD PRESSURE
5 4 3 2 1 0 FINAL SCORE
0-10 mmHg 11-20 mmHg 21-40 mmHg >40 mmHg
SBP At target
above target or above target or above target or above target or
Normotensive with
0-5 mmHg 6-10 mmHg 11-20 mmHg >20 mmHg
DBP medicine
above target above target above target above target

Target BLOOD PRESSURE is the clinical decision.

 C: CHOLESTEROL
5 4 3 2 1 0

All 3 At Target TG > 500 or

All 3 At Target One Of The 3 Two Of The 3 All 3 Above
C Without LDL > 190 or
With Medicine Above Target Above Target Target
Medicine Non HDL > 220

• CHLOLESTEROL TARGETS
– LDL < 100
– NON HDL < 130
– TG < 150
LIPID TARGET
 D: Diet
5 4 3 2 1 0
Mostly Non- Totally Non
Fully Compliant Mostly Compliant Partially Compliant
Compliant Compliant

200-400 kcal 400-600 kcal

100-200 kcal >600 kcal
Total Calorie As per prescription more than more than
more than prescribed above prescribed Not
prescribed prescribed
willing
Composition to
change
Carbohydrate (%) <50 % 50-60% 60-70% 70-80% >80%
Meal Pattern
Major 3 3 2 2 1,2
Minor 2,3 1 1 0 0
 E: EXERCISE
5 4 3 2 1 0
Mostly Non- Totally Non
Fully Compliant Mostly Compliant Partially Compliant
Compliant Compliant
Aerobic activity
Low intensity >60 min or 30-60 min or 20-30 min or 20-30 min or <15 min
Not willing
Moderate intensity >30 min or 15-30 min or 10-15 min or 10-15 min or <10 min
to change
Vigorous intensity >15 min 10-15 min 5-10 min 5-10 min <5 min
Work related activity >15 min 10-15 min 5-10 min 0 0
Muscle strengthening
>15 min 10-15 min 5-10 min 0 0
exercise
 F: FOLLOW UP
5 4 3 2 1 0
Mostly Partially Mostly Non- Totally Non Not willing or
Fully Compliant
Compliant Compliant Compliant Compliant not able

As advised or at
At least once a
CLINIC least every 3 3 monthly 3-6 monthly 6-12 monthly >1 year
year
month

Less than Less than Less than

SMBG As advised never never
advised advised advised

Less than Less than Less than

LAB As advised As advised never
advised advised advised

MEDICATION
9-10 7-8 5-6 3-4 1-2 0
ADHERENCE

American Diabetes Association Standards of Medical Care in Diabetes 2018

One point for each no.
The total score ranges from 0-10 with a higher score indicating better
adherence
 G: GENERAL HEALTH
5 4 3 2 1 0
Co ≥5/8 or ≥1 advanced
0/8 1/8 2/8 3/8 4/8
morbidities disease* condition

1. Obesity: BMI ≥ 25 kg/m2

2. OSA: AHI ≥5 OR ESS ≥ 9
3. Chronic respiratory disease
4. Anemia Hb < 10 (female) and < 11 (male)
5. Thyroid disease: hypo or hyperthyroidism
6. Inadequate BONE HEALTH: OSTEOPOROSIS or NONTRAUMATIC FRACTURE
7. MENTAL HEALTH (Anxiety or Depression): Clinical decision
8. Liver dysfunction: liver enzyme ≥3 times upper normal limit or chronic liver
disease
*Advanced disease: disease which is a constant threat to life or requires
hospitalization at least ≥1 time in last 3 months
American Diabetes Association Standards of Medical Care in Diabetes 2017
 H: HABITS: SMOKING/TOBACCO
CHEWING
5 4 3 2 1 0

Light Smoker
Ex Smoker/ Moderate
(<10) Heavy (>20)
H Never Ex tobacco Smoker (10-20) Not willing
Light Tobacco Tobaco ( >10)
chewer Tobacco (5-10)
(<5)

Non-smoker: Patients who have never smoked more than 20 grams of tobacco in their
lifetime.
Ex-smoker: Patients who stopped smoking >=365 days ago.
Current smoker: Patients who smoke 1 or more tobacco products

Lifetime abstainers: Patients who have never drunk.

Former drinker: Patients who stopped drinking >=365 days ago. Consider a "drink" to be a can
or bottle of beer, a glass of wine, a wine cooler, or one cocktail or a shot of hard liquor (like
scotch, gin, or vodka)
Social drinker: Patients who drink alcohol chiefly on social occasions and only in moderate
quantities.
Heavy drinker: women who consume 8 or more drinks per week. And for men, 15 or more
drinks a week.
 I: INFECTION
5 4 3 2 1 0 FINAL SCORE
Fully Partial Vaccinated
vaccinated vaccinated Not Vaccinated (F/P)
Recurrent Recurrent
I and taking all Taking No precautions Precautions ±
non-severe severe
precautions precautions No infections Occasional
No infections No infections infections

Vaccination recommended: flu, pneumonia, hepatitis B

Occasional infection: Not >1 in last 6 months
Recurrent infections: ≥1 episodes in last 3 months
Severe infection: requires hospitalisation

American Diabetes Association Standards of Medical Care in Diabetes 2018

J: JEOPARDY of DIABETES MANAGEMENT
(hypoglycemia, Drug ADR)
5 4 3 2 1 0
Probable mild ADR needing Documented
ADR/ drug ADR needing Documented ADR / Hypo
No ADR
J LEVEL 1 modification/ drug severe ADR/ requiring
No hypo hospitalisation
Symptomatic LEVEL 1 discont../ LEVEL 3
hypo Asymptomatic LEVEL 2

Standard of care ADA 2018

 HYPOGLYCEMIA RISK SCORE

1 2 3
h/o hypo in last 12 month 0 1-2 3 or more
h/o hypo in last 3 month 0 1-2 3 or more
Insulin No Basal only Basal – Bolus or premix
SU No Yes Yes
e GFR >60 45-60 <45
Age 18-35 35-70 >70

Score: < 6 : Low; > 18 high; 6-18 = Intermediate

Score 5 4 3 2 1 0 Score
A. Average blood sugar - hba1c
0.1-0.5% more than 0.6-1% more than 1.1-2.0 % more than
A1c At or below target 2.1-4.0% off target >4.0% off target
target target target
A. Blood pressure (BP)
0-10 mmHg above 11-20 mmHg above 21-40 mmHg above target >40 mmHg above target
SBP
At target with target or target or or or
Normotensive
medicine 0-5 mmHg above 6-10 mmHg above
DBP 11-20 mmHg above target >20 mmHg above target
target target
A. Cholesterol TG, LDL, non HDL
TG > 500 or
All 3 at target with One of the 3 above Two of the 3 above
C No dyslipidemia All 3 above target LDL > 190 or
medicine target target
Non HDL > 220
A. Diet*
D Fully adherent Mostly adherent Partially adherent Mostly non-adherent Totally non adherent Not willing
A. Exercise** ; aerobic/yoga- meditation /resistance
E Fully adherent Mostly adherent Partially adherent Mostly non - adherent Totally non-adherent Not willing
A. Follow up***: clinical, lab, SMBG
F Fully adherent Mostly adherent Partially adherent Mostly non adherent Totally non adherent Not willing or not able
General health*** Obesity, respiratory disease/OSA, mental stress/disease, malignancy, liver dysfunction/NAFLD, bone/joint problems, thyroid disorder, anemia
≥5/8 or ≥1 advanced
G 0/8 1/8 2/8 3/8 4/8
disease* condition
A. Habits****
Moderate smoker (10-
Light smoker (<10) Heavy (>20)
H Never Ex smoker 20) Not willing
light tobacco (<5) Tobacco ( >10)
Tobacco (5-10)
A. Infection*****
Vaccinated
Fully vaccinated and Partial vaccinated Not vaccinated
(fully/partial) Recurrent
I taking all precautions Taking precautions No precautions Recurrent severe
Precautions ± Non-severe
No infections No infections No infections
Occasional infections
A. Jeopardy of Diabetes Management*****
Probable ADR Probable ADR Documented severe
No ADR Documented ADR ADR / Hypo that needs
J LEVEL 1 LEVEL 1 ADR
No hypo LEVEL 2 hoospitalisation
Asymptomatic Symptomatic LEVEL 3

Maximum Score: 50
KOMPLICATIONS
CARDIO-CEREBRAL
0 1 2 3 4 5
Chest pain or
Optimally Partially Borderline Treated
CARDIOVASCULAR Evaluated And Evaluated And Abnormal & disease NYHA 2-3 dyspnea of
NYHA CLASSS 4
Normal Normal Asymptomatic NYHA 1 or EF < 30%
Borderline Disability Disability
Optimally Partially Abnormal / h/o TIA limiting ADL limiting ADL
CEREBROVASCULAR Evaluated And Evaluated And carotid bruit & not more than
Normal Normal Asymptomatic No disability 25% OF more than 25%
OF NORMAL
NORMAL

Standard of care ADA 2018

IDF Diabetes foot CPR 2017
 RETINO-RENAL
0 1 2 3 4 5
KIDNEY
e-GFR ≥60 ≥90 60-89 30-59 15-29 <15
UACR
<30 ≥30 ≥30 ≥30 ≥30 ≥30
mg/G Cr
ST DR or
Mild-Mod Severe any
EYES No DR No DR PDR
NPDR NPDR untreated
DR

Standard of care ADA 2018

J Diabetes Invest 2015; 6: 242–246 doi:10.1111/jdi.12319
 FOOT COMPLICATIONS
SCORE LOPS PAD DFS
0 - - -
1 + - -
2 + + -
3 +/- ± Deformity or Onychomycosis or p/h/o DFU or neuropathic
fracture
4 +/- ± Active DFS
5 amputaion

IDF Diabetes foot CPR 2017

 KOMPLICATIONS Score
• C: (Cardio-Cerebral):
• R: Retino-Renal:
• F: Foot:

• Blue Index  DHS/KS

 STRENGTH
 Continuous patient education and Motivation
 Strong tool for holistic evaluation of disease status, complications and
overall health
 Comprehensive coverage of
 Glucose control,
 Vasculo-metabolic health,
 General health.
 Equal weightage to patient efforts and treatment targets
 Respectful of
 WHO definition of health
 Bio psychosocial model of health
 Patient-centred approach
 UTILITY
 To assess current diabetes care
 To assess trends in diabetes care
 To identify persons who need intensive intervention
 To identify specific areas of health which need intensive
intervention
 To serve as positive motivational tool
 To serve as teaching tool
• Blue Index—The Diabetes Health Score. Dharmendra Panchal et al. Diabetes Jul 2018, 67 (Supplement 1) 1327-
P; DOI: 10.2337/db18-1327-P

• The Blue Index – A Comprehensive Diabetes Assessment Score. Sanjeev Phatak et al. JCD VOL 5 NO. 2 JUL - SEP
2018 1-5