Background: Screening principles differ by prevalence. For rare diseases, specificity prevents false alarms; for highly prevalent diseases, sensitivity prevents missed cases. India faces a dysglycemia epidemic with 101 million diabetes and 136 million prediabetes cases (ICMR-INDIAB). In our outpatient cohort, dysglycemia prevalence was 83.9%. In such settings, a false negative is costlier than a false positive, as confirmatory HbA1c is inexpensive and widely accessible.

Methods: Multicentric prospective observational study conducted across four geographic zones of India (South, North, West, East) in OPD setting. Total n=1054 adults >18 years underwent BRS-D scoring and HbA1c as the gold standard (Diabetes ≥6.5%, Prediabetes 5.7-6.4%, Normal <5.7%). 567 (53.8%) had diabetes, 317 (30.1%) prediabetes, and 170 (16.1%) normal. True dysglycemia burden was 884/1054 (83.9%). BRS-D high-risk defined as ≥4, was compared head-to-head with IDRS and ADA risk score for sensitivity, specificity, PPV, NPV, and accuracy

Results: BRS-D classified 91.3% of participants as high-risk, closely mirroring the true disease burden, and significantly outperformed IDRS and ADA with the highest sensitivity (92.65% vs 65.72% vs 46.38%) and accuracy (80.27% vs 63.85% vs 50.76%). It also missed far fewer true dysglycemia cases (false negative rate 7.35% vs 34.28% vs 53.62%), with a PPV of 85.14% confirming its efficiency for triage; performance was best in South India (sensitivity 96.21%, accuracy 84.31%).

Conclusion: For mass screening of a highly prevalent and silent disease, a high-sensitivity rule-out safety net approach is scientifically imperative. BRS-D, with 92.65% sensitivity and 80.27% accuracy, significantly outperforms IDRS and ADA scores. As a free, non-invasive, questionnaire-based tool requiring no blood test, BRS-D is ideal as a first-step population screening strategy to catch the silent epidemic before confirmatory HbA1c.

Mahesh D.M. completed his MBBS from Bangalore Medical College (2003), MD in General Medicine (2010), and DM in Endocrinology from Christian Medical College, Vellore (2014), followed by a DNB (Endo) in 2015. He currently serves as Senior Consultant Endocrinologist at Aster CMI Hospital, Bengaluru. His special interests include type 1 diabetes, diabetic foot, pituitary disorders, transgender medicine, and endocrine disorders in pregnancy. He has authored over 60 peer-reviewed publications and served as Principal Investigator for the LANDMARC study. He has been felicitated as one of the Top Endocrinologists in South India by India Today and Outlook (2022, 2024, 2025, 2026)