This article appeared in a journal published by Elsevier.

The attached copy is furnished to the author for internal non-commercial research and education use, including for instruction at the authors institution and sharing with colleagues. Other uses, including reproduction and distribution, or selling or licensing copies, or posting to personal, institutional or third party websites are prohibited. In most cases authors are permitted to post their version of the article (e.g. in Word or Tex form) to their personal website or institutional repository. Authors requiring further information regarding Elseviers archiving and manuscript policies are encouraged to visit: http://www.elsevier.com/copyright

Author's personal copy

Diabetes & Metabolic Syndrome: Clinical Research & Reviews 4 (2010) 5759

Contents lists available at ScienceDirect

Diabetes & Metabolic Syndrome: Clinical Research & Reviews

journal homepage: www.elsevier.com/locate/dsx

Brief communication

A clinical decision support system using multi-layer perceptron neural network to predict quality of life in diabetes
Manda R. Narasinga Rao a, G.R. Sridhar b,*, K. Madhu c, Allam Appa Rao d
a

Department of Computer Science and Engineering, Vignan Institute of Information Technology, Duvvada, Visakhapatnam, India Endocrine and Diabetes Center, 15-12-16, Krishnanagar, Visakhapatnam, India c Department of Psychology, Andhra University, Visakhapatnam, India d Jawaharlal Nehru Technological University Kakinada Kakinada Andhra Pradesh, India
b

A R T I C L E I N F O

A B S T R A C T

Keywords: MLP neural network Supervised learning Back propagation Type 2 diabetes Weight Fasting plasma glucose Satisfaction Impact and social and diabetes worry

Background: In diabetes mellitus, quality of life is recognized to be an integral outcome measure of management. We have developed a neural network system which is trained to predict the measurements of quality of life in diabetes, using data generated in real life. Methods: We developed a multi-layer perceptron neural network (NN) model, which had been trained by back propagation algorithm. Data was obtained from a cohort of 241 individuals with diabetes, which has been published. We used age, gender, weight, fasting plasma glucose as a set of inputs and predicted measures of quality of life (satisfaction, impact, social and diabetes worry). Results: Using the NN model, men reported signicantly higher levels of satisfaction with the treatment being provided to them than women. Women had greater social and diabetes worry. The results have been considered based on the observation of the normalized system error (NSE) values of the neural network and are consistent with results obtained from traditional statistical methods. Conclusion: We have developed a prototype neural network model to measure the quality of life in diabetes, when biological or biographical variables are given as inputs. 2009 Diabetes India. Published by Elsevier Ltd. All rights reserved.

1. Background Quality of life (QOL) is an integral outcome measure in the management of diabetes mellitus. It can be used to assess the results of different management methods, in relation to diabetic complications and in ne-tuning management methods [1]. A diabetes-specic, psychometrically validated QOL instrument has been used in different populations, including in India (Refs. [2 5]). Earlier we applied the instrument in south Indian subjects with diabetes and showed gender differences, with men having better QOL [3,9]. There have been few other reports that have generated data from Asian Indians [46]. Therefore in this presentation we have obtained the key variables (gender, age and fasting plasma glucose, body weight) and developed a neural network model (NN) to predict the QOL outcomes. NN is open ended; as more data is given to the model, the prediction would become more reliable.

2. Methods The DCCT quality of life questionnaire was employed, which measures the patients personal experience of diabetes care and treatment. Responses are obtained on a ve-point scale. Summing the responses to core items and dividing by the number of core items in the subscale obtains scores. Higher the score, better the QOL [1]. The input variables were either measured or were obtained from a psychometrically validated questionnaire on quality of life specically used in diabetes, where the specic attributed of terms satisfaction, impact and social and diabetes worry have been taken into consideraton [4,6,7]. Method of Korrapati was used to arrive at the variables [7]. We used the multi-layer perceptron (MLP) network models with back propagation in which weighted sum of inputs and bias term are passed to the activation level through the transfer function to produce the output [8]. The learning algorithm we have used is a generalized Delta learning rule. The units are arranged in layered feed forward topology [feed forward neural networks (FFNN)]. The schematic representation of feed forward, back propagated neural network with four inputs, 1 or more number of hidden layers with 6 neurons each and three output units in the output layer is given in Fig. 1. The sigmoid transfer function is

* Corresponding author. Tel.: +91 891 2566301. E-mail addresses: mrn702002@yahoo.co.in (M.R. Narasinga Rao), sridharvizag@gmail.com (G.R. Sridhar), mkosuri@sify.com (K. Madhu), apparaoallam@gmail.com (A.A. Rao).

1871-4021/$ see front matter 2009 Diabetes India. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dsx.2009.04.002

Author's personal copy

58 M.R. Narasinga Rao et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 4 (2010) 5759

Fig. 1. Feed forward neural network. The operation of the typical MLP with back propagation algorithm is given in Supplementary data.

Table 1 Comparison of neural network outcome with statistical outcome (gender vs. satisfaction, gender vs. impact, gender vs. social and diabetes worry). Variable Quality of life Satisfaction Mean SD Impact Mean SD Males (143) Females (101) t-Value NSE value for neural network (for males 143) NSE value for neural network (for females 101)

78.75 6.68

76.11 7.75

2.81

2860.55 (for 50 samples) 2955.55 (for 100 samples

2526.23 (for 50 samples) 2851.37 (for 100 samples)

78.41 5.68

77.45 5.62

1.34

2845.98 (for 50 samples) 2972.64 (for 100 samples)

2737.71 (for 50 samples) 2942.69 (for 100 samples)

Social and diabetes worry Mean 40.70 SD 1.95

40.90 1.69

0.63

767.97 (for 50 samples) 772.09 (for 100 samples)

764.36 (for 50 samples) 797.05 (for 100 samples)

chosen such that the algorithm requires a response function with a continuous, single valued with rst derivative existence [8]. These networks were trained in an iterative process. In this project, one or more hidden layers are considered for the purpose. The data was taken from earlier published work on 241 subjects with diabetes mellitus, who were assessed for a variety of psychological and social parameters, including quality of life [1]. The schematic representation of the neural network with an input layer, one or more number of hidden layers and an output layer is given (Fig. 1). 3. Results Gender differences are signicant with regard to satisfaction, impact, social and diabetes worry (Table 1). More specically, male patients report signicantly higher levels of satisfaction with the treatment being provided to them than their female counter parts. This has been proved both statistically and the neural network model by considering the normalized system error (NSE) values of the neural network. Also, males and females have been represented as one and two, respectively. Also, male patients report higher levels of impact than their female counter parts. This also has been proved both statistically and the neural network model by considering the normalized system error (NSE) values of the neural network.

Also, it is observed that, female diabetics reported poorer quality of life than their male counterparts. A comparison of these values has been given in the following tables given below. In Table 1, other variables of the neural network like momentum rate, learning rate, maximum total error, maximum individual error, maximum number of iterations, number of hidden layers, number of units in the hidden layer, number of samples have been taken as 0.9, 0.7, 0.01, 0.001, 5000, 3, 5, 50 or 100. Table 2 provides descriptive statistics of the psychosocial correlates, compared to the absolute mean values [3]. These calculations are for both males and females. Table 3 shows the comparison of males and females with regard to weight versus satisfaction. Here, number of hidden layers considered are three, number of units in hidden layer are ve, number of iterations are 5000 keeping the rest of the values of the
Table 2 Descriptive statistics of the psychosocial correlates (for both males and females). Variable Quality of life Satisfaction Impact Social and diabetes worry Minimum Maximum Mean SD

45.00 43.75 32.00

91.67 90.00 44.00

77.48 77.81 40.77

7.34 6.12 1.85

Author's personal copy

M.R. Narasinga Rao et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 4 (2010) 5759 Table 3 Gender difference (weight vs. satisfaction for both males and females). Mean weight Males 64.96 SD weight 11.10 No. of samples 50 100 50 100 NSE values of neural network (weight vs. satisfaction) 2860.55 2955.55 2526.23 2851.37 59

Females

58.76

9.70

Table 4 Gender difference (weight vs. impact for both males and females). Mean weight Males 64.96 SD weight 11.10 No. of samples 50 100 50 100 NSE values of NN (weight vs. impact) 2845.98 2972.64 2737.71 2942.69

Females

58.76

9.70

Table 5 Gender difference (weight vs. social and diabetes worry for both males and females). Mean weight Males 64.96 SD weight 11.10 No. of samples 50 100 50 100 NSE values of NN (weight vs. social and diabetes worry) 767.97 772.09 764.36 797.05

Females

58.76

9.70

variables of the neural network same as above. It is observed that, males who are having weight between 39 and 102 feel more satised with the treatment being provided to them than females who are having weight between 40 and 85. Table 4 shows the comparison of males and females with regard to weight versus impact. Here, number of hidden layers considered are three, number of units in hidden layer are ve, number of iterations are 5000 keeping the rest of the values of the variables of the neural network same as above. It is observed that, males who are having weight between 39 and 102 have more impact value than the females who are having weight between 40 and 85. Table 5 shows the variation of social and diabetes worry between males and females along with the weight values. These variations have been found basing on the NSE values of the neural network. Here, number of hidden layers considered are three, number of units in each hidden layer are 5 and number of iterations considered are 5000. The rest of the variables of the neural network are same as above. It is observed that females are leading with poorer quality of life than their male counter parts. 4. Discussion The multi-layer perceptron neural network model has been trained by back propagation algorithm to predict quality of life in diabetes mellitus using biographical and biological variables. Neural network models have been employed in a variety of other clinical medicine settings, but to our knowledge this is the rst time they are being used to predict quality of life in diabetes [10]. Unlike traditional statistical methods, the neural network model provides dynamic output as further data is fed to it. It does not require the skills and insight needed to perform and analyze sophisticated statistical methods. It is recognized that translational research is essential to bring knowledge gained from the bench to patient care; the development of our model is a practical tool to predict QOL variables based on biographical and biological variables. As more data are generated, the system improves in precision and can be more widely employed in patient care and research.

In summary we developed a NN model using the available information on psychological outcome (quality of life) demonstrated that it gave results, consistent with our recent application of the method to predict well-being [11]. Conict of interest: None. Financial disclosure: None.

Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.dsx.2009.04.002. References
[1] Sridhar GR, Madhu K. Psychosocial and cultural issues in diabetes mellitus. Curr Sci 2002;83:155664. [2] Jacobson AM. The Diabetes Control and Complications Trial Research Group. The diabetes quality of life measure. In: Bradley C, editor. Handbook of psychology and diabetes. Hardwood Academic Publication Switzerland; 1994 . p. 6587. [3] Sridhar GR, Madhu K, Veena S, Radha Madhavi P, Sangeetha B, Asha Rani S. Living with diabetes: Indian experience. Diab Met Syndr Clin Res Rev 2007;1:1817. [4] Shobhana R, Rama Rao P, Lavanya A, Padma C, Vijay V, Ramachandran A. Quality of life and diabetes integration among subjects with type 2 diabetes. J Assoc Physicians India 2003;51:3635. [5] Singh H, Bradley C. Quality of life in diabetes. Int J Diab Dev Countries 2006;26:10. [6] Varghese RT, Salini S, Abraham P, Reeshma KK, Vijaykumar K. Determinants of the quality of life among diabetic subjects in Kerala, India. Diab Met Syndr Clin Res Rev 2007;1:1739. [7] Korrapati RA. Methodology. In: Korrapati R, editor. A Bayesian model framework to determine patient compliance in Glaucoma cases. New York: Iuniverse Inc; 2000. pp. 1534. [8] Venkatesan P, Anitha S. Application of a radial basis function neural network for diagnosis of diabetes mellitus. Curr Sci 2006;91:11959. [9] Veena S, Madhu K, Sridhar GR. Gender differences in coping with type 2 diabetes mellitus. Int J Diab Dev Countries 2001;21:10311. [10] Papik K, Molnar B, Schaefer R, Dombovari Z, Tulassay Z, Feher J. Application of neural networks in medicinea review. Med Sci Mon 1998;4:53846. [11] Narasinga Rao MR, Sridhar GR, Madhu K, Rao AA. A Clinical Decision Support System Using Multilayer Perceptron Neural Network to Assess Well Being in Diabetes. J Assoc Physicians India 2009;57:12733.