{
  "engine": {
    "id": "cpe-002",
    "code": "CPE-002",
    "name": "Insulin Resistance–Associated Metabolic Pattern Engine",
    "version": "1.0.0",
    "url": "https://biod.ai/tools/metabolic",
    "status": "Specification v1.0.0. Sandbox rules are disabled by default. Reviewed by Dr. Vinicius Amaral, D.O. Not for clinical production use."
  },
  "notice": "Clinical decision support for licensed clinicians. Synthetic-data demonstration. Not FDA cleared. Physician adjudication required.",
  "rules": [
    {
      "id": "VALIDITY-001",
      "name": "Pregnancy Routing",
      "group": "Validity and context",
      "status": "active",
      "classification": "Priority 1",
      "summary": "Pregnancy Routing. Fires when pregnancy_status IN ['confirmed','probable'].",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "pregnancy_status IN ['confirmed','probable']"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "ROUTE_TO_PREGNANCY_GLYCEMIC_PATHWAY"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "interpretation validity state = VALIDITY-OUT-OF-SCOPE"
          ]
        },
        {
          "heading": "Suppresses",
          "items": [
            "STANDARD ADULT RUNTIME"
          ]
        }
      ],
      "evidence": [
        "EV-ADA-2026-DIAG"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/validity-001"
    },
    {
      "id": "VALIDITY-002",
      "name": "Fasting Required for Insulin Pattern",
      "group": "Validity and context",
      "status": "active",
      "classification": "Priority 2",
      "summary": "Fasting Required for Insulin Pattern. Fires when fasting_insulin IS NOT NULL AND fasting_confirmed is not true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "fasting_insulin IS NOT NULL AND fasting_confirmed != true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "FASTING_STATUS_NOT_CONFIRMED"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "interpretation validity state = VALIDITY-LIMITED"
          ]
        },
        {
          "heading": "Suppresses",
          "items": [
            "HOMA IR INTERPRETATION",
            "IRP PATTERN RULES"
          ]
        }
      ],
      "evidence": [
        "EV-NIDDK-IR"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/validity-002"
    },
    {
      "id": "VALIDITY-003",
      "name": "Treated Metabolic State",
      "group": "Validity and context",
      "status": "active",
      "classification": "Priority 2",
      "summary": "Treated Metabolic State. Fires when metformin_active OR glp1_ra_active OR gip_glp1_active OR glucose_lowering_medication_active.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "metformin_active OR glp1_ra_active OR gip_glp1_active OR glucose_lowering_medication_active"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "TREATED_METABOLIC_STATE_PRESENT"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "interpretation validity state = VALIDITY-MODIFIED"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/validity-003"
    },
    {
      "id": "VALIDITY-004",
      "name": "Exogenous Insulin or Secretagogue Suppression",
      "group": "Validity and context",
      "status": "active",
      "classification": "Priority 2",
      "summary": "Exogenous Insulin or Secretagogue Suppression. Fires when insulin_therapy_active OR insulin_secretagogue_active.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "insulin_therapy_active OR insulin_secretagogue_active"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "INSULIN_MEASUREMENT_NOT_INTERPRETABLE_FOR_BASELINE_PATTERN"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "interpretation validity state = VALIDITY-LIMITED"
          ]
        },
        {
          "heading": "Suppresses",
          "items": [
            "FASTING INSULIN PATTERN CLASSIFICATION",
            "HOMA IR PATTERN CLASSIFICATION"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/validity-004"
    },
    {
      "id": "A1C-REL-001",
      "name": "HbA1c Reliability Limitation",
      "group": "Validity and context",
      "status": "active",
      "classification": "Priority 2",
      "summary": "HbA1c Reliability Limitation. Fires when a1c_interference_present is true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "a1c_interference_present == true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "A1C_RELIABILITY_LIMITATION_PRESENT"
          ]
        },
        {
          "heading": "Suppresses",
          "items": [
            "A1C AS SOLE BASIS FOR CLASSIFICATION"
          ]
        }
      ],
      "evidence": [
        "EV-NGSP-A1C"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/a1c-rel-001"
    },
    {
      "id": "SAFE-GLY-001",
      "name": "Diabetes-Range Laboratory Finding",
      "group": "Safety alerts",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Diabetes-Range Laboratory Finding. Fires when (hemoglobin_a1c at or above 6.5 AND a1c_interference_present is not true) OR (fasting_plasma_glucose at or above 126 AND fasting_confirmed) OR (ogtt_75g_glucose_2h at or above 200 AND ogtt_protocol_confirmed).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "(hemoglobin_a1c >= 6.5 AND a1c_interference_present != true) OR (fasting_plasma_glucose >= 126 AND fasting_confirmed) OR (ogtt_75g_glucose_2h >= 200 AND ogtt_protocol_confirmed)"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "DIABETES_RANGE_FINDING_REQUIRES_PHYSICIAN_REVIEW"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "glycemic state = GLY-DIABETES-RANGE",
            "safety state = SAFE-PRIORITY-REVIEW"
          ]
        }
      ],
      "evidence": [
        "EV-ADA-2026-DIAG"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/safe-gly-001"
    },
    {
      "id": "SAFE-GLY-002",
      "name": "Symptomatic Random Glucose Finding",
      "group": "Safety alerts",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Symptomatic Random Glucose Finding. Fires when random_plasma_glucose at or above 200 AND classic_hyperglycemia_symptoms_or_crisis is true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "random_plasma_glucose >= 200 AND classic_hyperglycemia_symptoms_or_crisis == true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "SYMPTOMATIC_DIABETES_RANGE_FINDING"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "glycemic state = GLY-DIABETES-RANGE",
            "safety state = SAFE-PRIORITY-REVIEW"
          ]
        }
      ],
      "evidence": [
        "EV-ADA-2026-DIAG"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/safe-gly-002"
    },
    {
      "id": "SAFE-DM-TYPE-001",
      "name": "Possible T1D or LADA Review",
      "group": "Safety alerts",
      "status": "active",
      "classification": "Priority 1",
      "summary": "Possible T1D or LADA Review. Fires when glycemic_state is 'GLY-DIABETES-RANGE' AND (rapid_unintentional_weight_loss OR ketones is 'positive' OR classic_hyperglycemia_symptoms_or_crisis).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "glycemic_state == 'GLY-DIABETES-RANGE' AND (rapid_unintentional_weight_loss OR ketones == 'positive' OR classic_hyperglycemia_symptoms_or_crisis)"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "POSSIBLE_T1D_OR_LADA_REVIEW"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "safety state = SAFE-URGENT-REVIEW"
          ]
        },
        {
          "heading": "Suppresses",
          "items": [
            "INSULIN RESISTANCE PRIMARY FRAMING"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/safe-dm-type-001"
    },
    {
      "id": "SAFE-HYPO-001",
      "name": "Hypoglycemia with Inappropriate Insulin Concern",
      "group": "Safety alerts",
      "status": "active",
      "classification": "Priority 1",
      "summary": "Hypoglycemia with Inappropriate Insulin Concern. Fires when event_glucose_low is true AND inappropriate_insulin_during_event is true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "event_glucose_low == true AND inappropriate_insulin_during_event == true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "HYPERINSULINEMIC_HYPOGLYCEMIA_PATHWAY_REVIEW"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "safety state = SAFE-URGENT-REVIEW"
          ]
        },
        {
          "heading": "Suppresses",
          "items": [
            "IRP PATTERN RULES"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/safe-hypo-001"
    },
    {
      "id": "SAFE-TG-001",
      "name": "Severe Hypertriglyceridemia",
      "group": "Safety alerts",
      "status": "active",
      "classification": "Priority 3",
      "summary": "Severe Hypertriglyceridemia. Fires when triglycerides at or above 500.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "triglycerides >= 500"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "SEVERE_HYPERTRIGLYCERIDEMIA_PANCREATITIS_RISK_REVIEW"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "safety state = SAFE-PRIORITY-REVIEW"
          ]
        }
      ],
      "evidence": [
        "EV-ACC-TG-2021"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/safe-tg-001"
    },
    {
      "id": "SAFE-TG-002",
      "name": "Very Severe Hypertriglyceridemia",
      "group": "Safety alerts",
      "status": "active",
      "classification": "Priority 1",
      "summary": "Very Severe Hypertriglyceridemia. Fires when triglycerides at or above 1000.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "triglycerides >= 1000"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "VERY_SEVERE_HYPERTRIGLYCERIDEMIA_REQUIRES_URGENT_REVIEW"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "safety state = SAFE-URGENT-REVIEW"
          ]
        }
      ],
      "evidence": [
        "EV-ACC-TG-2021"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/safe-tg-002"
    },
    {
      "id": "GLY-001",
      "name": "No Dysglycemia Criterion Identified",
      "group": "Glycemic state",
      "status": "active",
      "classification": "Priority 4",
      "summary": "No Dysglycemia Criterion Identified. Fires when at_least_one_interpretable_glycemic_test AND no_prediabetes_or_diabetes_range_criterion.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "at_least_one_interpretable_glycemic_test AND no_prediabetes_or_diabetes_range_criterion"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "NO_GLYCEMIC_CRITERION_FOR_PREDIABETES_OR_DIABETES_IDENTIFIED"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "glycemic state = GLY-NO-DYSGLYCEMIA-CRITERION-IDENTIFIED"
          ]
        }
      ],
      "evidence": [
        "EV-ADA-2026-DIAG"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/gly-001"
    },
    {
      "id": "GLY-002",
      "name": "Prediabetes by FPG",
      "group": "Glycemic state",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Prediabetes by FPG. Fires when fasting_plasma_glucose at or above 100 AND fasting_plasma_glucose at or below 125 AND fasting_confirmed.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "fasting_plasma_glucose >= 100 AND fasting_plasma_glucose <= 125 AND fasting_confirmed"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "PREDIABETES_FPG_CRITERION_MET"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "glycemic state = GLY-PREDIABETES"
          ]
        }
      ],
      "evidence": [
        "EV-ADA-2026-DIAG"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/gly-002"
    },
    {
      "id": "GLY-003",
      "name": "Prediabetes by A1C",
      "group": "Glycemic state",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Prediabetes by A1C. Fires when hemoglobin_a1c at or above 5.7 AND hemoglobin_a1c at or below 6.4 AND a1c_interference_present is not true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "hemoglobin_a1c >= 5.7 AND hemoglobin_a1c <= 6.4 AND a1c_interference_present != true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "PREDIABETES_A1C_CRITERION_MET"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "glycemic state = GLY-PREDIABETES"
          ]
        }
      ],
      "evidence": [
        "EV-ADA-2026-DIAG"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/gly-003"
    },
    {
      "id": "GLY-004",
      "name": "Prediabetes by IGT",
      "group": "Glycemic state",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Prediabetes by IGT. Fires when ogtt_75g_glucose_2h at or above 140 AND ogtt_75g_glucose_2h at or below 199 AND ogtt_protocol_confirmed.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "ogtt_75g_glucose_2h >= 140 AND ogtt_75g_glucose_2h <= 199 AND ogtt_protocol_confirmed"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "PREDIABETES_IGT_CRITERION_MET"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "glycemic state = GLY-PREDIABETES"
          ]
        }
      ],
      "evidence": [
        "EV-ADA-2026-DIAG"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/gly-004"
    },
    {
      "id": "METS-COMP-001",
      "name": "Waist Component",
      "group": "Metabolic syndrome",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Waist Component. Fires when waist_circumference_cm at or above configured_waist_threshold.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "waist_circumference_cm >= configured_waist_threshold"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "METS_WAIST_COMPONENT_MET"
          ]
        }
      ],
      "evidence": [
        "EV-METS-2009"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/mets-comp-001"
    },
    {
      "id": "METS-COMP-002",
      "name": "Triglyceride Component",
      "group": "Metabolic syndrome",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Triglyceride Component. Fires when triglycerides at or above 150 OR qualifying_tg_treatment_active.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "triglycerides >= 150 OR qualifying_tg_treatment_active"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "METS_TG_COMPONENT_MET"
          ]
        }
      ],
      "evidence": [
        "EV-METS-2009"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/mets-comp-002"
    },
    {
      "id": "METS-COMP-003",
      "name": "HDL Component",
      "group": "Metabolic syndrome",
      "status": "active",
      "classification": "Priority 5",
      "summary": "HDL Component. Fires when (sex_for_threshold_application is 'male' AND hdl_cholesterol below 40) OR (sex_for_threshold_application is 'female' AND hdl_cholesterol below 50).",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "(sex_for_threshold_application == 'male' AND hdl_cholesterol < 40) OR (sex_for_threshold_application == 'female' AND hdl_cholesterol < 50)"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "METS_HDL_COMPONENT_MET"
          ]
        }
      ],
      "evidence": [
        "EV-METS-2009"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/mets-comp-003"
    },
    {
      "id": "METS-COMP-004",
      "name": "Blood Pressure Component",
      "group": "Metabolic syndrome",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Blood Pressure Component. Fires when systolic_bp_mmhg at or above 130 OR diastolic_bp_mmhg at or above 85 OR antihypertensive_medication_active.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "systolic_bp_mmhg >= 130 OR diastolic_bp_mmhg >= 85 OR antihypertensive_medication_active"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "METS_BP_COMPONENT_MET"
          ]
        }
      ],
      "evidence": [
        "EV-METS-2009"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/mets-comp-004"
    },
    {
      "id": "METS-COMP-005",
      "name": "Glucose Component",
      "group": "Metabolic syndrome",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Glucose Component. Fires when (fasting_plasma_glucose at or above 100 AND fasting_confirmed) OR glucose_lowering_medication_active.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "(fasting_plasma_glucose >= 100 AND fasting_confirmed) OR glucose_lowering_medication_active"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "METS_GLUCOSE_COMPONENT_MET"
          ]
        }
      ],
      "evidence": [
        "EV-METS-2009"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/mets-comp-005"
    },
    {
      "id": "METS-001",
      "name": "Metabolic Syndrome Criteria Met",
      "group": "Metabolic syndrome",
      "status": "active",
      "classification": "Priority 5",
      "summary": "Metabolic Syndrome Criteria Met. Fires when metabolic_syndrome_components_met_count at or above 3.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "metabolic_syndrome_components_met_count >= 3"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "METABOLIC_SYNDROME_CRITERIA_MET"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "metabolic syndrome state = METS-CRITERIA-MET"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not independently confirm insulin resistance."
          ]
        }
      ],
      "evidence": [
        "EV-METS-2009"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/mets-001"
    },
    {
      "id": "LIPID-002",
      "name": "Atherogenic Dyslipidemia Supporting Pattern",
      "group": "Lipid patterns",
      "status": "active",
      "classification": "Priority 6",
      "summary": "Atherogenic Dyslipidemia Supporting Pattern. Fires when triglycerides at or above 150 AND low_hdl_by_sex_threshold is true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "triglycerides >= 150 AND low_hdl_by_sex_threshold == true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "ATHEROGENIC_DYSLIPIDEMIA_SUPPORTING_PATTERN"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not diagnose insulin resistance."
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/lipid-002"
    },
    {
      "id": "CLIN-001",
      "name": "Acanthosis Screening Trigger",
      "group": "Clinical modifiers",
      "status": "active",
      "classification": "Priority 6",
      "summary": "Acanthosis Screening Trigger. Fires when acanthosis_nigricans_confirmed is true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "acanthosis_nigricans_confirmed == true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "HIGH_PRIORITY_METABOLIC_SCREENING_OPPORTUNITY"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not confirm hyperinsulinemia or insulin resistance."
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/clin-001"
    },
    {
      "id": "CLIN-002",
      "name": "Family History Modifier",
      "group": "Clinical modifiers",
      "status": "active",
      "classification": "Priority 7",
      "summary": "Family History Modifier. Fires when first_degree_family_history_t2d is true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "first_degree_family_history_t2d == true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "FIRST_DEGREE_T2D_FAMILY_HISTORY_PRESENT"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/clin-002"
    },
    {
      "id": "CLIN-003",
      "name": "Prior Gestational Diabetes Modifier",
      "group": "Clinical modifiers",
      "status": "active",
      "classification": "Priority 7",
      "summary": "Prior Gestational Diabetes Modifier. Fires when history_of_gestational_diabetes is true AND pregnancy_status NOT IN ['confirmed','probable'].",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "history_of_gestational_diabetes == true AND pregnancy_status NOT IN ['confirmed','probable']"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "PRIOR_GESTATIONAL_DIABETES_HIGH_RISK_MODIFIER"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/clin-003"
    },
    {
      "id": "CLIN-004",
      "name": "PCOS Modifier",
      "group": "Clinical modifiers",
      "status": "active",
      "classification": "Priority 7",
      "summary": "PCOS Modifier. Fires when pcos_documented is true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "pcos_documented == true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "PCOS_METABOLIC_RISK_MODIFIER_PRESENT"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/clin-004"
    },
    {
      "id": "CROSS-MASLD-001",
      "name": "MASLD/Liver Review Trigger",
      "group": "Cross-engine triggers",
      "status": "active",
      "classification": "Priority 7",
      "summary": "MASLD/Liver Review Trigger. Fires when documented_hepatic_steatosis OR persistent_alt_elevation_with_cardiometabolic_context.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "documented_hepatic_steatosis OR persistent_alt_elevation_with_cardiometabolic_context"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "MASLD_OR_LIVER_RISK_REVIEW"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not diagnose MASLD or insulin resistance by itself."
          ]
        }
      ],
      "evidence": [
        "EV-AASLD-MASLD"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/cross-masld-001"
    },
    {
      "id": "CROSS-MASLD-002",
      "name": "FIB-4 Routing",
      "group": "Cross-engine triggers",
      "status": "active",
      "classification": "Priority 7",
      "summary": "FIB-4 Routing. Fires when liver_risk_review_indicated AND fib4_index at or above 1.3.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "liver_risk_review_indicated AND fib4_index >= 1.3"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "SECONDARY_FIBROSIS_RISK_ASSESSMENT_CONSIDERATION"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Interpret within hepatic pathway only."
          ]
        }
      ],
      "evidence": [
        "EV-AASLD-MASLD"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/cross-masld-002"
    },
    {
      "id": "CROSS-CV-001",
      "name": "Cardiovascular Risk Review",
      "group": "Cross-engine triggers",
      "status": "active",
      "classification": "Priority 7",
      "summary": "Cardiovascular Risk Review. Fires when metabolic_syndrome_state is 'METS-CRITERIA-MET' OR atherogenic_dyslipidemia_supporting_pattern.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "metabolic_syndrome_state == 'METS-CRITERIA-MET' OR atherogenic_dyslipidemia_supporting_pattern"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "CARDIOVASCULAR_RISK_REVIEW"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/cross-cv-001"
    },
    {
      "id": "MISS-001",
      "name": "Insulin Pattern Missing Data",
      "group": "Missing data",
      "status": "active",
      "classification": "Priority 8",
      "summary": "Insulin Pattern Missing Data. Fires when fasting_insulin IS NULL.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "fasting_insulin IS NULL"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "IR_PATTERN_NOT_FULLY_ASSESSABLE_WITH_CURRENT_DATA"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/miss-001"
    },
    {
      "id": "MISS-002",
      "name": "Metabolic Syndrome Incomplete Data",
      "group": "Missing data",
      "status": "active",
      "classification": "Priority 8",
      "summary": "Metabolic Syndrome Incomplete Data. Fires when one_or_more_mets_components_missing AND metabolic_syndrome_components_met_count below 3.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "one_or_more_mets_components_missing AND metabolic_syndrome_components_met_count < 3"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "METABOLIC_SYNDROME_ASSESSMENT_INCOMPLETE"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/miss-002"
    },
    {
      "id": "MED-001",
      "name": "Systemic Corticosteroid Dysglycemia Modifier",
      "group": "Validity and context",
      "status": "active",
      "classification": "Priority 2",
      "summary": "Systemic Corticosteroid Dysglycemia Modifier. Fires when systemic_corticosteroid_active_or_recent is true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "systemic_corticosteroid_active_or_recent == true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "POSSIBLE_DRUG_ASSOCIATED_DYSGLYCEMIA"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "interpretation validity state = VALIDITY-MODIFIED"
          ]
        },
        {
          "heading": "Suppresses",
          "items": [
            "ATTRIBUTION OF DYSGLYCEMIA TO BASELINE IR ALONE"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/med-001"
    },
    {
      "id": "CTX-ATHLETE-001",
      "name": "Athlete Physiology Context Modifier",
      "group": "Clinical modifiers",
      "status": "active",
      "classification": "Priority 7",
      "summary": "Athlete Physiology Context Modifier. Fires when endurance_athlete_or_high_training_load is true.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "endurance_athlete_or_high_training_load == true"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "ATHLETE_PHYSIOLOGY_CONTEXT_PRESENT"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not suppress ADA-defined glycemic findings."
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/ctx-athlete-001"
    },
    {
      "id": "GLY-005",
      "name": "Discordant Glycemic Test Results",
      "group": "Glycemic state",
      "status": "active",
      "classification": "Priority 4",
      "summary": "Discordant Glycemic Test Results. Fires when two_or_more_interpretable_glycemic_tests_available AND glycemic_classifications_discordant.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "two_or_more_interpretable_glycemic_tests_available AND glycemic_classifications_discordant"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "GLYCEMIC_RESULTS_REQUIRE_CLINICAL_RECONCILIATION"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "interpretation validity state = VALIDITY-MODIFIED"
          ]
        }
      ],
      "evidence": [
        "EV-ADA-2026-DIAG",
        "EV-NGSP-A1C"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/gly-005"
    },
    {
      "id": "LIPID-001",
      "name": "TG to HDL Ratio Informational Calculation",
      "group": "Lipid patterns",
      "status": "active",
      "classification": "Priority 9",
      "summary": "TG to HDL Ratio Informational Calculation. Fires when triglycerides IS NOT NULL AND hdl_cholesterol IS NOT NULL AND hdl_cholesterol above 0.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "triglycerides IS NOT NULL AND hdl_cholesterol IS NOT NULL AND hdl_cholesterol > 0"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "TG_HDL_RATIO_CALCULATED"
          ]
        },
        {
          "heading": "Note",
          "items": [
            "Classification effect: none until validated"
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/lipid-001"
    },
    {
      "id": "IRP-001",
      "name": "Metabolic Screening Opportunity",
      "group": "Insulin-resistance–associated pattern",
      "status": "active",
      "classification": "Priority 6",
      "summary": "Metabolic Screening Opportunity. Fires when acanthosis_nigricans_confirmed OR metabolic_syndrome_state is 'METS-CRITERIA-MET' OR first_degree_family_history_t2d OR history_of_gestational_diabetes OR pcos_documented OR atherogenic_dyslipidemia_supporting_pattern.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "acanthosis_nigricans_confirmed OR metabolic_syndrome_state == 'METS-CRITERIA-MET' OR first_degree_family_history_t2d OR history_of_gestational_diabetes OR pcos_documented OR atherogenic_dyslipidemia_supporting_pattern"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "METABOLIC_SCREENING_OPPORTUNITY_IDENTIFIED"
          ]
        },
        {
          "heading": "States it sets",
          "items": [
            "ir associated pattern state = IRP-SCREENING-OPPORTUNITY"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Risk context identified; insulin resistance is not diagnosed."
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/irp-001"
    },
    {
      "id": "MISS-003",
      "name": "Medication Context Missing",
      "group": "Missing data",
      "status": "active",
      "classification": "Priority 8",
      "summary": "Medication Context Missing. Fires when active_medication_list_available is false.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "active_medication_list_available == false"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "MEDICATION_CONTEXT_NOT_AVAILABLE"
          ]
        },
        {
          "heading": "Note",
          "items": [
            "Medication-related modification of glucose, insulin or lipids cannot be excluded."
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/miss-003"
    },
    {
      "id": "IRP-002",
      "name": "Hyperinsulinemic Supporting Pattern",
      "group": "Insulin-resistance–associated pattern",
      "status": "sandbox",
      "classification": "Sandbox — disabled by default",
      "summary": "Hyperinsulinemic Supporting Pattern. Fires when fasting_insulin above validated_institutional_or_assay_specific_threshold.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "fasting_insulin > validated_institutional_or_assay_specific_threshold"
          ]
        },
        {
          "heading": "Required before it can be enabled",
          "items": [
            "Assay specific threshold profile",
            "External endocrinology validation",
            "Fasting confirmed",
            "No insulin or secretagogue interference"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "HYPERINSULINEMIC_SUPPORTING_PATTERN_IDENTIFIED"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not independently establish insulin resistance."
          ]
        }
      ],
      "evidence": [
        "EV-NIDDK-IR"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/irp-002"
    },
    {
      "id": "IRP-003",
      "name": "Elevated HOMA-IR Supporting Finding",
      "group": "Insulin-resistance–associated pattern",
      "status": "sandbox",
      "classification": "Sandbox — disabled by default",
      "summary": "Elevated HOMA-IR Supporting Finding. Fires when homa_ir above validated_configured_support_threshold.",
      "sections": [
        {
          "heading": "Condition",
          "items": [
            "homa_ir > validated_configured_support_threshold"
          ]
        },
        {
          "heading": "Required before it can be enabled",
          "items": [
            "Validated homa ir support threshold profile",
            "Fasting confirmed",
            "Same collection episode",
            "No insulin or secretagogue interference"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "ELEVATED_HOMA_IR_SUPPORTING_FINDING"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Does not independently establish insulin resistance."
          ]
        }
      ],
      "evidence": [
        "EV-NIDDK-IR"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/irp-003"
    },
    {
      "id": "IRP-004",
      "name": "Convergent IR-Associated Pattern",
      "group": "Insulin-resistance–associated pattern",
      "status": "sandbox",
      "classification": "Sandbox — disabled by default",
      "summary": "Convergent IR-Associated Pattern. Research rule, disabled in production until externally validated.",
      "sections": [
        {
          "heading": "Required before it can be enabled",
          "items": [
            "IRP-002 OR IRP-003 triggered",
            "One or more corroborating metabolic findings",
            "External validation"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "PATTERN_COMPATIBLE_WITH_INSULIN_RESISTANCE_ASSOCIATED_METABOLIC_DYSFUNCTION"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Pattern detection only; no autonomous diagnosis of insulin resistance."
          ]
        }
      ],
      "evidence": [
        "EV-NIDDK-IR"
      ],
      "url": "https://biod.ai/tools/metabolic/rules/irp-004"
    },
    {
      "id": "TREND-MET-001",
      "name": "Composite Metabolic Deterioration Warning",
      "group": "Longitudinal (sandbox)",
      "status": "sandbox",
      "classification": "Sandbox — disabled by default",
      "summary": "Composite Metabolic Deterioration Warning. Research rule, disabled in production until externally validated.",
      "sections": [
        {
          "heading": "Required before it can be enabled",
          "items": [
            "Longitudinal comparability protocol",
            "Alert fatigue validation",
            "Treatment context tracking"
          ]
        },
        {
          "heading": "Output",
          "items": [
            "LONGITUDINAL_METABOLIC_DETERIORATION_WARNING"
          ]
        },
        {
          "heading": "Diagnostic boundary",
          "items": [
            "Trajectory signal only; not etiology or treatment recommendation."
          ]
        }
      ],
      "evidence": [],
      "url": "https://biod.ai/tools/metabolic/rules/trend-met-001"
    }
  ],
  "evidence": [
    {
      "id": "EV-ADA-2026-DIAG",
      "citation": "American Diabetes Association Professional Practice Committee for Diabetes. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1):S27-S49.",
      "supports": [
        "Prediabetes criteria based on A1C, fasting plasma glucose, and 2-hour plasma glucose after 75-g OGTT.",
        "Diabetes-range findings based on A1C, fasting plasma glucose, OGTT, or symptomatic random plasma glucose."
      ]
    },
    {
      "id": "EV-NIDDK-IR",
      "citation": "National Institute of Diabetes and Digestive and Kidney Diseases. Insulin Resistance & Prediabetes.",
      "supports": [
        "Insulin resistance testing is not routine diagnostic testing in the same way as prediabetes testing.",
        "Prediabetes testing uses A1C, fasting plasma glucose, or OGTT."
      ]
    },
    {
      "id": "EV-METS-2009",
      "citation": "IDF/AHA/NHLBI/WHF/IAS/IASO Joint Interim Statement. Harmonizing the Metabolic Syndrome. Circulation. 2009;120:1640-1645.",
      "supports": [
        "Metabolic syndrome is classified when three abnormal findings out of five are present.",
        "Waist thresholds require population-specific configuration."
      ]
    },
    {
      "id": "EV-NGSP-A1C",
      "citation": "National Glycohemoglobin Standardization Program. Factors that Interfere with HbA1c Test Results.",
      "supports": [
        "Hemoglobin variants and altered red-cell lifespan may interfere with A1C interpretation.",
        "Iron deficiency may cause higher A1C values."
      ]
    },
    {
      "id": "EV-ACC-TG-2021",
      "citation": "American College of Cardiology Expert Consensus Decision Pathway. Persistent Hypertriglyceridemia. 2021.",
      "supports": [
        "Triglycerides >=500 mg/dL require severe hypertriglyceridemia review.",
        "Triglycerides >=1000 mg/dL warrant urgent attention for pancreatitis/chylomicronemia risk."
      ]
    },
    {
      "id": "EV-AASLD-MASLD",
      "citation": "American Association for the Study of Liver Diseases. Noninvasive Assessment of Patients with MASLD.",
      "supports": [
        "FIB-4 <1.3 is generally used as an initial low-risk result in appropriate populations.",
        "FIB-4 >=1.3 prompts consideration of secondary assessment within a hepatic pathway."
      ]
    }
  ]
}