Improving diabetes prevention and management amidst varied resources: from local implementation to global learnings.

Over the past decade, diabetes prevalence has risen even more rapidly in lowand middle-income countries (LMICs) than in high-income countries (HICs). Globally, diabetes was the seventh leading cause of death in 2016 [1]. It is estimated that four out of five people with diabetes now live in LMICs and the top two LMICs with the largest number of people with Type 2 diabetes are China (114 million) and India (72.9 million) [2]. In addition, 43% of all deaths attributable to diabetes occur prematurely before the age of 70 years, with the majority of them occurring in LMICs. Diabetes and its complications contribute to a significant economic loss to people with diabetes, their families, health systems, and national economies. It is estimated that the global losses in GDP due to diabetes during 2011–2030, including both the direct and indirect costs, total more than US$1.7 trillion, comprising US$900 billion for HICs and US$800 billion for LMICs [3]. With a growing burden of Type 2 Diabetes in LMICs, these costs will continue to increase in the coming decades. A significant proportion of Type 2 diabetes results from long-term, modifiable lifestyle and behavioral factors; these and other sociobehavioral factors related to long-term management are also important determinants of outcomes for those with diabetes. These factors can be substantially addressed using multifaceted approaches at population and individual levels. Many studies have now demonstrated effective diabetes control through a combination of diet and physical activity interventions [4,5]. Compelling evidence also suggests that the prevention of diabetes should take a life-course approach that integrates healthy eating habits and physical activity early in life [1]. Awareness of diabetes status and treatment coverage is very low in LMICs. More than half of the people with diabetes are not aware of their diabetes status [2] and only half of those who know their status are receiving treatment [6,7]. If left uncontrolled, diabetes can damage the heart, blood vessels, eyes, kidneys, and nerves and increase the risk of heart disease and stroke. A comprehensive cardiovascular disease risk approach that enables integrated management of hypertension, diabetes, and other cardiovascular risk factors in primary care settings is also very important [8]. The increase in the prevalence of diabetes along with its confluence with other chronic diseases in many populations is leading to changes in the spectrum of the types of associated morbidities and causes of death [9]. The presence of shared risk factors is one of the reasons for the resulting multimorbidity. Addressing the complexities of chronic conditions requires a whole-of-government and whole-of-society approach with effective roles played by sectors beyond health. Yet, little is known about how to achieve this, particularly in LMICs [10]. To address this very significant implementation gap, real-world implementation research that engages a range of stakeholders across all stages of evidence development, implementation, and scale-up is required. But there is, currently, a very modest evidence base to inform this approach in LMICs. Most of the evidence on the effectiveness of lifestyle and other kinds of interventions for diabetes prevention and control has emanated from HICs, although this is beginning to change in LMICs [11]. However, more evidence on cultural adaptation, implementation, and scale-up in LMICs to improve diabetes and related outcomes is a high priority. Three key questions related to this continuum include: what to adapt or scale-up, how to adapt or scale up, and how to evaluate the adaptation or scale-up. While there are many interventions or programs that have been developed and well researched in HICs, their adaptation to the LMICs context has been limited. In addition, interventions that have been developed and tested in some LMICs have significant potential for adaptation and/or scale-up in other LMICs. A lot of recent research has demonstrated the importance of adaptation of interventions to improve fit to the local context, and there are also important theories, models, and frameworks that can be applied to improve diabetes and associated outcomes in LMICs. These include “SelfManagement Approach and Reciprocal learning for Type 2 Diabetes” (SMART2D) [12], Consolidated Framework for Implementation Research (CFIR) [13], the Theoretical Domains Framework (TDF) [14], Normalization Process Theory (NPT) [15], and applyparastyle "fig//caption/p[1]" parastyle "FigCapt" applyparastyle "fig" parastyle "Figure" applyparastyle "article/front/article-meta/contrib-group/affiliation/aff " parastyle "Affiliation"