Title: NIHR Global Health Research Unit on Diabetes and Cardiovascular Disease in South Asians, Imperial College London
Funder: Department of Health and Social Care

Abstract: Strategic objectives and positioning Imperial College London identifies improving global health and wellbeing as one of four key strategic objectives.(1) Transformational global health research for T2D and CVD is delivered through the School of Public Health, the Wellcome Centre for Global Health Research, the WHO Collaborating Centre for NCD Surveillance and Epidemiology, the WHO Collaborating Centre for Public Health Education and Training, the Institute of Global Health Innovation, the Clinical Trials Unit and Imperial College Business School. Our inter-disciplinary team (9 Chairs, >30 researchers) harnesses expertise in translational research for prevention and control of T2D and CVD in national and global settings, including South Asia. Imperial further commits 2 tenured Lecturer positions, educational funding for LMIC researchers (stipends for MPH courses, an exchange program, and an international workshop), and space within the School of Public Health. Institutional partnerships and strategies We take advantage of partnerships with clinical institutions, academic centres of excellence, non-governmental and governmental organisations in Bangladesh, India, Pakistan and Sri Lanka (Letters of Support [LoS], Diagrams 1-3). We are aligned to national programmes for prevention and control of T2D and CVD,(2-5) and leverage ongoing investments by partners in all 4 countries. We will strengthen Centres of Excellence in Translational Research, establish Translational Research Networks (Diagram 2), and support programmes for high quality training in each country, to build sustainable capacity and capability. Stakeholders are committed to contributing resources to projects (eg Corporate Social Responsibility, see FICCI LoS). Proposed programme of research -Scientific strategy We will develop acceptable, equitable, efficient, scalable and sustainable approaches to prevention and control of T2D and CVD in South Asia, taking advantage of low-cost innovative technologies, to enhance the efficiency, effectiveness and equity of health systems. Our goal is to translate knowledge into practice and policy, to reverse the current epidemics of T2D and CVD, and improve health and welfare in South Asia. We focus on T2D and CVD based on the high burden of these related diseases on the Indian subcontinent.(6-8) The similarities between South Asian countries will facilitate South-South learning, rapid dissemination, early implementation and wide impact. -Global health agenda CVD and T2D are leading, inter-linked global health challenges: 422M people live with T2D, while CVD caused 17.5M deaths in 2012 (31% of global mortality).(9, 10) T2D and CVD pose enormous economic burdens on individuals, families and healthcare systems,(11-13) and contribute to poverty, inequality and social instability (Diagram 4). Our proposal is targeted to reversing the global epidemic of these diseases, and contributing to the UN Sustainable Development Goals, and WHO Global Action Plan for Prevention and Control of NCDs (Diagram 5).(14,15) The burden of T2D and CVD are especially high in South Asia,(6-8) the most populous and densely populated region of the world (1.73 billion people in 2015, 25% of world population, 3% of land area). There remains little evidence base to inform healthcare interventions for T2D and CVD in these resource-poor environments. This knowledge gap contributes to the continued, rapid increase in the burden of T2D and CVD, and to widening global health inequality. -Aims and objectives (Diagrams 6-10) i. Surveillance: strengthen surveillance systems to provide robust data on the burden of T2D, CVD and their risk factors (health observatories), and on quality of care (disease registers) in South Asia. Thus, quantify needs, inform priorities, and impact of healthcare interventions. ii. Strategies for prevention and control: prioritise strategies for prevention, early detection and management of T2D and CVD, taking account of equity, acceptability, cost-effectiveness, scalability and sustainability in South Asia. Learn from successful implementation projects such as the UK NHS Diabetes Prevention Programme. Evaluate selected interventions as demonstration projects and quantify outcomes (social, behavioural, equity, health, economic impacts). Thus provide evidence of what works, in which population groups, and in what settings. iii. Build capacity: Strengthen or establish five Centres of Excellence for Translational Research (Bangladesh, India North & South, Pakistan, Sri Lanka), as hubs for regional Translational Research Networks in South Asia. Facilitate evidence based, high-quality training of postgraduate researchers and health professionals in prevention and control of T2D and CVD. iv. Service frameworks: in partnership with policymakers and other stakeholders, support development of frameworks for dissemination and implementation, including guidelines, quality standards, care pathways, clinical networks and resource allocation mechanisms for T2D and CVD. -Projects pursued in the first two years Objective 1. Surveillance systems. Strengthen the currently fragmented systems for routine surveillance of T2D and CVD in South Asia: i. harmonise protocols & definitions, ii. catalyse data-sharing, iii. optimise health metrics, iv. establish Health Observatories in high priority areas of unmet need; and v. implement electronic Disease Registers at sentinel sites (primary & secondary care). Merge data with health system financing, and organization characteristics. Output: Robust data on the burden of T2D and CVD, and their quality of care across South Asia. Thus enable researchers, healthcare providers and policy makers to i. identify needs and priorities; ii. evaluate effectiveness of health systems and interventions, including demonstration projects; iii. learn from experiences in other health systems.(16-18) Objective 2. Prioritise and evaluate interventions. Identify promising interventions for prevention and control of T2D and CVD based on: established research frameworks and expertise of the Unit’s UK and international partners; stakeholder meetings; and systematic review of available evidence. Taking into consideration acceptability, equity, cost-effectiveness, scalability and sustainability, prioritise interventions for evaluation in demonstration projects in 3 complementary themes: i. Community interventions. Promote healthy behaviours (improved diet, weight and physical activity, smoking cessation), using education through trusted sources (eg schools), regulation (eg food labelling, advertising), public policy (eg smoking in public places) and/or taxation (eg sugar tax, sweetened drinks).(19-29) Project development and implementation is enabled by our partnerships with state government and food regulators (eg FSSAI). ii. Health promotion and behavioural intervention for high-risk individuals delivered through community health workers (CHWs) and/or digital technologies (eHealth, mHealth).(19, 30-34) We show that mHealth interventions lower weight, improve diet, and reduce risk of T2D in urban workplaces in India, providing a rationale for evaluation in a wider range of settings.(35) Digital technologies offer unique opportunities to deliver personalized lifestyle interventions to large populations at low cost.(36,37) iii. Early diagnosis and better management. CHWs can enhance management of blood pressure and T2D.(19, 38-40) Innovations in digital decision-support technologies, in portable low-cost diagnostics and in low cost pharmaceuticals offer further opportunities to upskill CHWs and deliver cost-effective care in resource poor settings.(19,41) Demonstration projects will be supported by qualitative research to assess attitudes, acceptability, obstacles and facilitators, and modelling of impacts on risk factors, behavioural determinants, and outcomes. Output: Interventional frameworks prioritised by end year 1, and initiated as demonstration projects in year 2. Engagement Partners and stakeholders are embedded into all aspects of the Unit’s work, to ensure our research is focussed on issues important to South Asia. The Steering Committee includes members from Bangladesh, India (North and South), Pakistan and Sri Lanka (Organogram). Working and Project Groups are co-led by the UK and South Asia. Governments of all 4 countries, regulators and key industrial partners, are agreed collaborators and stakeholders, and will provide material support (LoS). The International Advisory Group brings expertise in NCD prevention and control from other LMIC regions (Sub-Saharan Africa [AP Kengne], MENA [B Larijani], Latin America [JA Rivera], Pacific [P Zimmet]). Commissioning Calls for proposals will be developed with partners (year 1), then disseminated and assessed in collaboration with national research funders (eg Wellcome Trust India, TBC), to ensure efficiency and transparency, and to maximise audience and impact. We will award small grants (<£10K, <24 months) in keeping with ODA rules. Responsive capacity We will retain 10% of funding to respond to emerging global health research needs, including: i. calls for research that widen the scope or enhance sustainability of our work, and ii. investing in projects with promising results to strengthen findings and impact. Funds will be allocated by the Steering Committee using transparent mechanisms. Sustainability Sustainable collaborations will be promoted by: i. translating research into business models that bring financial stability to partners (eg fee-based, affordable training, digital tools, diagnostics, healthcare provision), as pioneered by BRAC; ii. building expertise at partner organisations in leadership and delivery of high-quality research, and in fund-raising; and iii. embedding translational research into practice and policy (eg tools for surveillance, service evaluation and resource allocation

Lay abstract: Heart disease and diabetes are the world’s leading health problems. Approximately 18 million people die from heart disease every year and another 420 million people live with diabetes. The burden of heart disease and diabetes are especially high in South Asia. The ambition of the GHRU on Diabetes and Cardiovascular Disease in South Asians is to create an inter-disciplinary environment that fosters development and implementation of acceptable, equitable, scalable and sustainable approaches to reduce the burden of diabetes and heart disease in Bangladesh, India, Pakistan and Sri Lanka. Working in partnership with leading Universities and Healthcare organisations in the partner countries, we are pursuing 5 inter-related projects •Strengthening disease surveillance. We will work in partnership with the Governmental and Non-Governmental sectors to establish a sustainable network of Health Observatories in the 4 countries and distributed in both rural and urban settings. The information generated will provide researchers and healthcare providers high quality information on the burden and trajectory of diabetes and heart disease, to better understand the causes of these major diseases and to inform healthcare policy decisions. •Improving disease prediction. We will define how metabolic and cardiovascular risk factors predict future development of diabetes and CVD in South Asians. We will achieve this by bringing together and sharing data from a range of sources in the UK and the partner countries. The results will enable development of new tools for identification of high risk individuals, thus enabling earlier and better targeted interventions. •Primary care interventions. We will evaluate and strengthen primary health care system approaches for delivery of essential interventions for prevention and control of diabetes and CVD in South Asia. Our ambition will be to work with existing frameworks of frontline workers (governmental and non-governmental), who are currently primarily focused on Maternal and Child Health, to extend or repurpose these primary care teams towards prevention and control of NCDs, in a scalable and sustainable fashion. •Digital interventions. We will evaluate digital applications (smartphone Apps) for health promotion to improve cardiovascular and metabolic health amongst high-risk South Asians from across the Indian subcontinent. We will start by establishing service and quality specifications for digital applications for delivery of lifestyle modification and education, for prevention and control of diabetes and heart disease amongst South Asians. We will then use a pragmatic clinical trial to evaluate their effectiveness for health promotion, to provide definitive evidence. •Population based prevention of diabetes and CVD. We will apply the principles of health promotion to design, implement and evaluate a multi-pronged community wide intervention to improve health related behaviours and reduce the prevalence of diabetes and heart disease. For example through education, food policy and regulation. Our ambition is to develop a scalable “health village” model that can enhance health for all in the community. The results of this research will lead to a better understanding of the diabetes and heart disease in South Asian, including underlying mechanisms, optimal approaches to identification of high risk individuals, and scalable approaches for personalised and community wide preventative strategies.

Research activity codes: 3.5 RESOURCES AND INFRASTRUCTURE (PREVENTION);7.4 RESOURCES AND INFRASTRUCTURE (DISEASE MANAGEMENT)
Health categories: CARDIOVASCULAR;METABOLIC AND ENDOCRINE