NIHR Global Health Research Unit and Network for Diabetes and Cardiovascular disease in South Asia Theme 1. Understanding the drivers of diabetes and cardiovascular disease in South Asia

South Asians (SAs) are recognised to be at increased risk of both cardiovascular disease (CVD) and type 2 diabetes (T2D) compared to European populations. Data from the UK, Europe and North America suggests that the high risk of CVD and T2D in SAs is not explained by differences in traditional cardiovascular or metabolic risk factors.

We will advance understanding of the lifestyle, environmental and molecular factors influencing T2D and CVD and provide much needed new insight into the determinants of T2D and CVD in SA populations. The results will inform development of effective personalised, policy based, environmental and public health interventions.

Theme 2. Digital interventions for prevention of T2D and CVD in South Asians.

Our Non-Communicable Diseases (NCD) Surveillance study reveals that >30% of SAs have established diabetes or CVD and that a further >30% have obesity, prediabetes or are at high CVD risk. Quality of care is poor and there is major inequality between socio-demographic groups. Our programme of digital health research aims to understand how technology platforms can be used to improve prevention of diabetes and CVD in SA in a scalable, sustainable and equitable fashion. 

Informed by the results of the trial data, we will make digital interventions available for wider use by community users and healthcare providers. In collaboration with the theme 3 work strand, we will use trial data to build decision trees that help prioritise the applications to people who will benefit most. The decision support algorithms will be incorporated into the theme 3 community-facing ‘Health hub’ as a demonstration of a scalable model for integrated end-end digital care co-ordination.

Theme 3. Accelerating the digital transformation of NCD management in South Asia
 
Digital technologies offer the potential to transform primary healthcare (PHC) systems in LMICs and improve both access to and quality of healthcare. The emergence of the COVID-19 pandemic has intensified the need for digital technologies to support decentralised NCD care.

We will advance understanding of how digital platforms can be used to strengthen prevention and control of T2D, CVD and their risk factors in SA.

Our PHC collaborators in Bangladesh and Sri Lanka are already committed to strengthening health information systems for PHC teams and are working to national solutions. We will bring learnings from demonstration projects to support these efforts and scale up the digital care coordination tools we have developed. This will be facilitated by the implementation toolkits and inter-operable frameworks we will establish in conjunction with the WHO. Successful demonstration projects will thus lead to a high likelihood of sustainable scale-up of our digital training and care-co-ordination modules.

Theme 4: Policy and environmental interventions for primary prevention of NCDs

Among the most important actions to reverse the epidemics of T2D and CVD are to understand the built environment around people’s everyday life and to develop population-based interventions. Published evidence to support the effectiveness of policy and environmental interventions for improving health behaviours and prevention of cardio-metabolic disease comes mainly from high-income countries. It remains unclear whether such ‘whole of society’ approaches are acceptable, feasible or effective in SA settings, where resources are limited, the priorities of individuals are different, and the burden of disease is high and increasing.
Our overarching goal is to implement and evaluate a community-based intervention for prevention of T2D and CVD, at national scale in Sri Lanka, and to provide evidence that other countries in SA can learn from in.
The insights from the research will be used to develop policy recommendations in South Asian countries for health promotion and prevention of T2D and CVD. Theme 1. We will advance understanding of the lifestyle, environmental and molecular factors influencing T2D and CVD in South Asia. We will:
1.	Ascertain health outcomes over four years for the ~150,000 South Asian men and women participating in our NCD Surveillance study, to identify new onset CVD and T2D
2.	carry out molecular profiling of the baseline samples, including lipid profile and other measures of metabolic risk, and genome-wide genotyping with whole exome sequencing.
3.	analyse the data to determine the age- and gender-specific incidence for T2D and CVD amongst South Asians in different settings; identify the behavioural, environmental and genomic exposures that underlie T2D and CVD in South Asians; strengthen approaches for identification of South Asian individuals and communities who are at increased risk for CVD

Theme 2. We will test whether digital intervention with AI driven education or gamification for behaviour change reduces weight (primary endpoint) and improves quantitative measures of cardiometabolic health, amongst South Asian men and women aged 30-60 years with overweight or obesity, compared to usual care over 2 years.

Theme 3. We will advance understanding of how digital platforms can be used to strengthen prevention and control of T2D, CVD and their risk factors, in South Asia. 

We align with the Principles for Digital Development and collaborate with WHO. We will:
1.	adapt our ‘Co-ordinate’ platform for use in wider South Asians settings. Extend functionality to include digital training and to empower self-management by community users
2.	demonstrate and evaluate platform performance in diverse South Asian settings to provide objective assessment of utility for care co-ordination
3.	modularise and generalise the platform, align to global digital health standards, and collaborate with WHO, to make our approaches available to the global health technology ecosystem

Theme 4
Our overarching goal is to implement and evaluate a community-based intervention for prevention of diabetes and cardiovascular disease, at national scale in Sri Lanka, and to provide evidence that other countries in South Asia can learn from in formulation of policy. 

Our specific aims are:
1.	comprehensively assess drivers of health risky behaviours linked with T2D and CVD through the linkage of surveillance and exposure to the built environmental data
2.	implement the ‘Happy Village Plus’ intervention (including community-based and school- based components) in 75 surveillance sites across Sri Lanka and evaluate the effectiveness of the intervention using a cluster randomised trial design
3.	benchmark government policies aimed at tackling NCDs in India, Pakistan and Bangladesh, applying the INFORMAS (International Network for Food and Obesity/Non-Communicable Diseases (NCDs) Research, Monitoring and Action Support) framework, extended to physical activity and tobacco policies.