Diabetes prevention and lifestyle intervention in resource-limited settings
Authors: Thirunavukkarasu Sathish
Journal: The Lancet Diabetes & Endocrinology (2019)

Type 2 diabetes is a major public health problem, affecting an estimated 425 million adults worldwide, three-quarters of whom live in low-income and middle-income countries.1International Diabetes FederationIDF Diabetes Atlas.8th edn. International Diabetes Federation, Brussels2017Google Scholar The economic implications of type 2 diabetes are enormous, with global annual costs to health-care systems and society in the trillions of US dollars.2Bommer C Sagalova V Heesemann E et al.Global economic burden of diabetes in adults: projections from 2015 to 2030.Diabetes Care. 2018; 41: 963-970Crossref PubMed Google Scholar There is a clear and urgent need to curtail the diabetes epidemic via effective and cost-effective strategies, targeting not only high-risk individuals, but also the general population. In this context, the findings from the DMagic trial, reported by Edward Fottrell and colleagues3Fottrell E Ahmed N Morrison J et al.Community groups or mobile phone messaging to prevent and control type 2 diabetes and intermediate hyperglycaemia in Bangladesh (DMagic): a cluster-randomised controlled trial.Lancet Diabetes Endocrinol. 2019; (published online Feb 4.)http://dx.doi.org/10.1016/S2213-8587(19)30001-4PubMed Scopus (50) Google Scholar in The Lancet Diabetes & Endocrinology, are timely. The cluster-randomised controlled trial was done in rural Bangladesh, with 96 villages randomly assigned (1:1:1) to a participatory learning and action (PLA) community mobilisation intervention, mHealth mobile messaging, or usual care. In the general population, a baseline cross-sectional survey was done in a random sample of 12 140 adults (aged ≥30 years), with a repeat cross-sectional survey done in a new random sample of 11 454 individuals after about 2 years (end of study). A cohort of 2470 participants with intermediate hyperglycaemia (defined as impaired fasting glucose [IFG] or impaired glucose tolerance [IGT]) was identified from the general population sample at baseline, with 2100 (85%) followed-up at 2 years. Community mobilisation was achieved through a PLA approach focusing on diabetes prevention and control, including monthly group meetings facilitated by trained lay people over a period of 18 months. mHealth participants received behaviour change and diabetes awareness-raising voice messages to their mobile phones, twice per week, for 14 months. The primary outcomes were the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the overall population and the 2-year cumulative incidence of type 2 diabetes in the intermediate hyperglycaemia cohort. The combined population prevalence of intermediate hyperglycaemia and type 2 diabetes was significantly lower in the community mobilisation group compared with usual care at study end (adjusted odds ratio [aOR] 0·36, 95% CI 0·27–0·48). In the intermediate hyperglycaemia cohort, community mobilisation resulted in a significant reduction in diabetes incidence relative to usual care (aOR 0·39, 0·24–0·65; absolute incidence reduction 8·7% [3·5–14·0]). The mHealth intervention was not effective in reducing the combined prevalence of intermediate hyperglycaemia and type 2 diabetes in the general population sample (aOR 0·93, 0·74–1·16) or the incidence of diabetes in the intermediate hyperglycaemia cohort (aOR 1·02, 0·73–1·43). The community mobilisation intervention was determined to be cost-effective for both of the primary outcomes, based on incremental cost-effectiveness ratios of INT$316 per case of intermediate hyperglycaemia and type 2 diabetes prevented and $6518 per case of type 2 diabetes prevented among the intermediate hyperglycaemia cohort. The DMagic trial findings are surprising and uncertain for several reasons. In the general population sample, the effect size for the primary outcome with community mobilisation was large, with the intervention successfully countering the trend of increasing prevalence of intermediate hyperglycaemia and type 2 diabetes seen with usual care. Notably, apart from increasing participants' knowledge about diabetes, community mobilisation had no effects on any of the other secondary outcomes, including blood pressure, overweight or obesity, diet, physical activity, and quality of life and wellbeing. Mobile phones have high penetration and reach in the general population and are a low-cost technology and therefore potentially scalable. For the mHealth intervention in DMagic, there was no effect on disease outcomes, despite the intervention being informed by formative research and behaviour change theories. By contrast, a previous trial in India (done in an urban population of working men) showed a significant 36% reduction in the incidence of diabetes with a text message-based intervention among men with IGT.4Ramachandran A Snehalatha C Ram J et al.Effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle modification in men in India: a prospective, parallel-group, randomised controlled trial.Lancet Diabetes Endocrinol. 2013; 1: 191-198Summary Full Text Full Text PDF PubMed Scopus (221) Google Scholar In that study, the message content was based on the transtheoretical model of behavioural change. Evidence suggests that mobile phone text messaging can improve glycaemic control in patients with type 2 diabetes.5Arambepola C Ricci-Cabello I Manikavasagam P Roberts N French DP Farmer A The impact of automated brief messages promoting lifestyle changes delivered via mobile devices to people with type 2 diabetes: a systematic literature review and meta-analysis of controlled trials.J Med Internet Res. 2016; 18: e86Crossref PubMed Scopus (102) Google Scholar However, evidence for the role of mHealth in preventing diabetes seems to be mixed and unclear. Although much is known concerning the effects of lifestyle intervention in the prevention of type 2 diabetes, some important questions remain. First, lifestyle interventions within their current form (ie, increasing physical activity, healthy dietary habits, and weight loss) can reduce the progression to diabetes in people with IGT.6Glechner A Keuchel L Affengruber L et al.Effects of lifestyle changes on adults with prediabetes: a systematic review and meta-analysis.Prim Care Diabetes. 2018; 12: 393-408Summary Full Text Full Text PDF PubMed Scopus (74) Google Scholar However, such interventions do not appear to reduce diabetes incidence in those with IFG,7Thankappan KR Sathish T Tapp RJ et al.A peer-support lifestyle intervention for preventing type 2 diabetes in India: a cluster-randomized controlled trial of the Kerala Diabetes Prevention Program.PLoS Med. 2018; 15: e1002575Crossref PubMed Scopus (74) Google Scholar, 8Weber MB Ranjani H Staimez LR et al.The stepwise approach to diabetes prevention: results from the D-CLIP randomized controlled trial.Diabetes Care. 2016; 39: 1760-1767Crossref PubMed Scopus (97) Google Scholar, 9Saito T Watanabe M Nishida J et al.Lifestyle modification and prevention of type 2 diabetes in overweight Japanese with impaired fasting glucose levels: a randomized controlled trial.Arch Intern Med. 2011; 171: 1352-1360Crossref PubMed Scopus (192) Google Scholar which is different in terms of pathophysiology from IGT.10Faerch K Borch-Johnsen K Holst JJ Vaag A Pathophysiology and aetiology of impaired fasting glycaemia and impaired glucose tolerance: does it matter for prevention and treatment of type 2 diabetes?.Diabetologia. 2009; 52: 1714-1723Crossref PubMed Scopus (163) Google Scholar IFG is a more common form of intermediate hyperglycaemia in South Asians11Anjana RM Deepa M Pradeepa R et al.Prevalence of diabetes and prediabetes in 15 states of India: results from the ICMR–INDIAB population-based cross-sectional study.Lancet Diabetes Endocrinol. 2017; 5: 585-596Summary Full Text Full Text PDF PubMed Scopus (346) Google Scholar and some other ethnic groups.12Sentell TL He G Gregg EW Schillinger D Racial/ethnic variation in prevalence estimates for United States prediabetes under alternative 2010 American Diabetes Association criteria: 1988–2008.Ethn Dis. 2012; 22: 451-458PubMed Google Scholar Therefore, innovative approaches targeting the pathophysiology of IFG are required. Second, how do we translate community-based interventions tested in the DMagic trial, as well as in randomised trials from other low-income and middle-income countries,7Thankappan KR Sathish T Tapp RJ et al.A peer-support lifestyle intervention for preventing type 2 diabetes in India: a cluster-randomized controlled trial of the Kerala Diabetes Prevention Program.PLoS Med. 2018; 15: e1002575Crossref PubMed Scopus (74) Google Scholar, 8Weber MB Ranjani H Staimez LR et al.The stepwise approach to diabetes prevention: results from the D-CLIP randomized controlled trial.Diabetes Care. 2016; 39: 1760-1767Crossref PubMed Scopus (97) Google Scholar into real-world settings? Finally, how do we scale up and implement these interventions more widely in view of the resource constraints, health workforce shortfalls, governance difficulties, and other challenges in resource-limited settings? Process evaluation data from DMagic and other studies13Aziz Z Mathews E Absetz P et al.A group-based lifestyle intervention for diabetes prevention in low- and middle-income country: implementation evaluation of the Kerala Diabetes Prevention Program.Implement Sci. 2018; 13: 97Crossref PubMed Scopus (19) Google Scholar should hopefully provide some useful insights into these implementation and dissemination issues. I declare no competing interests. Community groups or mobile phone messaging to prevent and control type 2 diabetes and intermediate hyperglycaemia in Bangladesh (DMagic): a cluster-randomised controlled trialOur data provide strong evidence to support the use of community mobilisation based on PLA to prevent type 2 diabetes in this rural Bangladeshi population. Despite raising knowledge and awareness of diabetes, the mHealth intervention did not change disease outcomes in our population. Replication studies in other populations should be a priority. 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