Prevention of Diabetes

Primary prevention of diabetes is a major strategy to combat the rising global burden of diabetes and is of utmost importance in developing countries such as ours. However, these strategies have to be formulated considering the cultural, socio-economic aspects and structure of the health care system.

Today science has progressed to the extent that not only can diabetes be identified early but we can detect subjects even with pre-diabetes (those with risk of developing diabetes). The main components of identifying high risk individuals are positive family history, obesity, especially central adiposity (big tummy), sedentary life habits and stress. Studies including ours have shown that diabetes can be prevented by life style modification in people with prediabetes. This has changed the strategy in tackling diabetes in public health.

Indian Diabetes Prevention Programmes IDPP 1 and IDPP 2 have been the pioneer studies from South Asia which have shown that moderate, but consistent lifestyle modification is effective in preventing diabetes in high risk subjects. These studies have also highlighted several peculiarities in the Indians with respect to the risk factors and the response to therapeutic interventions. Among Indians a new translation research project is now in progress to identify a cheaper and widespread communication strategy such as SMS by cell phones, to motivate persons with high risk for diabetes to adhere to the LSM strategies.

Research Programmes undertaken during the last 5 years

1. Insulin Resistance and Clustering of Cardiometabolic Risk Factors in Urban Teenagers in Southern India.

Scope: The occurrence of cardiometabolic risk variables, their clustering, and their association with insulin resistance among 2640 healthy adolescents in urban south India were studied. Cardiometabolic abnormalities were present in nearly 68% of young healthy Asian-Indian adolescents. Insulin resistance is associated with individual cardiometabolic factors, and plasma insulin showed association with clustering of some variables.

2. Plasma Adiponectin Does Not Correlate With Insulin Resistance and Cardiometabolic Variables in Nondiabetic Asian Indian Teenagers.

Scope: The objectives of this study were to determine age- and sex-specific concentrations of adiponectin in 196 Asian Indian teenagers and adults and to assess whether its blood levels correlated with insulin resistance and other cardiometabolic parameters. It was found that in Asian Indian adults and teenagers, adiponectin did not correlate directly with measures of insulin sensitivity, overweight and other cardiometabolic variables.

3. Awareness about diabetes and its complications in the general and diabetic population in a city in southern India.

Scope: The study was done to find out the levels of awareness on diabetes in urban adult Indian population and to identify factors that influenced the awareness, including presence of diabetes. Knowledge regarding causes of diabetes, its prevention and the methods to improve health was significantly low among the general population. Diabetic subjects had better knowledge about symptoms of diabetes and the preventive aspects. Awareness was low especially in women and subjects with low education. The study highlights the urgent need to spread awareness about diabetes in the general population.

4. High Prevalence of Diabetes and Cardiovascular Risk Factors Associated With Urbanization in India.

Scope: Prevalence of diabetes, impaired glucose tolerance (IGT), impaired fasting glucose (IFG), and cardiovascular risk factors between a city (n= 2192), a town (n=2290), and periurban villages (PUVs) (n=2584) in southern India were compared and temporal changes in the city and PUVs were also looked into. Present and previous data in the city and the PUVs were compared. Overweight, elevated waist circumference, hypertension and dyslipidemia were more prevalent in the city. Diabetes increased from 13.9% to 18.6% in 6 years and IGT decreased significantly in the city. The town and city had similar prevalence; in the PUVs diabetes prevalence, had increased compared with that in a previous survey. Cardiometabolic abnormalities were more prevalent in urban populations.

5. Beneficial effects of strategies for primary prevention of diabetes on cardiovascular risk factors: results of the Indian Diabetes Prevention Programme.

Scope: In subjects with impaired glucose tolerance (IGT) who participated in the Indian Diabetes Prevention Programme (IDPP), abnormalities related to body mass index (BMI), waist circumference (WC), blood pressure (BP), lipid profile and electrocardiography were analysed. The result was Asian Indian IGT subjects were observed to have a high prevalence of cardiovascular risk factors. LSM and MET had beneficial effects on the atherogenic phenotype of lipids but had no influence on blood pressure.

6. Changes in Insulin Secretion and Insulin Sensitivity in Relation to the Glycemic Outcomes in Subjects With Impaired Glucose Tolerance in the Indian Diabetes Prevention Programme-1.

Scope: The Indian Diabetes Prevention Programme-1 (IDPP-1) showed that lifestyle modification (LSM) and metformin were effective for primary prevention of diabetes in subjects with impaired glucose tolerance (IGT). A 3 year follow-up showed, risk reduction relative to control group was more in LSM and LSM plus MET groups. In this analysis, changes in insulin secretion and action in improving the outcome were studied. In the IDPP-1 subjects, beneficial outcomes occurred because of improved insulin action and sensitivity caused by the intervention strategies.

7. Pioglitazone does not enhance the effectiveness of lifestyle modification in preventing conversion of impaired glucose tolerance to diabetes in Asian Indians: results of the Indian Diabetes Prevention Programme-2 (IDPP-2).

Scope: This was a 3 year, prospective, randomized placebo-controlled study in 407 IGT subjects. The objective was to study whether combining pioglitazone with lifestyle modification would enhance the efficacy of lifestyle modification in preventing type 2 diabetes in Asian Indians with impaired glucose tolerance. The results showed that lifestyle modification (improved physical activity and healthy diet practices) reduced the conversion to diabetes, but addition of pioglitazone (30mg/day) to lifestyle modification did not improve the efficacy.

8. Cardiovascular risk factors in the normoglycaemic Asian-Indian population-influence of urbanization.

Scope: The aim of this study was to investigate the prevalence of cardiovascular risk factors in normoglycaemic Asian-Indians and its association with urbanization and plasma glucose. The study revealed high prevalence of cardiovascular risk factors even among normoglycaemic individuals, and this is highest in urban areas. Fasting plasma glucose level showed an association with dyslipidaemia but not hypertension.

9. Immediate impact of a diabetes training programme for primary care physicians—An endeavour for national capacity building for diabetes management in India.

Scope: National capacity for management of diabetes has to be strengthened by improving knowledge of physicians treating diabetes, especially in semi urban and rural areas. A training programme was formulated and conducted at national level, as a step towards this goal. The training significantly improved knowledge on treatment, complications, pathophysiology and diagnosis of diabetes. Patient education and team-training were considered important in diabetes management. Well-planned short training programmes are useful in improving knowledge and in creating enthusiasm to improve diabetes care and awareness.

10. Multifaceted Determinants for Achieving Glycemic Control The International Diabetes Management Practice Study (IDMPS).

Scope: The International Diabetes Mellitus Practice Study is a 5-year survey documenting changes in diabetes treatment practice in developing regions. The analysis of the first phase showed that both in type 1 and type 2 diabetes patients, in Latin America, Eastern Europe and Asia including India, Korea, China, Indonesia, Hong Kong, Taiwan, Malaysia, and Thailand, only about one third of the patients achieved the desired goal of glycaemic and lipid control. It was observed that in developing countries, factors pertinent to patients, doctors, and health care systems all impact on glycemic control.

11. Predictive value of HbA1c for incident diabetes among subjects with impaired glucose tolerance—analysis of the Indian Diabetes Prevention Programmes.

Scope: The objectives of this study were to assess the predictive value of baseline HbA1c for incident diabetes among the participants with impaired glucose tolerance in the Indian Diabetes Prevention Programmes 1 and 2. Baseline HbA1c values had heterogenous distribution. The distribution was similar in isolated impaired glucose tolerance or in impaired glucose tolerance in combination with impaired fasting glucose. A progressive increase in diabetes occurred with increasing HbA1c. HbA1c showed the strongest association with incident diabetes in the multiple logistic regression analysis (odds ratio 3.548, P < 0.0001).

12. Efficacy of Primary Prevention Interventions When Fasting and Postglucose Dysglycemia Coexist-Analysis of the Indian Diabetes Prevention Programmes (IDPP-1 and IDPP-2).

Scope: Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) have different pathophysiological abnormalities, and their combination may influence the effectiveness of the primary prevention tools. The hypothesis was tested in this analysis, which was done in a pooled sample of two Indian Diabetes Prevention Programmes (IDPP-1 and IDPP-2). Subjects with IGT_IFG had a higher proportion developing diabetes in 3 years and a lower rate of reversal to normoglycaemia. The effectiveness of primary prevention strategies appears to be similar in subjects with IIGT or with combined IGT_IFG. However, the possibility remains that a larger study might show that the effectiveness is lower in those with the combined abnormality.

13. Relationship Between A1C and Fasting Plasma Glucose in Dysglycemia or Type 2 Diabetes- An analysis of baseline data from the ORIGIN trial.

Scope: Baseline A1C and FPG data from the Outcome Reduction with Initial Glargine Intervention (ORIGIN) trial participants (n=12,527) were analyzed to 1) elucidate the relationship between A1C and FPG in people with moderate dysglycemia (A1C 5.6–9.0% [38–75 mmol/mol]) and additional risk factors for cardiovascular disease, 2) determine whether this relationship is altered by use of an OAD, and 3) study whether geographic and ethnic differences exist. A strong relationship between FPG and the corresponding A1C was seen across different geographic regions and ethnic groups. A smaller increase in A1C per unit increase in FPG occurred for persons taking an OAD versus those not taking an OAD.

14. Reinforcement of Adherence to Prescription Recommendations in Asian Indian Diabetes Patients Using Short Message Service (SMS)-A Pilot Study.

Scope: This study was done to investigate the acceptability and feasibility of using short message services (SMS) via cell phones to ensure adherence to management prescriptions by diabetic patients. Type 2 diabetic patients with 5 or more years of diabetes and having HbA1c between 7.0% to 10% were randomized to the control arm (n=105) to receive standard care and to the intervention arm (SMS, n=110). Messages in English on principles of diabetes management were sent once in 3 days. The study duration was 1 year. A comparative assessment of the clinical, biochemical and anthropometric outcomes was made among the groups at the annual visit. SMS was acceptable to the patients and the median number requested was 2 per week. HbA1c and plasma lipids improved significantly in the SMS group. The pilot study showed that frequent communication via SMS was acceptable to diabetic patients and it helped to improve the health outcomes.