Background
Type 2 Diabetes Mellitus is a major public health issue in India
Evidence supports lifestyle interventions for diabetes prevention
Transferability and uptake in resource poor settings requires critical evaluation
Methods
Review of empirical studies
Study (Author) | Target population | Study design | Intervention | Study outcomes | |
---|---|---|---|---|---|
Target risk factor | Components | Response | |||
1. Indian Diabetes Prevention Programme (IDPP) 1&2 (Ramachandran A et al. 2010): Risk for and incidence of T2DM | - Follow-up of 845 out of 869 IGT subjects from IDPP 1and 2 studies,recruited from clinic setting followed up for 3 years | - 3 yr RCT |
Individual:
| - IDPP 1: 502 out of 531 (94.5%) participants found to have IGT after standard Oral Glucose Tolerance Test (OGTT) | - IDPP-1: Decrease in relative risk 29% (LSM), 26% (Metformin) & 28% (LSM+Metformin) |
- IDPP 1: 4 groups | - Personal sessions at 6-month intervals | ||||
1) Control with standard advice: | - 0.15-0.75 h/year by dietician & social worker & monthly telephone contacts | ||||
2) LSM | - LSM: diet & physical activity modification | ||||
3) Metformin (500 mg/day) | - IDPP-2: Cumulative incidences at 36 months: 30% (LSM +Pioglitazone) & 32% (LSM+placebo) | ||||
- 2 groups of participants: Group 1 (n=667): Baseline isolated IGT; Group 2 (n=178): IGT+IFG | 4) LSM + Metformin | ||||
- IDPP 2: 2 groups | - IDPP 2: 367 out of 407 (90.2%) participants found to have IGT after standard OGTT | ||||
1) LSM + placebo | - No additional benefit with drugs | ||||
2) LSM + Pioglitazone (30 mg/day) | |||||
2. Diabetes Prevention & Management (DPM) programme (Balagopal P et al. 2008): Proportion with high fasting blood glucose levels | 850 village inhabitants, comprising adults and youth aged 10–92 years (included healthy, impaired fasting glucose and T2DM individuals) | 7-month community-based non-pharmacological lifestyle intervention |
Individual:
| - Total eligible residents: 950 | FBG levels decreased by 3% (healthy adults), 11% (adults with IFG), 17% (youth with IFG) & 25% (adults with T2DM) |
- 10 face-to-face interviews | |||||
- Baseline survey: 850 | |||||
Group:
| |||||
- Post-intervention survey: 703 (Attrition rate due to migrations & refusals: 17%) | |||||
- Culturally sensitive sessions on physical activity & diet | |||||
Community:
| - Response rate at baseline: 89.5% | ||||
- Participatory analysis of village | |||||
- Involvement of village leaders, peer educators & residents | |||||
3. Chennai Urban Population Study-17 (Mohan V et al., 2006): Physical inactivity | All individuals above age of 20 living in two residential colonies of urban Chennai | Community-based intervention for increasing physical activity. Baseline cross-sectional survey and a 7-yr follow-up cross-sectional survey. |
Individual:
| - Baseline cross-sectional survey (1996): 479 out of 524 eligible participants (91.4%) - 7-yr follow-up cross-sectional survey (2004): 705 out of 712 eligible participants (99%) | - Proportion of light-grade activity reduced in both men (55% to 36%) and women (74% to 57%) - Proportion of residents exercising increased from 14% to 59% - Community’s response: residents mobilised resources and constructed a park. |
- Culturally tailored education campaign & materials, social worker visits - Diabetes and high risk intervention: information on diabetic status & individual counseling
Population:
- Awareness programme using public lectures, video clippings & short skits | |||||
4. Community-based intervention in Ballabgarh, India (Krishnan A et al. 2010): Non-communicable disease risk factors | Residents in urban areas of Ballabgarh block, Faridabad district, Haryana (near New Delhi) | - Community-based demonstration project using the Health Settings approach. - Cross-sectional surveys at pre-intervention and 3-year follow-up: pre-intervention survey in 2003-04 and post-intervention survey in 2006-07 |
Individual:
- Advocacy and medication - Individual empowerment
Community:
- Social enhancement and community empowerment - Reorientation of health services | Not mentioned | - Programme reach (proportion of community who came in contact with the programme): 25% - Change from baseline proportion: consuming < 5 servings of fruits and vegetables decreased by 3% (men), 5% (women); Elevated BP decreased 9% (men), 2% (women) |
5. Work site intervention programme on cardiovascular risk factors (Prabhakaran et al. 2009): Cardiovascular risk factors | Employees and their family members (age 10–69 years) from 10 centres (Bangalore, Coimbatore, Delhi, Dibrugarh, Hyderabad, Lucknow, Ludhiana, Nagpur, Pune and Trivandrum) | Work site demonstration project: - Intervention sites: Baseline cross-sectional survey, 4-year health intervention programme and a repeat cross-sectional survey. - Control sites: Baseline cross-sectional survey, 4-year minimal interventions and a repeat cross-sectional survey. |
Individual:
- One-on-one interactions between the trained health project personnel and the participants
Group:
- Dynamic group interactions and healthy meals
Population or community:
- Use of posters, banners at strategic locations in the industry | - Baseline cross-sectional survey: Intervention sites: 82.4% and control site: 90.0% - Repeat cross-sectional survey: Intervention sites: 98.3% and control site: 90.7% | Change in proportion of risk factors in intervention vs. control sites: tobacco use: 39% to 29% vs. 17% to 20%, extra salt use: 28% to 13% vs. 22% to 25%, median physical activity score: 6 to 11 vs. 8 to 6, fruit consumption: 38% to 45% vs. 36% to 38% |
- Handouts, booklets and video films shown on the internal cable network | |||||
6. Community-based intervention for tobacco cessation in rural Tamil Nadu, India: A cluster randomised trial (Kumar MS et al. 2012): Tobacco use (smoking and smokeless tobacco) | Men aged 20–40 years using any form of tobacco who were residing in Tiruchirapalli district, Tamilnadu. | A cluster randomised trial with two months follow up. |
Group:
| - Attendance in first intervention session: 88.5%; second intervention session: 60.5%. The follow-up rates for intervention and control arms were 90.5% and 92.5%, respectively. | At 2 months: |
Two sessions of health education was offered by a health professional, five weeks apart, along with self-help material on tobacco cessation to intervention group. The control group received only self-help material. | - Self-reported point prevalence abstinence: 13% (intervention), 6% (control) | ||||
- Quit attempt: 27% (intervention), 20% (control) | |||||
- Harm reduction: 22% (intervention) 9% (control) | |||||
7. Government of India smokeless tobacco campaign (Murukutla N et al. 2011): Tobacco use | Individuals aged 16–50 years in urban and rural areas who are current smokeless tobacco users and have access to mass media (television or radio) | The six weeks campaign (November and December 2009) was evaluated with a nationally representative household survey of 2898 smokeless tobacco users during 20 December 2009 to 10 January 2010. |
Population:
| Screening interviews were completed in 92% of the respondents | - Awareness of the campaign: 63% (smokeless-only users), 72% (dual users) |
- An oral cancer surgeon from a tertiary care hospital in Mumbai described the serious illnesses and disfigurement of his patients, caused by cancers resulting from use of smokeless tobacco. | |||||
- Concern about their habit: 75% (smokeless-only users), 77% (dual users) |
Review of policy and other relevant documents
Conduct of focus groups
Triangulation and synthesis of findings from different sources
Results
Review of empirical studies
Risk factors
Health behaviours
Community-based interventions
Policy document review
Year | Recommendations | Implementing agency |
---|---|---|
TOBACCO USE | ||
2003 |
Cigarettes and Other Tobacco Products Act (COTPA) 2003:
| The Department of Health and Family Welfare in each state is primarily responsible for implementation in coordination with other departments, authorised officers and various other stakeholders. |
- Prohibition of smoking in public places | ||
- Prohibition of advertisement of cigarettes and other tobacco products | ||
- Prohibition of sale of tobacco products to minors (below 18 years of age) | ||
- Prohibition of sale of tobacco products by minors | ||
- Prohibition of sale of tobacco products within 100 yards of the educational institutions | ||
- Specified health warnings on tobacco products | ||
- Testing of tobacco products for their harmful contents and emissions | ||
2007-2012 |
Programme components of National Tobacco Control Programme (NTCP):
| NTCP to support implementation with national, state and district level actions and actors |
National level: | ||
- Mass media campaigns to create public awareness | ||
- Establishment of tobacco testing labs | ||
- Mainstreaming the programme components as part of the health delivery mechanism under the overall NRHM framework | ||
- Mainstreaming research and training on alternate crops and livelihoods and monitoring and evaluation including surveillance | ||
State level: | ||
- Establishment of a tobacco control cell | ||
District level: | ||
- Tobacco control centres | ||
- Information, Education and Communication activities | ||
- Training of professionals | ||
DIET
| ||
2008 (pilot phase) |
Guidelines by National Programme for Prevention and Control of Diabetes, Cardiovascular diseases and Stroke (NPDCS)*
| Ministry of Health and Family Welfare, Govt. of India |
- Increase intake of green leafy vegetables and fresh fruits. | ||
- Consume less salt; avoid adding or sprinkling salt to cooked and uncooked food. | ||
- Preparations that are high in salt and need to be moderated are: Pickles, chutneys, sauces and ketchups, papads, chips and salted biscuits, cheese and salted butter, bakery products and dried salted fish. | ||
- Restrict all forms of free sugars and refined carbohydrates for example biscuits, breads, naan, kulchas, cakes, and so on. | ||
- Steamed and boiled food should be preferred over fried food. | ||
- Have fresh lime water instead of carbonated drinks. | ||
- Avoid eating fast or junk foods and aerated drinks. Instead of fried snacks, eat a fruit. | ||
- In practice, it is best to use mixture of oils. Either buy different oils every month or cook different food items in different oils. Oils that can be mixed and matched are mustard oil, soya bean oil, groundnut oil, olive oil, sesame oil, and sunflower oil. | ||
- Ghee, vanaspati, margarine, butter and coconut oil are harmful and should be moderated. | ||
- If you are a non-vegetarian, try to take more of fish and chicken. They should not be fried. Red meat should be consumed in small quantities and less frequently. | ||
- Eat variety of foods to ensure a balanced diet | ||
2010 |
Guidelines by National Institute of Nutrition (NIN)
| These guidelines were proposed by the National Institute of Nutrition, Hyderabad which works under the aegis of Indian Council of Medical Research, Ministry of Health and Family Welfare, Govt. of India |
- Combine different food groups to obtain a well-balanced diet. Recommended balanced diet for adults with moderate physical activity (for reference men and women weighing 60 and 55 kg respectively): net energy (kcal/day): 2730 (men), 2230 (women); Fats and oils (visible fat): 5gX6 (men), 5gX5 (women); Sugar: 5gX6; Milk and milk products: 100gX3; Pulses: 30gX3 (men), 30gX2.5 (women); Vegetables (excluding roots and tubers): 100gX3; Fruits: 100gX1; Cereals and millets: 30gX15 (men), 30gX11 (women). | ||
- Ensure provision of extra food and healthcare to pregnant and lactating women. | ||
- Promote exclusive breastfeeding for six months and encourage breastfeeding till two years. | ||
- Feed home based semi-solid foods to the infant after six months. | ||
- Ensure adequate and appropriate diets for children and adolescents in health and sickness. | ||
- Ensure moderate use of edible oils and animal foods and less use of ghee, vanaspati, and so on. | ||
- Overeating should be avoided to prevent overweight and obesity. | ||
- Restrict salt intake to minimum, should not exceed 6 g per day. | ||
- Ensure safe and clean foods and practice right cooking methods and healthy eating habits. | ||
- Drink plenty of water and take beverages in moderation. A normal healthy person needs to drink about 8 glasses (2 litre) of water per day. | ||
- Minimize the use of processed foods rich in salt, sugar and fats. The intake of trans-fatty acids should not exceed 2% of energy intake. | ||
- Include micronutrient rich foods in the diets of elderly people for them to be fit and active. | ||
- Eat plenty of vegetables and fruits. | ||
- Exercise regularly and be physically active to maintain ideal body weight. | ||
PHYSICAL ACTIVITY
| ||
2008 (pilot phase) |
Guidelines by the NPCDCS*
| Ministry of Health and Family welfare, Govt. of India with WHO collaboration |
- Physical activity is a key determinant of energy expenditure. | ||
- Regular exercise is important for promoting weight control or weight loss. | ||
- Exercise regularly (moderate to vigorous) for 5–7 days per week; start slowly and work up gradually. | ||
○ At least 30 min (accumulated) of physical activities per day for cardiovascular disease protection. | ||
○ 45 min/day (accumulated) for fitness. | ||
○ 60 min/day (accumulated) for weight reduction. | ||
- Discourage spending long hours in front of television. | ||
- Encourage outdoor activities like cycling, gardening and so on. | ||
- A minimum 30–45 min brisk walk/physical activity of moderate intensity improves overall health. | ||
- Include ‘warm-up’ and ‘cool- down’ periods, before and after exercise regimen. | ||
2010 |
Guidelines by NIN
| Guidelines were proposed by the National Institute of Nutrition, Hyderabad which works under the aegis of Indian Council of Medical Research, Ministry of Health and Family Welfare, Govt. of India |
- Physical activity is essential to maintain ideal body weight by burning excess calories and is of vital significance for health and prevention of diseases. | ||
- Physical activity is essential for the reduction of morbidity and mortality due to several chronic diseases and may reduce the risk of falls and injuries in the elderly. | ||
- Exercise is a prescriptive medicine. | ||
- Move your body as much as you can. | ||
- Physical activity is a major modifiable risk factor in reduction of non-communicable chronic diseases. | ||
- Recommended to carry out at least 45 min of moderate intensity activity, which may reduce the risk of chronic diseases. | ||
- To lose weight 60 min of moderate to vigorous intensity physical activity may be taken for most of the days in a week. | ||
- Children and teenagers need at least 60 min of physical activity every day. In the case of pregnant women 30 min or more of moderate-intensity physical activity every day is recommended. |
Focus groups
Theme 1: What to intervene on with respect to behavioural targets and their determinants? | Theme 2: How to intervene in terms of preferences with respect to programme implementation? | ||
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Sub-themes | Description and quotes | Sub-themes | Description and quotes |
1. Knowledge and beliefs of diabetes | General interest to know more about diabetes and its prevention. | 1. Trusted sources of health information or potential intervention agents | · Health centers. |
· Physicians, health care providers. | |||
· Grass root level non-physician health workers. | |||
· Accredited Social Health Activists (ASHAs). | |||
· ‘Kudumbasree’ (local women’s self-help groups) | |||
2. Risk factors | · Strong family history and the modern lifestyle. | ||
· Unhealthy dietary habits including regular consumption of foods rich in fats and sugar like sweets, roots like tapioca and certain fruits, particularly sweet bananas like ‘rasakathali’. High consumption of pastries and snacks as parts of urban lifestyle. | |||
2. Use and acceptance of Information Communication Technology (ICT) | · Telephone used by all and highly accepted for practical organization of meetings. | ||
· Mobile phones used and accepted for incoming calls. | |||
· Physical inactivity, particularly in sedentary occupations and in urban environment. “People just don’t walk now-a-days.” | · SMS used but not accepted. | ||
· Internet not used. | |||
· Long-term medications: “Since I am on a lot of medication, I expect that I may get it. I have read in articles that those who take medicines for blood pressure and other things have a higher chance of getting such illnesses.” | |||
· Protective factors other than healthy food habits – e.g., “using no sugar in tea for the last 15 years” – rarely mentioned. | |||
3. Risk perception | · No awareness of pre-diabetes status. | 3. Preferences for intervention delivery |
“If meeting points or places can be identified for each locality and the intervention is done as a group, it is better. It should be a place where people in that area can walk to or access easily.”
· Regarding low male participation to regular village meetings (Gramsabha), “active men should invite other men”. · Venue: a. Easy access. b. Within walking distance. c. Health centres, reading rooms or anganwadis.
d. Participants’ homes. · Format: a. Group of 10–25 participants, important for generating different ideas that would benefit the whole group. b. Including at least two people per family and neighbours. Women might need permission from their husbands. · Time: a. Duration 1–1.5 h. b. Once-a-week. c. On holidays. d. When children are at school (for housewives). |
· Diabetes risk perceived higher for women, a group seen as less physically active, with a tendency to over eat and to ignore early symptoms. | |||
· Perceived own risk: i. Little to no risk: Participants, who perceived their food habits were healthy; had no family history; or had faith that regardless of habits, they were simply not at risk. “I don’t believe in any of this. I don’t feel I have any risk. I still need double sugar in my tea.”
ii. Fifty percent or more risk: Participants who already had a related illness like hypertension or myocardial infarction; or hypertensive or anti-cholesterol medication, perceived to contribute to high blood sugar; or who had significant family history. “I expect a 50% risk as I am a hypertensive for the last 18 years and have been on medication and I had a heart attack 10 years back.”iii. Don’t know: Not able or were not willing to speculate about their risk. | |||
4. Outcome expectations | · Diabetes has no cure, but can be controlled with oral medicines, injections, dietary and other lifestyle changes. | ||
· Low outcome expectations for lifestyle modification after the pre-clinical or very early stages of the disease: “You can only control it or decrease it. When food is controlled along with treatment, up to 80% can be controlled. Once you get the illness, you have no choice but to go for treatment.”
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5. Self-efficacy | · A collective low self-efficacy regarding the ability to make and sustain changes in lifestyle. “I don’t think it is possible to make modifications in our lifestyle. No matter what you say, it will just continue like this.”
· Dietary habits not within individual control. · Cultural norms such as “fruits other than bananas belong to children’s diet only” and collective household decision-making guide dietary practices. · Physical activity is related to everyday chores, like walking to the market, or to job like farm work, not to leisure-time. “I am a driver working in the Gulf. When I come home for vacation, I do farming for four hours every day. I also have cows, so I get enough exercise. When I am in the Gulf, there is no time to walk or for any other exercise.” For men, availability of time is a barrier while for women both time and space restrict the possibilities to be physically active. “I used to do Yoga in the mornings. (…) When we go to the room, there should be no one else there. We need privacy. Slowly, it has become difficult to find such a time and space so, now I don’t do it anymore”. “I have heard that walking is good. But we have to start kitchen work at 6.30 in the morning, so when can we walk?” “We can’t go out of our own compound to walk. If we have space in our own backyard, it will work.”
· Quitting tobacco is hard because of social pressure. “I have quit several times, each time for varying duration (…) Inevitably, I will see some of my friends smoking or they will offer a cigarette and I will start smoking again.”
· Professional help is not sought for quitting. “If we want to stop smoking, we can decrease slowly not suddenly. If you smoke 10, you can make it 5, then 2 and then stop.”
· Women can only influence men’s use of tobacco by asking them not to smoke inside the homes. |