Evidence based review of type 2 diabetes prevention and management in low and middle income countries

Table 4 Diabetes prevention: United States Diabetes Prevention Program like prevention interventions (allied health professionals and lay member facilitated)

Country	Ref.	Objective	Study design	Sample Size/characteristics	Components of intervention	Measurements	Outcome measures	Conclusion
Brazil	Pimentel et al[80]	To evaluate effectiveness of NEP	RCT	n = 67, 24 in intervention group and 43 in control group, IGT + 1 other risk factor for T2DM	Individual sessions once per month and group counseling twice per month with nutritionist	HbA1c, fasting glycemia + insulin, postprandial glycemia + insulin	0 and 12 mo	Long-term NEP improves metabolic parameters for high-risk DM individuals. Intervention group had a decrease in fasting glycemia (-14.0%, P = 0.03), fasting insulin (-9.0%, P = 0.05), postprandial glycemia (-21%, P = 0.02), postprandial insulin (-71.0%, P = 0.02) and HbA1c (-24.0%, P = 0.006). No significant changes were observed in control group
India	Ramachandran et al[81]	To determine whether lifestyle modification could influence development of diabetes in IGT individuals	RCT	n = 531, 136 in control, 133 in lifestyle modification, 133 in metformin, 129 in lifestyle modification and metformin, 35-55 yr, IGT	Diet advice in reduction of calories, refined carbs and fats by dietician, exercise recommendations for at least 30 min of brisk walking each day for sedentary lifestyle, metformin initial dose 250 mg twice daily increased to 500 mg twice daily after 2 wk by physician	HbA1c, blood glucose	0, 6, 12, 18, 24, 30 and 36 mo	Lifestyle modification significantly reduced the incidence of diabetes in Asian Indians. Cumulative incidence of diabetes was 55% in 3 yr in control group, and it was significantly lower in all three intervention groups (LSM = 39.3%, MET = 40.5%, LSM + MET = 39.5%)
India	Balagopal et al[85]	To evaluate effectiveness of community-based lifestyle intervention on diabetes prevention	CBPR, single group	n = 850, 10-92 yr, village resident	Dietary advice from certified diabetes educator, stress relaxation techniques, physical activity promotion from physical education trainers, 10 one-on-one sessions with health messages	FBG, diabetes incidence, BMI, BP, nutrient composition of diet	0 and 7 mo	Educational intervention was successful in improving dietary patterns in individuals with pre-diabetes/diabetes. FBG levels decreased from 94.4 mg/dL to 91.2 mg/dL (P = 0.045)
India	Balagopal et al[86]	To evaluate effectiveness of community based diabetes prevention and management program	CBPR, single group	n = 1681, > 18 yr, village resident	Lifestyle modification, group and one-on-one counseling, 5 group sessions and 5 one-on-one encounters by community health workers	FBG, diabetes prevalence, BMI, BP, nutrient composition of diet	0 and 6 mo	Community-based participatory programs are a useful model for prevention and management of diabetes. FBG levels decreased from 96.26 mg/dL to 94.94 mg/dL (P < 0.001)
India	Singhal et al[82]	To evaluate effectiveness of repetitive nutrition education and lifestyle intervention on adolescents in North India	RCT	n = 106, Intervention had 56, control had 50, 15-17 yr	Individual counseling for parents on phone every month for 10 min each, lectures of 30 min each for 10 wk, individual counseling for student every week for 1 h on diet by trained nutritionist, lifestyle and physical activity for at least 30 min, trained student volunteers for dissemination of health messages	HOMA-IR, waist circumference, HOMA-BCF, DI	0 and 6 mo	The intervention model has a potential to prevent T2DM in Indian adolescents HOMA-BCF changed 56.7 in intervention group (P = 0.003) and 24.5 in control group (P = 0.002). Disposition index changed 30.3 (P = 0.003) in intervention group and 8.3 in control group (P = 0.01). No significant changes in fasting insulin and HOMA-IR were noted
Iran	Harati et al[88]	To evaluate effectiveness of lifestyle intervention in development of T2DM	Non-randomized cluster controlled trial	n = 4747, 2992 in control group, 1754 in lifestyle modification group, no baseline diabetes	Educational interviews and lectures, nutritional educational classes 4 d/wk, health volunteers distributed educational material	FBG, diabetes incidence, BMI, lipid profile	0 and 42 mo	Lifestyle interventions could decrease the risk of developing T2DM in the general population, not just high-risk patients. Incidence of diabetes in the control and intervention groups was 12.2 and 8.2 per 1000 person-years, respectively, with a relative risk reduction of 65% (P < 0.003). FPG change from baseline was -2.9 (P < 0.01)
Thailand	Numbenjapon et al[87]	To evaluate lifestyle modification vs combined treatment (lifestyle modification + metformin) to prevent diabetes	Two group experimental	n = 19, IGT, Fam Hx of T2DM	Monthly visit with nurse educator, nutritionist, physician and psychologist for 3 consecutive months, and then every 2 to 3 mo afterward	BMI, 2 h plasma glucose	1 yr	BMI and 2-h plasma level were significantly decreased after treatment in normal OGTT group (P < 0.05)

NEP: Nutrition Education Program; RCT: Randomized control trial; T2DM: Type 2 diabetes mellitus; BMI: Body mass index; BCF: Beta-cell function; DI: Disposition index.