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

Table 1 Diabetes management: Diabetes Prevention Program like interventions (allied health professionals and lay member facilitated)

Country	Ref.	Objective	Study design	Sample size/characteristics	Components of intervention	Measurements	Outcome measures	Conclusion
Argentina	Gagliardino et al[29]	To evaluate effect of combined physician and/or patient education and effect of system interventions (100% coverage of medications, formalized data collection)	Randomized 2 × 2 design trial	n = 468, 117 in control group (g1), 117 in physician education group (g2), 117 in patient education group (g3), 117 in physician and patient education group (g4), T2DM for at least 2 yr, age b/w25 and 75 yr	For T2DM pts - 90-120 min weekly teaching units For physicians - 25 structured module interactive course	HbA1c, BMI, FBG	0, 6, 12, 18, 24, 30, 36, 42 mo	HbA1c decreased from 4 mmol/mol to 10 mmol/mol (P < 0.05), with the largest decrease being in g4 (physician and patient education group)
Brazil	Cezaretto et al[30]	To evaluate effect of interdisciplinary intervention program	Two group randomized longitudinal	n = 135, 60 in traditional group, 75 in intensive group, high risk individuals for T2DM between ages 18 and 79	Intensive Intervention group - 2 h group sessions from 4 sessions in month 1 to 2 sessions in month 2 and 1 monthly sessions until 9 mo, print materials, telephone calls, interdisciplinary team included endocrinologist, psychologist, nutritionist, and physical educator	FBS, BMI, post load plasma glucose	0 and 9 mo	Intensive intervention group decreased fasting plasma glucose from 98.9 to 95.3 (P < 0.001), while the traditional intervention group was not significant. Intensive intervention group BMI decreased from 31.7 to 30.9 (P < 0.001) while the traditional intervention group BMI decreased from 29.9 to 29.1 (P < 0.001)
Brazil	Chaves-Fonseca et al[31]	To evaluate effectiveness of “staged diabetes management” protocol	RCT	n = 113, 47 in control group, 66 in intervention group > 30 yr old, T2DM	SDM protocol (as developed International diabetes center) with doctor, nurse, pharmacist and health technicians	HbA1c, random glucose	0, 12 and 18 mo	Random glucose decreased from 12.7 to 10.5 (P = 0.004) and HbA1c decreased from 9.2 to 7.7 (P < 0.001) in intervention group, while there was no significant change in intervention group
Brazil	Mourão et al[49]	To evaluate effectiveness of pharmaceutical care program	RCT	n = 100, 50 in control and interventional, > 18 yr, HbA1c > 7%, post prandial capillary glucose > 180 mg/dL, T2DM	Two research pharmacists conducted education on drug therapy problems, medication adherence	HbA1c, fasting blood glucose	0 and 6 mo	HbA1c decreased -0.6% and fasting blood glucose decreased -21.4 mg/dL in intervention group (P = 0.001)
Brazil	Correr et al[50]	To evaluate effect of pharmacotherapy follow up	RCT	n = 96, 50 in intervention and 46 in control, > 30 yr old, diagnosed T2DM, oral meds or insulin use	Monthly visit with pharmacist for education, suggestion in changes of medication and dosage changes	HbA1c, fasting capillary glycemia	0 and 12 mo	Relative to the control group, the intervention group exhibited greater glycosylated haemoglobin (HbA1) reduction [-2.2% (95%CI, -2.8%: -1.6%) vs -0.3 (95%CI, -0.8:0.2); P < 0.001] and greater fasting capillary glycaemia reduction [-20.1 mg/dL (95%CI, -31.9 mg/dL: -8.3 mg/dL) vs 4.3 mg/dL (95%CI, -13.4 mg/dL: 22.2 mg/dL); P = 0.022]
Brazil	Borges et al[51]	To evaluate effect of pharmaceutical care	Two group experimental	n = 71, 31 in control group and 40 in intervention group, > 18 yr old, T2DM	Individual visit with pharmacist monthly, patient education, dosage adjustment	Fasting glycemia, HbA1c	0 and 12 mo	A significant reduction in the levels of glycosylated haemoglobin was detected in patients in the pharmaceutical caregroup, and an average increase was observed in the control group
Bulgaria	Petkova et al[52]	To evaluate effectiveness of educational programme by pharmacists	Single group	n = 24, 31-75 yr, diagnosed T2DM	Educational Sessions with five teaching units over one month	Blood glucose levels, frequency of hypoglycemic Incidents	0, 1, 3 and 6 mo	Education of diabetic patients by pharmacists can decrease the economic cost of T2DM management and benefit patients. Blood glucose levels decreased from 8 to 7.2 mmol/L (P < 0.05)
Bulgaria	Tankova et al[26]	To evaluate effectives of a teaching program 1 to 2 yr after implementation	RCT	n = 560, 319 in experimental group, 241 in control group, Insulin treated T1 + 2DM	Geneva-Düsseldorf Education Session Model (consists of lessons on DM, practical training on self-control, injection techniques, preparing meals, construction of menu, physical exercise) education is conducted by team of doctors, nurses and rehab therapist using interactive approach	HbA1c, Well-being as measured by 22-item questionnaire	0, 12 and 24 mo	Structured teaching education program improves patient's well being. Improvement in glycemic control of educated patients as compared to control group (P < 0.01) and increase in overall wellbeing (P < 0.001)
Cameroon	Kengne et al[35]	To evaluate effectiveness of nurse-led care	Population based sample participants referred to either one of the 2 rural clinics or one of the 3 urban clinics	n = 225, 39 in rural clinic and 186 in urban, T2DM	Education, clinic visits, monitoring, follow-up	Mean fasting capillary glucose	0 and visit 6 (varied over 1110 patient-months)	Difference in mean levels of fasting glucose between baseline and final visit was 1.6 mmol/L (P < 0.001)
Cameroon	Labhardt et al[36]	To evaluate effectiveness of non-physician clinician facility care	Included all of the 75 clinics in central region of cameroon	n = 79, T2DM	Protocol-drive care by non-physician clinicians (nurses), diet and lifestyle education	Fasting Plasma glucose	0 and 2 yr	Fasting plasma glucose decreased -7.8 mmol/L (P < 0.001)
China	Liu et al[28]	To evaluate effectiveness of group visit and self management model	RCT	n = 176, 98 in intervention group and 78 in control group, T2DM, between 35-80 yr	12 1.5 h sessions on self management education, one-on-one visits with health care providers, including nurse, general practitioner and diabetes specialist	BMI, SBP, DBP	0 and 12 mo	No significant changes in BMI or DBP in either group, significant change in SBP in intervention group of 1.48 (P = 0.04). Larger studies need to be done to determined effects of group visits on blood glucose and other metabolic parameters
China	Chen et al[119]	To evaluate effectiveness of nurse diabetes intervention	Quasi-experiment, pre and post-test	n = 150, 75 in each control and case groups, > 65 yr, diagnosed T2DM, HbA1c > 8.5%	Self-management education with visits lasting 30 min each, telephone follow-up two weekly	BP, HbA1c, Weight	0 and 3 mo	Nurse-led education and consultation is effective in improving management in T2DM patients. HbA1c in case group changed -0.8% (P < 0.001) while the control group had no significant change
Iran	Sarrafzadegan et al[27]	To evaluate effect of comprehensive, community based healthy lifestyle program on cardiometabolic risk factors	Multi-stage cluster, 2 areas	n = 9032, 4179 in intervention area, 4853 in reference area, general population (htn, metabolic syndrome, diabetes, cardiac disease pts)	Public education through mass media, healthy nutrition, increased physical activity, tobacco control and coping with stress	Cholesterol, abdominal obesity, fasting blood glucose	0, 7 yr	Mean fasting blood glucose increased, but prevalence of abdominal obesity, htn, hypercholesterolemia and hypertriglyceridemia decreased significantly in intervention area (P < 0.05), no significant change in prevalence of diabetes
Iran	Farsaei et al[47]	To evaluate effectiveness of pharmacist-led education program	RCT	n = 172, diagnosed T2DM, HbA1c > 7%	Two educational sessions followed by weekly phone calls and appointments, medication consultation	FBS, HbA1c	0 and 3 mo	There is improvement in diabetes management by involvement of pharmacist in multidisciplinary health care team. HbA1c and FBS (-1.7% and -30.8 mg/dL) were decreased in intervention group (P < 0.001)
Jamaica	Less et al[53]	To evaluate effectiveness of involvement of LDFs	Two group experimental	n = 293, 158 in intervention group and 135 in control group, 25-75 yr, diagnosed T2DM	Educational Sessions during 3 monthly visits, self-monitoring forms	HbA1c, BMI	0 and 6 mo	Patient education by LDFs improved glycemic control of T2DM patients. HbA1c reduced from 0.6% in intervention group (P < 0.001) while comparison group had an increase of 0.6% (P < 0.001)
Jordan	Jarab et al[48]	To evaluate effectiveness of pharmacist-led pharmaceutical care intervention program	RCT	n = 171, 85 in intervention group and 86 in control group, > 18 yr, diagnosed T2DM for at least 1 yr, HbA1c > 7.1%	Medication consultation, lifestyle education, follow-up calls 8 weekly	FBG, HbA1c, BMI, Lipid Panel, BP	0 and 6 mo	Pharmacist-led pharmaceutical care led to an improvement in glycemic parameters. Intervention group had a mean reduction of 0.8% HbA1c verses a mean increase of 0.1% in the usual care group (P = 0.019). FBG in intervention group had a reduction of 2.3 mmol/L and the intervention group showed an increase of 0.9 mmol/L (P = 0.014)
Malaysia	Tan et al[33]	To evaluate effectiveness of structured diabetes education program	Single blind RCT	n = 164, 82 in control and intervention group, > 18 yr, diagnosed T1 + T2DM, HbA1c > 7%	Educational sessions once a month for 3 mo self-care practices, individual counseling with nurse and physician	HbA1c, SMBG frequency	0, 1, 2 and 3 mo	A self-management diabetes education program improves the well-being of diabetic patients. Intervention group had lower HbA1c than control group by the end of study (intervention group –P < 0.001, hbac decreased 8.75 ± 1.75; control group 9.67 ± 2.01)
Mexico	Gallegos et al[39]	To evaluate effectiveness of nurse-led education	Two group quasi-experiment	n = 45, 25 in experimental group and 20 in control group, diagnosed T2DM	6 Educational sessions lasting 90 min each, 20 individual counseling sessions lasting 30 to 90 min throughout 50 wk	HbA1c, psychological adaptation, diabetes care skills	0, 3, 6, 9 and 12 mo	Counseling and education model is an effective intervention to improve metabolic control in T2DM patients. HbA1c decreased from 10.36 at baseline to 8.04 (P = 0.000) while comparison group HbA1c levels changed from 9.44 to 9.77
Samoa	DePue et al[37]	To evaluate effectiveness of nurse-community health workers team intervention for diabetes management	Cluster rct	n = 243, 140 in usual care group, 104 in intervention group, > 18 yr, T2DM	Group visits and individual visits based on risk of patients	HbA1c	0 and 12 mo	Mean HbA1c was significantly lower among CHW participants, compared with usual care, after
South Africa	Price et al[40]	To determine long-term glycemic outcome of a structured nurse-led care	Single group, single center	n = 80, T2DM	Nurse led drug titration, structured empowerment based diabetes education	HbA1c, BMI	0, 6 mo, 18 mo, 2 yr, 4 yr	BMI at 6 and 18 mo was significantly higher than at baseline (both P < 0.01), but the 48 mo value was not significantly different from 0 mo. Compared with baseline, HbA1c falls were all significant (P < 0.001 for 6, 18 and 24 mo and P = 0.015 for 48 mo)
South Africa	Gill et al[41]	To determine effectiveness for a nurse-led intervention and education based program	Single group	n = 284, diagnosed T2DM	Self-management education, pictorial based education	HbA1c, BMI	0, 6 and 18 mo	Nurse-led protocol and education based intervention improve glycemic parameters in diabetic patients. HbA1c was 11.6% at baseline, but improved to 7.7% at 18 mo
Thailand	Wattana et al[42]	To evaluate effectiveness of self-diabetes management program	RCT	n = 147, 72 in control and 75 in experimental, > 35 yr, Diagnosed T2DM, FPG > 140 mg	120 min of small group diabetes education class, four 90 min group discussions and two individual home visit sessions by nurse educators	HbA1c, CHD risk, quality of life assessment	0 and 6 mo	A diabetes self-management program is effective in improving metabolic control for T2DM patients. HbA1c change was -0.68 in experimental group (P = 0.029) and 0.07 in control group
Thailand	Navicharern et al[43]	To evaluate effect of multifaceted nurse-coaching intervention	Quasi experiment, 2 group	n = 40, 20 in control and experimental group, T2DM	3 individualized sessions, 2 follow-up phone calls over 12 wk	HbA1c	0 and 3 mo	Mean average of HbA1c of the experimental group was significantly lower than that of the control group [x(exp) = 7.10, SD = 0.67 vs x(cont) = 7.72, SD = 0.97; P ≤ 0.5]
Thailand	Suppapitiporn et al[45]	To evaluate effect of pharmacist led intervention	RCT	n = 360, 180 in control and experimental group each (divided into 4 groups), T2DM	Drug counseling, special medical containers, diabetes booklet (in experimental group, 1 group received only drug counseling, 2nd group received drug counseling + special medical containers, 3rd group received drug counseling + diabetes booklet, 4th group received all)	HbA1c, mean fasting glucose	0, 3, 6 mo	Most favorable glycemic outcome was the group that received all of the interventions; mean FPG was reduced from 147.46 ± 36.07 to 125.38 ± 31.12 mg% (P < 0.000) in 1st visit (3 mo later) and still reducing effect on the 2nd visit (6 mo later) mean FPG from 147.46 ± 36.07 to 130.21
Thailand	Oba et al[44]	To evaluate effectiveness of community participation prevention program in diabetes prevention	Single group, pre-post test	n = 160, > 35 yr, BMI > 23 kg/m2, waist circumference > 80 cm (women) and > 90 cm (men), FBS 100-125 mg/dL, no baseline diabetes (but at risk patients)	Nutritional education provided by nurse practitioner, fitness schedule in daily exercise log	BMI, SBP, DBP	0, 1, 2, 3 mo	Average mean scores of the BMI (P < 0.001), SBP (P < 0.01) and waist circumference (P < 0.01) among persons who were at risk of DM after the intervention were lower than before intervention
Tunisia	Jenhani et al[32]	To evaluate effectiveness of education program on diabetes control	Pre/post-test experiment	n = 87, diagnosed T1 + T2DM, insulin usage	Six education sessions, interactive learning conducted by nurse and general practitioner	HbA1c, BMI, anxiety level	0 and 6 mo	Education program led to an improvement in diabetes control in patients. HbA1c decreased from 8.80% pre intervention to 7.62% (P < 0.000001)
Turkey	Mollaoğlu et al[25]	To evaluate effectiveness of nurse-led planned education	RCT	n = 50, 25 in experimental and control group, 18-65 yr, diagnosed T2DM	3 Educational Sessions 30-40 min each, home visit follow-ups	HbA1c, FBS, lipid panel	0, 1 and 2 mo	Regular, structured, repeated education improves glycemic parameters in T2DM patients, HbA1c and FBS levels changes were not statistically significant
Turkey	Turnacilar et al[46]	To evaluate effectiveness of pharmaceutical care program	Prospective longitudinal, cluster	n = 43, T2DM	6 pharmacy visits, drug counseling, weight control importance	Capillary whole blood glucose, BMI	0, 15, 30, 45, 60, 75, 90 d	Mean fasting blood glucose decreased from 167 to 128 mg/dL (P < 0.001)
Turkey	Kitiş et al[38]	To evaluate effect of home monitoring by public health nurse	Quasi experimental, single group, time series	n = 34, T2DM for at least 2 yr	Caloric calculation, exercise recommendations, medication compliance, monitoring blood glucose, education study group, booklets, 1st two months frequency of visits based on patients needs, with 2nd mo, visits every 2 mo	HbA1c, fasting blood glucose, postmeal blood glucose	0 and 6 mo	HbA1c decreased from 7.3% to 6.7% (P = 0.000), FBG decreased from 186 to 150 (P = 0.001), postmeal blood glucose decreased from 204 to 156 (P = 0.000)

T2DM: Type 2 diabetes mellitus; RCT: Randomized control trial; BMI: Body mass index; HbA1c: Hemoglobin A1c; LDFs: Lay diabetes facilitators.

Table 2 Diabetes management: Structured dietary change and exercise as main components (not lifestyle education)

Country	Ref.	Objective	Study design	Sample size/characteristics	Components of intervention	Measurements	Outcome measures	Conclusion
Brazil	Rodrigues Silva et al[60]	To evaluate effect of rice bran fiber diet	Single group	n = 11, 45-60 yr old, controlled diabetes by diet or oral hypoglycemic agents, T1DM + T2DM	1 wk low fiber diet, 2nd week low fiber diet + rice bran, cross over	Mean fasting and post prandial glucose	Daily fasting and postprandial glucose	Mean fasting and postprandial serumglucose levels were reduced, but values of high fiber diet were significantly lower (P < 0.001) than that of the lower fiber diet
China	Sun et al[71]	To evaluate effectiveness of structured integrated intervention program	RCT	n = 150, Intervention group 100 and control group 50, 18-70 yr, BMI > 23 kg/m2, T2DM	Nutritional counseling and meal replacement, physical activity instruction, education – monthly group lectures, sample meal plans with applications of meal exchanges and low glycemic index foods	FBG + insulin, HbA1c	0, 3 and 6 mo	An integrated intervention program can achieve improvements in glycemic control. Mean fasting blood glucose values at 24 wk were 7.4 ± 0.2 vs 8.9 ± 0.4 mmol/L (P < 0.001), intervention vs reference, respectively. No change in HbA1c in reference group, but a -0.8% change observed in intervention group (P < 0.001)
Costa Rica	Goldhaber-Fiebert et al[64]	To evaluate effectiveness of group-centered, community based public health intervention	RCT	n = 61, 33 in intervention group and 28 in control group, diagnosed T2DM	11 weekly nutrition classes 90 min each, triweekly walking physical activity sessions 60 min each	HbA1c, FBG	0 and 3 mo	Community-based, group-centered intervention including nutrition and exercise can improve glycemic control and is economically feasible. Change in FBG in intervention group change -19, control group 16 (P + 0.048). Change in HbA1c in intervention group -1.8, control group -0.4 (P = 0.028)
India	Pande et al[56]	To investigate effects of low/medium glycemic indexed Indian vegetarian snacks and meal plans on diabetics	Single group experimental	n = 15, 42-58 yr, diagnosed T2DM	Redesigned meal plan focusing on decreasing starches, lipids and increasing fiber	Blood glucose, HbA1c, lipid profile	0, 1, 2, 3 and 4 wk	Significant improvement in metabolic parameters was observed and can be improved if compliance to low/medium GI diet is continued. Blood glucose level of 173.6 mg% at baseline decreased to 137.8 mg% (P < 0.001), HbA1c of 8% at baseline decreased to 7.1% from baseline (P < 0.001)
India	Shenoy et al[62]	To evaluate effectiveness of aerobic walking program with pedometer and HRM	RCT	n = 40, 20 in control and 20 in intervention, 40-70 yr, diagnosed T2DM, Not enrolled in any other physical activity program	Timed walking schedule of target 150 min/wk to reach a 50%-70% maximum heart rate, pedometer, HRM	BMI, GWB	0 and 2 mo	Walking with a pedometer and HRM is more effective than walking alone and results in a better wellbeing for T2DM patients
India	Kosuri et al[70]	To evaluate effect of yoga on T2DM patients	Single group	n = 35, T2DM	40 d yoga camp with yoga exercises everyday	BMI, general well being	0 and 40 d	BMI decreased from 26.514 to 25.771 (P < 0.001) and there was also an improvement in total general well being
India	Agrawal et al[61]	To investigate effect of camel milk on glycemic control and insulin sensitivity	Two group experimental, crossover	n = 28, T2DM	Cow milk for non diabetic group, camel milk for diabetic group, followed by 3 mo washout period, with switch	FBS, HbA1c, HOMA-IR	0, 1 (run in period), 4 (camel milk period), 5 (washout period), 8 mo (cross over to cow milk)	HbAlc improved due to camel milk consumption (8.39 ± 0.64 to 7.27% ± 0.67%) whereas deteriorated in the case of cow milk (7.36 ± 0.66 to 8.26% ± 0.60%) in diabetic group
India	Misra et al[67]	To evaluate effectiveness of PRT	Single group	n = 30, diagnosed T2DM	Scheduled PRT training of six muscle groups (two sets, 10 repetitions each), 3 times/wk	HbA1c, blood glucose, lipid profile, BMI	0 and 3 mo	Moderate PRT is effective in improving metabolic parameters in T2DM patients and should be an integral part of their exercise regimen. HbA1c changed 0.54%, (P < 0.001), fasting blood glucose changed 2.7 mmol/L (P < 0.001)
India	Arora et al[68]	To evaluate effectiveness of PRT compared to aerobic exercise	RCT	n = 30, 10 in supervised PRT, 10 in control group and 10 in aerobic exercise group, 40-70 yr, diagnosed T2DM > 6 mo, inactive lifestyle	Scheduled PRT exercises of 3 sets of 10 repetitions for 2 times per week, aerobic exercise of walking 30 min/d three times a week	HbA1c, BP, BMI, lipid profile, GWB	0 and 2 mo	Metabolic parameters in T2DM patients improved more with PRT compared to aerobic exercise. HbA1c levels decreased (P < 0.05) both in the PRT group (7.57% to 6.23%) and in Aerobic Exercise group (8.11% to 6.66%)
Iran	Yazdanpanah et al[66]	To evaluate effectiveness of community based participatory diabetes care program	Single group, CBPR	n = 320, 30-65 yr, diagnosed T2DM, impaired fasting glucose	Nutrition classes 90 min each 2 d per week for 4 wk, structured physical activity 60 min sessions 3x a week for 13 wk	FBS, HbA1c, BP, lipid profile	0, 3 and 4.1 mo	Community-based participatory program is a feasible model for diabetes control. FBS decreased from 176 to 102 mg/dL (P < 0.01) and HbA1c decreased from 6.9 to 6.1 (P < 0.001)
Nigeria	Adeniyi et al[69]	To evaluate effect of 12 wk exercise program	Single group	n = 29, T2DM for min 6 mo, triglyceride levels > 1.7 mmol/L, waist circumference > 102 cm (men) or 88 cm (women) and BP > 130/85	Alternate day 45 min exercises (3 d in a week) for 12 wk, exercises included aerobic exercise, mobilization and resistance exercises	Fasting blood glucose, HbA1c	0, 2, 4, 6, 8, 12 wk	Improvement was observed in the fasting plasma glucose of both male (t = 8.059; P = 0.0001) and female groups (t = 13.007; P = 0.01)
Nigeria	Salau et al[57]	To evaluate effect of fruits and vegetables diet on selected hematological parameters	Single group	n = 30, T2DM	Two servings of diced fruit mix (100 g each) every day, 1 serving of edible green and leafy vegetables (100 g each) every day	ESR, hematocrit	0, 2, 4, 6, 8, 10 wk	ESR decreased from 49.40 to 32.8 (P < 0.05). Regular intake of fruits and vegetables can reduce cardiovascular risk factors in diabetic patients
Nigeria	Oli et al[55]	To evaluate effect of high carbohydrate diet	Single group	n = 160, weight not more than 10% above or below the mean weight for their age, sex and height, age at onset of diabetes > 30 yr, random blood glucose between 100 mL and 200 mg/100 mL, no ketonuria	250 g to 300 g of carbohydrate daily per patient depending on age and occupation	Mean fasting glucose	3 yr	Fifty-three patients (33.1%) achieved excellent control of their blood glucose (mean fasting blood glucose of 7.0 mmol/L or less); 38 patients (23.8%) achieved good control of their blood glucose (mean fasting blood glucose of 7.0-8.0 mmol/L); and 42 patients (26.3%) achieved fair control of their blood glucose (mean fasting blood, glucose of 8.0-9.0 mmol/L)
South Africa	van Rooijen et al[63]	To evaluate effectiveness of exercise intervention program vs a relaxation program	Single blind double intervention RCT	n = 149, 74 in relaxation group and 75 in exercise group, 40-65 yr, diagnosed T2DM for at least 1 yr	Home exercise program, fortnightly 45 min aerobics, 20 min tensing of muscles and relaxing for relaxation group, interactive group sessions, diet lectures	HbA1c, BMI, BP	0 and 3 mo	The exercise group did not impact the glycemic parameters greater than the relaxation group. HbA1c decreased -0.39 (P = 0.02) for exercise group
Thailand	Komindr et al[58]	To evaluate effect of long-term intake of Asian food with different glycemic indices	Single group cross over	n = 10, T2DM, b/w 32-60 yr	High glycemic diet or low glycemic diet was mainly glutinous rice or mungbean noodles, intermediate glycemic diet was solely white rice	HbA1c	2 mo	Ingestion of mungbean noodles (a low glycemic diet) without increasing fiber intake, can improve diabetic control and protein conservation in type 2 diabetes
Thailand	Chaiopanont[54]	To evaluate effect of a sitting and breathing exercise technique	Quasi-experiment, single group, pre and post-test	n = 50, 42-80 yr, diagnosed T2DM	Scheduled sitting and breathing techniques once a week for 30 min	Post Prandial glucose, FBS, BP	0, 1 and 2 wk	The somporn kantaradudsi-triamchaisri sitting and breathing techniques had a postprandial hypoglycemic effect in T2DM patients. Post prandial plasma glucose levels decreased from 19.26 mg/dL (P < 0.001) in the 2nd week to 17.64 mg/dL in the 3rd week (P < 0.001)
Turkey	Acik et al[65]	To evaluate effectiveness of education and lifestyle recommendations	Non-randomized cluster controlled trial	n = 80, 33 in standard diet, 28 in exercise + diet, 39 in control group, diagnosed T2DM	Nutritional counseling, structure physical activity schedule 3 times/wk	HbA1c, BMI, Blood Glucose	0, 1 and 2 mo	Diabetes education intervention program involving lifestyle modifications improves glycemic parameters. HbA1c in the diet + exercise group decreased from 9.9% to 7.9% (P = 0.001) and in the diet group, levels decreased from 7.8% to 7.5% (P = 0.001)
Mexico	Jimenez-Cruz et al[59]	To evaluate effectiveness of lower-higher-glycemic index mexican style diet	RCT crossover	n = 14, 35-75 yr, diagnosed T2DM	Pamphlets, detailed instructions on high-low GI foods, washout period of 6 wk with 6 wk periods of treatment alternating between low-GI period and high-GI period	FPG, HbA1c, BMI, lipid panel	0, 1.5 and 3 mo	A low-GI mexican style diet improves metabolic control in obese T2DM patients. HbA1c is lower in the low-GI period (8.1) than the high GI-period (8.6) P = 0.02

T2DM: Type 2 diabetes mellitus; RCT: Randomized control trial; BMI: Body mass index; GWB: General well being; PRT: Progressive resistance training; HbA1c: Hemoglobin A1c; GI: Gastrointestinal; PRT: Progressive resistance training.

Table 3 Diabetes management: Technology assisted interventions

Country	Ref.	Objective	Study design	Sample size/characteristics	Components of intervention	Measurements	Outcome measures	Conclusion
Bangladesh	Kibriya et al[72]	To evaluate effectiveness of HMBG	RCT	n = 64, 32 in each arm, T2DM requiring OHA/insulin, 35-64 yr, completed secondary school education, high SES	Health Education Sessions, HMBG Practical Sessions for 2 d	FBG, HbA1c	0, 3, 6, 9, 12, 15 and 18 mo	HMBG + education is cost-effective in developing country. FBG decreased by 2.49 mmol (P = 0.007) and HbA1c decreased by 1.37% (P = 0.02) in experimental group. FBG decreased by 1.47 mmol (P = 0.051) and HbA1c lost significance after 18 mo of follow up in control group
Bulgaria	Kempf et al[73]	To evaluate effectiveness of SMBG on T2DM patients	RCT	n = 124, 63 in SMBG group, 61 in control group	Structured lifestyle guidance manual, 150 test strips with blood glucose meter	HbA1c	0, 12 wk, 18 mo	At 12 wk of intervention the SMBG group significantly improved glycated hemoglobin (HbA1c) levels [from 7.4 to 6.9 (P < 0.001)], whereas HbA1c reduction were not significant in the control group. At 1.5-yr follow-up, in the control group HbA1c increased again, reaching baseline values (7.5%). In the SMBG group HbA1c remained stable [6.9%(P = 0.0003 for trend)]
China	Chen et al[75]	To evaluate the functionality of telehealth system	Two group experimental	n = 64, 32 in experimental and 32 in control, T2DM	Telehealth device package with blood glucose meter for frequent monitoring according to recommendations, telehealth data analysis platform, telephone to contact health care professional, diabetes education	HbA1c	0 and 1 yr	HbA1c decreased from 9.5 to 8 in telehealth group (P < 0.001), while in the control group, there was no significant improvement in HbA1c
India	Shetty et al[77]	To investigate feasibility of SMS	RCT	n = 215, 110 in SMS group and 105 in control group, diagnosed T2DM > 5 yr, 10% < HbA1c > 7%	SMS once in 3 d as reminders to follow diet, physical activity and prescription adherence reminders	HbA1c, FBG, Lipid profile	0, 4, 8 and 12 mo	SMS communication is acceptable and it improved health outcomes for diabetic patients. Mean FPG (185 mg/dL to 166, P < 0.002) and 2h PG 263 mg/dL to 220, P < 0.002) levels decreased significantly in the SMS group. There was no significant difference in the mean HbA1c values in both groups
Iran	Zolfaghari et al[76]	To evaluate effect of nurse short SMS vs telephone follow-ups	RCT	n = 80, 39 in SMS group and 42 in telephone follow-up group, T2DM, used oral medications only	SMS group received 6 messages every week with info on exercise, medication compliance, diet adherence; Telephone group received at least 2x a week call for 1st month and then weekly for 2nd and 3rd month, each call lasting 20 min	HbA1c, BMI	0 and 3 mo	HbA1c decreased -0.93 (P < 0.001) for telephone group and -1.01 (P < 0.001) for SMS group. Both follow-up interventions can decrease HbA1c levels
Iran	Nesari et al[34]	To evaluate effect of nurse telephone follow-up	RCT	n = 60, 30 in each group, < 65 yr, HbA1c > 7%	3 d diabetes self care education group before intervention, then telephone follow-up 2x/week for first month and then weekly for 2nd and third months with 30 min duration	HbA1c	0 and 3 mo	The change in HbA1c level was significant for the experimental group after 12 wk but not for the control group (-1.87%, P < 0.001 for the experimental group vs -0.4%, P < 0.15 for the control group)
Iran	Moattari et al[78]	To evaluate effectiveness of electronic education	RCT	n = 48, 24 in experimental and 24 in control, diagnosed T2DM, insulin usage, ability to use website/internet	Chat rooms, consultation service, educational films, personal file feedback from physician online	HbA1c, Lipid profile, FBG	0 and 3 mo	Electronic education program can be useful in improving metabolic parameters in T2DM patients sign differences. Change in HbA1c in experimental group was -2.03% (P < 0.0001) and -0.6 in control group. FBS change was -10.87 mg/dL (P = 0.681) in experimental group and -0.79 in control group
Malaysia	Ismail et al[74]	To evaluate effect of self-monitoring blood glucose	RCT	n = 105, 58 in intervention and 47 in control, T2DM, age 35-65 yr	Glucometer, health education, 2 d classes with demos of SMBG	HbA1c	0 and 6 mo	HbA1c level in the intervention group showed a statistically significant improvement of 1.3% (P = 0.001; 95%CI: 0.6-2.0), relative to the control group that underwent usual care
South Africa	Rotheram-Borus et al[79]	To evaluate feasibility of mobile phone-based peer support intervention	Single group	n = 22, diagnosed T2DM	Informational support meetings, weekly success sessions	BMI, blood glucose, Coping, Hours of sleep	0, 3 and 6 mo	Although the phone buddy system resulted in positive coping styles and better sleep, glucose levels increased in participants

HMBG: Home monitoring of blood glucose; RCT: Randomized control trial; T2DM: Type 2 diabetes mellitus; MS: Short message service; SMBG: Self-monitoring of blood glucose.

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.

Table 5 Diabetes prevention: Structured dietary change and exercise as main components (not lifestyle education)

Country	Ref.	Objective	Study design	Sample size/characteristics	Components of intervention	Measurements	Outcome measures	Conclusion
China	Pan et al[83]	To determine whether diet and exercise interventions will delay development of NIDDM in individuals with IGT	RCT	n = 530, control = 133, diet = 130, exercise = 141, diet + exercise = 126, > 25 yr, IGT	Diet plans, exercise recommendations with brochures on instructions on increasing leisure physical activities and counseling sessions on daily recommended food intake, weekly for one month, monthly for three months and once every three months by physicians and nurses	FBG, 2-h fasting glucose	0, 24, 48 and 72 mo	Diet and exercise led to a significant decrease in the incidence of diabetes in individuals with IGT. The diet, exercise, and diet-plus-exercise interventions were associated with 31% (P < 0.03), 46% (P < 0.0005), and 42% (P < 0.005) reductions in risk of developing diabetes, respectively
China	Xu et al[3]	Evaluate effectiveness of lifestyle intervention and meal replacement	RCT	n = 81, 41 in intervention, 40 in control, > 18 yr, IGR	Daily low-glycaemic meal replacement, individualized eating instructions, exercise recommendations, a dietician measured weekly intake and physician conducted medical evaluations	HbA1c, fasting plasma glucose, 1 hr plasma glucose	0 and 12 mo	HbA1c change was -0.12 (P = 0.02), 2 h plasma glucose change was -1.24 (P = 0.02), fasting plasma glucose change was -0.12 (P = 0.001) in intervention group, no significant changes were noted in control group
Peru	Lindgärde et al[89]	To evaluate feasibility of supervised endurance training	RCT	n = 59, 33 in control group and 26 in experimental, 25-64 yr, normal plasma fasting glucose	Structured training sessions, one per week in control group and three per week for experimental group for 60 min each approved by physiotherapist	BMI, FBG, VO2max	0 and 6 mo	Supervised exercise training is a low cost safe therapy with favorable benefits. Plasma glucose levels decreased from 5.1 mmol/L to 4.1 mmol/L (P < 0.001) in experimental group

RCT: Randomized control trial; IGT: Impaired glucose tolerance.