BackgroundThe major efficacy trials on diabetes prevention have used resource-intensive approaches to identify high-risk individuals and deliver lifestyle interventions. Such strategies are not feasible for wider implementation in low- and middle-income countries (LMICs). We aimed to evaluate the effectiveness of a peer-support lifestyle intervention in preventing type 2 diabetes among high-risk individuals identified on the basis of a simple diabetes risk score.Methods and findingsThe Kerala Diabetes Prevention Program was a cluster-randomized controlled trial conducted in 60 polling areas (clusters) of Neyyattinkara taluk (subdistrict) in Trivandrum district, Kerala state, India. Participants (age 30–60 years) were those with an Indian Diabetes Risk Score (IDRS) ≥60 and were free of diabetes on an oral glucose tolerance test (OGTT). A total of 1,007 participants (47.2% female) were enrolled (507 in the control group and 500 in the intervention group). Participants from intervention clusters participated in a 12-month community-based peer-support program comprising 15 group sessions (12 of which were led by trained lay peer leaders) and a range of community activities to support lifestyle change. Participants from control clusters received an education booklet with lifestyle change advice. The primary outcome was the incidence of diabetes at 24 months, diagnosed by an annual OGTT. Secondary outcomes were behavioral, clinical, and biochemical characteristics and health-related quality of life (HRQoL). A total of 964 (95.7%) participants were followed up at 24 months. Baseline characteristics of clusters and participants were similar between the study groups. After a median follow-up of 24 months, diabetes developed in 17.1% (79/463) of control participants and 14.9% (68/456) of intervention participants (relative risk [RR] 0.88, 95% CI 0.66–1.16, p = 0.36). At 24 months, compared with the control group, intervention participants had a greater reduction in IDRS score (mean difference: −1.50 points, p = 0.022) and alcohol use (RR 0.77, p = 0.018) and a greater increase in fruit and vegetable intake (≥5 servings/day) (RR 1.83, p = 0.008) and physical functioning score of the HRQoL scale (mean difference: 3.9 score, p = 0.016). The cost of delivering the peer-support intervention was US$22.5 per participant. There were no adverse events related to the intervention. We did not adjust for multiple comparisons, which may have increased the overall type I error rate.ConclusionsA low-cost community-based peer-support lifestyle intervention resulted in a nonsignificant reduction in diabetes incidence in this high-risk population at 24 months. However, there were significant improvements in some cardiovascular risk factors and physical functioning score of the HRQoL scale.Trial registrationAustralia and New Zealand Clinical Trials Registry ACTRN12611000262909.

Physical inactivity makes a significant contribution to the excess CHD mortality observed in the South Asian population in the UK. This highlights the importance of prioritising the promotion of physical activity in this high-risk population.

Aims/hypothesis To identify the impact of socioeconomic status on incident impaired glucose metabolism and type 2 diabetes and to investigate the mediating role of health behaviours on this relationship using national, populationbased data. Methods The Australian Diabetes Obesity and Lifestyle (AusDiab) Study is a national, population-based, longitudinal study of adults aged 25 years and above. A total sample of 4,405 people provided complete baseline (1999)(2000) and 5 year follow-up (2004-2005) data relevant for these analyses. Fasting plasma glucose and 2 h plasma glucose were obtained from an OGTT, and demographic, socioeconomic and behavioural data were collected by interview and questionnaire. Multinomial logistic regression examined the role of socioeconomic position in the development of diabetes and mediation analyses tested the contribution of health behaviours in this relationship. Results Highest level of education was a stronger predictor of incident impaired glucose tolerance and type 2 diabetes (p=0.002), compared with household income (p=0.103), and occupational grade (p=0.202). Education remained a significant independent predictor of diabetes in fully adjusted models. However, the relationship was attenuated by the health behaviours (smoking and physical activity). Mediation analyses indicated that these behaviours were partial mediators (explaining 27%) of the socioeconomic status-diabetes relationship. Conclusion/interpretation Smoking and physical activity partly mediate the relationship between low education and type 2 diabetes. Identification of these modifiable behavioural mediators should facilitate the development of effective health promotion campaigns to target those at high risk of developing type 2 diabetes.

BackgroundType 2 diabetes mellitus (T2DM) is a significant global public health problem affecting more than 285 million people worldwide. Over 70% of those with T2DM live in developing countries, and this proportion is increasing annually. Evidence suggests that lifestyle and other nonpharmacological interventions can delay and even prevent the development of T2DM and its complications; however, to date, programs that have been specifically adapted to the needs and circumstances of developing countries have not been well developed or evaluated.PurposeThe purpose of this article is to review published studies that evaluate lifestyle and other non-pharmacological interventions aimed at preventing T2DM and its complications in developing countries.MethodsWe undertook an electronic search of MEDLINE, PubMed, and EMBASE with the English language restriction and published until 30 September 2009.ResultsNine relevant publications from seven studies were identified. The reported interventions predominantly used counseling and educational methods to improve diet and physical activity levels. Each intervention was found to be effective in reducing the risk of developing T2DM in people with impaired glucose tolerance, and improving glycemic control in people with T2DM.ConclusionsThe current evidence concerning the prevention of T2DM and its complications in developing countries has shown reasonably consistent and positive results; however, the small number of studies creates some significant limitations. More research is needed to evaluate the benefits of low-cost screening tools, as well as the efficacy, cost-effectiveness, and sustainability of culturally appropriate interventions in such countries.

BackgroundIndia currently has more than 60 million people with Type 2 Diabetes Mellitus (T2DM) and this is predicted to increase by nearly two-thirds by 2030. While management of those with T2DM is important, preventing or delaying the onset of the disease, especially in those individuals at ‘high risk’ of developing T2DM, is urgently needed, particularly in resource-constrained settings. This paper describes the protocol for a cluster randomised controlled trial of a peer-led lifestyle intervention program to prevent diabetes in Kerala, India.Methods/designA total of 60 polling booths are randomised to the intervention arm or control arm in rural Kerala, India. Data collection is conducted in two steps. Step 1 (Home screening): Participants aged 30–60 years are administered a screening questionnaire. Those having no history of T2DM and other chronic illnesses with an Indian Diabetes Risk Score value of ≥60 are invited to attend a mobile clinic (Step 2). At the mobile clinic, participants complete questionnaires, undergo physical measurements, and provide blood samples for biochemical analysis. Participants identified with T2DM at Step 2 are excluded from further study participation. Participants in the control arm are provided with a health education booklet containing information on symptoms, complications, and risk factors of T2DM with the recommended levels for primary prevention. Participants in the intervention arm receive: (1) eleven peer-led small group sessions to motivate, guide and support in planning, initiation and maintenance of lifestyle changes; (2) two diabetes prevention education sessions led by experts to raise awareness on T2DM risk factors, prevention and management; (3) a participant handbook containing information primarily on peer support and its role in assisting with lifestyle modification; (4) a participant workbook to guide self-monitoring of lifestyle behaviours, goal setting and goal review; (5) the health education booklet that is given to the control arm. Follow-up assessments are conducted at 12 and 24 months. The primary outcome is incidence of T2DM. Secondary outcomes include behavioural, psychosocial, clinical, and biochemical measures. An economic evaluation is planned.DiscussionResults from this trial will contribute to improved policy and practice regarding lifestyle intervention programs to prevent diabetes in India and other resource-constrained settings.Trial registrationAustralia and New Zealand Clinical Trials Registry: ACTRN12611000262909.

Objective: Emerging evidence suggests that psychosocial stress may influence weight gain. The relationship between stress and weight change and whether this was influenced by demographic and behavioral factors was explored. Design and Methods: A total of 5,118 participants of AusDiab were prospectively followed from 2000 to 2005. The relationship between stress at baseline and BMI change was assessed using linear regression. Results: Among those who maintained/gained weight, individuals with high levels of perceived stress at baseline experienced a 0.20 kg/m 2 (95% CI: 0.07-0.33) greater mean change in BMI compared with those with low stress. Additionally, individuals who experienced 2 or !3 stressful life events had a 0.13 kg/m 2 (0.00-0.26) and 0.26 kg/m 2 (0.14-0.38) greater increase in BMI compared with people with none.These relationships differed by age, smoking, and baseline BMI. Further, those with multiple sources of stressors were at the greatest risk of weight gain. Conclusion: Psychosocial stress, including both perceived stress and life events stress, was positively associated with weight gain but not weight loss. These associations varied by age, smoking, obesity, and multiple sources of stressors. Future treatment and interventions for overweight and obese people should consider the psychosocial factors that may influence weight gain.

BackgroundEffective self-management of diabetes is essential for the reduction of diabetes-related complications, as global rates of diabetes escalate.MethodsRandomised controlled trial. Adults with type 2 diabetes (n = 120), with HbA1c greater than or equal to 7.5 %, were randomly allocated (4 × 4 block randomised block design) to receive an automated, interactive telephone-delivered management intervention or usual routine care. Baseline sociodemographic, behavioural and medical history data were collected by self-administered questionnaires and biological data were obtained during hospital appointments. Health-related quality of life (HRQL) was measured using the SF-36.ResultsThe mean age of participants was 57.4 (SD 8.3), 63% of whom were male. There were no differences in demographic, socioeconomic and behavioural variables between the study arms at baseline. Over the six-month period from baseline, participants receiving the Australian TLC (Telephone-Linked Care) Diabetes program showed a 0.8% decrease in geometric mean HbA1c from 8.7% to 7.9%, compared with a 0.2% HbA1c reduction (8.9% to 8.7%) in the usual care arm (p = 0.002). There was also a significant improvement in mental HRQL, with a mean increase of 1.9 in the intervention arm, while the usual care arm decreased by 0.8 (p = 0.007). No significant improvements in physical HRQL were observed.ConclusionsThese analyses indicate the efficacy of the Australian TLC Diabetes program with clinically significant post-intervention improvements in both glycaemic control and mental HRQL. These observed improvements, if supported and maintained by an ongoing program such as this, could significantly reduce diabetes-related complications in the longer term. Given the accessibility and feasibility of this kind of program, it has strong potential for providing effective, ongoing support to many individuals with diabetes in the future.

Background: South Asians in Britain experience high rates of coronary heart disease