Lifestyle change in Kerala, India: needs assessment and planning for a community-based diabetes prevention trial

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Abstract

Background

Type 2 Diabetes Mellitus (T2DM) has become a major public health challenge in India. Factors relevant to the development and implementation of diabetes prevention programmes in resource-constrained countries, such as India, have been under-studied. The purpose of this study is to describe the findings from research aimed at informing the development and evaluation of a Diabetes Prevention Programme in Kerala, India (K-DPP).

Methods

Data were collected from three main sources: (1) a systematic review of key research literature; (2) a review of relevant policy documents; and (3) focus groups conducted among individuals with a high risk of progressing to diabetes. The key findings were then triangulated and synthesised.

Results

Prevalence of risk factors for diabetes is very high and increasing in Kerala. This situation is largely attributable to rapid changes in the lifestyle of people living in this state of India. The findings from the systematic review and focus groups identified many environmental and personal determinants of these unhealthy lifestyle changes, including: less than ideal accessibility to and availability of health services; cultural values and norms; optimistic bias and other misconceptions related to risk; and low expectations regarding one’s ability to make lifestyle changes in order to influence health and disease outcomes. On the other hand, there are existing intervention trials conducted in India which suggests that risk reduction is possible. These programmes utilize multi-level strategies including mass media, as well as strategies to enhance community and individual empowerment. India’s national programme for the prevention and control of major non-communicable diseases (NCD) also provide a supportive environment for further community-based efforts to prevent diabetes.

Conclusion

These findings provide strong support for undertaking more research into the conduct of community-based diabetes prevention in the rural areas of Kerala. We aim to develop, implement and evaluate a group-based peer support programme that will address cultural and family determinants of lifestyle risks, including family decision-making regarding adoption of healthy dietary and physical activity patterns. Furthermore, we believe that this approach will be feasible, acceptable and effective in these communities; with the potential for scale-up in other parts of India.

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Most cited references 40

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The use of theory in health behavior research from 2000 to 2005: a systematic review.

Darren Mays, Stephanie E Painter, Denise Hynes … (2008)

Theory-based health behavior change programs are thought to be more effective than those that do not use theory. No previous reviews have assessed the extent to which theory is used (that is, operationalized and tested) in empirical research. The purpose of this study was to describe theory use in recent health behavior literature and to assess the proportion of research that uses theory along a continuum from: informed by theory to applying, testing, or building theory. A sample of empirical research articles (n = 193) published in ten leading public health, medicine, and psychology journals from 2000 to 2005 was coded to determine whether and how theory was used. Of health behavior articles in the sample, 35.7% mentioned theory. The most-often-used theories were The Transtheoretical Model, Social Cognitive Theory, and Health Belief Model. Most theory use (68.1%) involved research that was informed by theory; 18% applied theory; 3.6% tested theory; and 9.4% sought to build theory. About one third of published health behavior research uses theory and a small proportion of those studies rigorously apply theory. Patterns of theory use are similar to reports from the mid-1990s. Behavioral researchers should strive to use theory more thoroughly by applying, testing, and building theories in order to move the field forward.

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Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males.

M Noda, T Kuzuya, K Kosaka (2005)

Prevention of type 2 diabetes by intensive lifestyle intervention designed to achieve and maintain ideal body weight was assessed in subjects with impaired glucose tolerance (IGT). Male subjects with IGT recruited from health-screening examinees were randomly assigned in a 4:1 ratio to a standard intervention group (control group) and intensive intervention group (intervention group). The final numbers of subjects were 356 and 102, respectively. The subjects in the control group and in the intervention group were advised to maintain body mass index (BMI) of <24.0 kg/m2 and of <22.0 kg/m2, respectively, by diet and exercise. In the intervention group, detailed instructions on lifestyle were repeated every 3-4 months during hospital visits. Diabetes was judged to have developed when two or more consecutive fasting plasma glucose (FPG) values exceeded 140 mg/dl. A 100g oral glucose tolerance test was performed every 6 months to detect improvement of glucose tolerance. The subjects were seen in an ordinary outpatient clinic. The cumulative 4-year incidence of diabetes was 9.3% in the control group, versus 3.0% in the intervention group, and the reduction in risk of diabetes was 67.4% (P < 0.001). Body weight decreased by 0.39 kg in the control group and by 2.18 kg in the intervention group (P < 0.001). The control group was subclassified according to increase and decrease in body weight. The incidence of diabetes was positively correlated with the changes in body weight, and the improvement in glucose tolerance was negatively correlated. Subjects with higher FPG at baseline developed diabetes at a higher rate than those with lower FPG. Higher 2h plasma glucose values and higher BMI values at baseline were also associated with a higher incidence of diabetes, but the differences were not significant. Subjects with a low insulinogenic index (DeltaIRI/DeltaPG 30 min after an oral glucose load) developed diabetes at a significantly higher rate than those with a normal insulinogenic index. Comparison of the BMI data and incidence of diabetes in five diabetes prevention studies by lifestyle intervention revealed a linear correlation between the incidence of diabetes and the BMI values, with the exception of the DaQing Study. However, the slope of the reduction in incidence of diabetes in the intensive intervention groups was steeper than expected simply on the basis of the reduction of BMI, suggesting that the effect of lifestyle intervention cannot be solely ascribed to the body weight reduction. We conclude that lifestyle intervention aimed at achieving ideal body weight in men with IGT is effective and can be conducted in an outpatient clinic setting.

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Prevention of type 2 (non-insulin-dependent) diabetes mellitus by diet and physical exercise. The 6-year Malmö feasibility study.

K F Eriksson, F Lindgärde (1991)

From a previously reported 5-year screening programme of 6,956 47-49-year-old Malmö males, a series of 41 subjects with early-stage Type 2 (non-insulin-dependent) diabetes mellitus and 181 subjects with impaired glucose tolerance were selected for prospective study and to test the feasibility aspect of long-term intervention with an emphasis on life-style changes. A 5-year protocol, including an initial 6-months (randomised) pilot study, consisting of dietary treatment and/or increase of physical activity or training with annual check-ups, was completed by 90% of subjects. Body weight was reduced by 2.3-3.7% among participants, whereas values increased by 0.5-1.7% in non-intervened subjects with impaired glucose tolerance and in normal control subjects (p less than 0.0001); maximal oxygen uptake (ml.min-1.kg-1) was increased by 10-14% vs decreased by 5-9%, respectively (p less than 0.0001). Glucose tolerance was normalized in greater than 50% of subjects with impaired glucose tolerance, the accumulated incidence of diabetes was 10.6%, and more than 50% of the diabetic patients were in remission after a mean follow-up of 6 years. Blood pressure, lipids, and hyperinsulinaemia were reduced and early insulin responsiveness to glucose loading preserved. Improvement in glucose tolerance was correlated to weight reduction (r = 0.19, p less than 0.02) and increased fitness (r = 0.22, p less than 0.02). Treatment was safe, and mortality was low (in fact 33% lower than in the remainder of the cohort).(ABSTRACT TRUNCATED AT 250 WORDS)

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Author and article information

Contributors

Meena Daivadanam

Pilvikki Absetz

Thirunavukkarasu Sathish

K R Thankappan

Edwin B Fisher

Neena Elezebeth Philip

Elezebeth Mathews

Brian Oldenburg

Journal

Journal ID (nlm-ta): BMC Public Health

Journal ID (iso-abbrev): BMC Public Health

Title: BMC Public Health

Publisher: BioMed Central

ISSN (Electronic): 1471-2458

Publication date Collection: 2013

Publication date (Electronic): 1 February 2013

Volume: 13

Page: 95

Affiliations

[1 ]Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

[2 ]Division of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Nobels vag 9, Stockholm, 171 77, Sweden

[3 ]National Institute for Health and Welfare, Helsinki, Finland

[4 ]School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

[5 ]Department of Health Behaviour and Health Education, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA

Article

Publisher ID: 1471-2458-13-95

DOI: 10.1186/1471-2458-13-95

PMC ID: 3576354

PubMed ID: 23375152

SO-VID: 777efa22-37b1-41ce-960b-cc061662bc4a

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 25 June 2012

Date accepted : 16 January 2013

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Lifestyle change in Kerala, India: needs assessment and planning for a community-based diabetes prevention trial

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Most cited references 40

The use of theory in health behavior research from 2000 to 2005: a systematic review.

Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males.

Prevention of type 2 (non-insulin-dependent) diabetes mellitus by diet and physical exercise. The 6-year Malmö feasibility study.

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Cited by 32

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