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Primary prevention of type 2 diabetes in India

Dr A Ramachandran, Chennai
There have been several pioneering prevention programs in the world like the DPP in the US, IDPP in India. The first prevention program was in China.
IDPP screened populations to recruit subjects at risk of developing diabetes with outcome to prevent or postpone onset of type 2 diabetes.
IDPP-1 (Diabetologia 2006;49:289-297) formed the background to do further studies on prevention of diabetes in subjects with IGT among Indians (Diabetologia May 2009; The Lancet Diabetes Sept 2013).
IDPP-1 randomized study subjects into 4 groups: No intervention, lifestyle modification, metformin and lifestyle modification + metformin. We had 95% participation adherence after 3 years. The trial concluded that lifestyle modification significantly reduced conversion to diabetes by 28.5%, metformin by 26.4% and lifestyle modification + metformin by 28.2%.
Difference between Indian study and western studies
Indians develop IGT at least one decade earlier
BMI is much lower
We use metformin at a much lower dose
Moderate lifestyle modification advocated
Weight loss was not significant
The primary prevention trials so far, have proved that lifestyle intervention can reduce incidence of diabetes in high risk subjects. But, such programs are labour intensive, costly and have not been widely implemented, even in high-income countries.
The pilot study in J Assoc Physicians India 2011 Nov;59:711-4 by Shetty AS et al showed that frequent communication via SMS was acceptable to diabetic patients and it helped to improve the health outcomes.
A new study evaluated whether tailored SMSs encouraging lifestyle changes could reduce incidence type 2 diabetes in Indian men with IGT (Lancet Diabetes Endocrinol. 2013 Nov;1(3):191-8). In the study, controls were given standard care advice; intervention group received standard care + motivational text messages, which were tailored according to stage of TTM. There was 36% relative risk reduction in T2DM and 9% absolute risk reduction. HDL-C improved, dietary adherence improved, no sign of improvement in physical activity.
A study published in Nov 2014 issue of Diabetes Care showed that early improvement was associated with a 75% lower incidence of diabetes in 2 years when compared with the remaining dysglycemic persons.
Increased triglycerides and increased waist circumference strongly associated with IR (Diabetes Medicine 2014 Jun 9): hypertriglyceridemic waist phenotype (HTWP): WC =90 cm; serum TG = 1.7 mmol/l. It can be used as a simple proxy for IR.
The oral disposition index is a strong predictor of incident diabetes in Asian Indian prediabetic men (Acta Diabetol. 2015 Feb 12).

Key messages from the SMS study

Mobile messaging could be a practical and affordable strategy to deliver lifestyle advice to delay or prevent onset of T2DM.
The ancillary studies have provided insight into the prediction and pathogenesis of diabetes in the Indian population.

This study is one of the 1st examples of clinical outcome using mobile technology or m-Health.

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