Diabetes education & prevention.

The prevalence of diabetes mellitus, especially type 2 diabetes mellitus (T2DM) is increasing worldwide123. As per the International Diabetes Federation (IDF), 366 million people had diabetes in 2011, a number that is estimated to rise to 552 million by 20301. This epidemic will affect developing countries disproportionately as 80 per cent of people with diabetes reside in low- and middle-income countries. Currently, India is 2nd only to China in the total number of people living with diabetes. In 2011, 61.3 million Indians were projected to have diabetes, a number that is expected to rise to 101.2 million in 20301. If unchecked, this epidemic will not only affect the health and well-being of our population but can also impact our economy4. The majority of people with diabetes are between 40-59 yr of age. As a result, in addition to direct costs, diabetes is associated with huge indirect costs due to lost earnings5. Therefore, it is urgent to pay attention to this disease so that effective preventive strategies can be developed.

Existing evidence links rising rates of obesity and T2DM to urbanization and adoption of a Western lifestyle that includes consumption of energy-rich foods and decreased physical activity67. More and more people in developing countries are able to afford a Western life-style. Temporal trends from 1989 to 2003 showed an improvement in overall living conditions, occupational changes from more manual to office based work and better economic conditions in India8. Along with these desirable changes, there was an increase in obesity and prevalence of diabetes8. In rural India, there was a three-fold increase in the prevalence of diabetes during this time period8. A significant increase in abdominal obesity and glucose levels was reported between 2003 and 2008 among adolescent children in north India9. While poverty in developing countries is still mostly associated with malnutrition6, urbanization is linked to high rates of obesity and diabetes even among the poor1011. In a large survey of the general population of India, diabetes was reported in 3.1 per cent of the rural and 7.3 per cent of the urban population12. Urban residents with abdominal obesity and sedentary lifestyle had the highest prevalence of diabetes while rural residents without abdominal obesity and demanding physical work had the lowest prevalence12. These data suggest that the high prevalence of T2DM is intimately related to lifestyle. Thus, changing the habits of our population from an unhealthy lifestyle to a healthy lifestyle can be an effective strategy for the prevention of T2DM.

Education plays a significant role not only in the prevention of diabetes itself but also in preventing its complications. Currently, health education to prevent diabetes in rural India is non-existent. Major gaps also exist in education about health and nutrition among urban populations. In a study of school children, awareness about lifestyle risk factors for non-communicable diseases was found to be unsatisfactory13. Children in private schools may have slightly better awareness than those in government schools14. Even among the affluent class, including the Indians living abroad, health awareness is lower than among the other populations15. Among individuals working in urban Indian industries where universal access to health care was available, a large proportion of the diabetic patients were unaware that they had diabetes16. Individuals in the lower educational groups had lower levels of awareness even though they had a higher prevalence of T2DM16. In a study of the general population of Chennai, 25 per cent population was completely unaware of the condition called diabetes17. Only 60 per cent people knew that the prevalence of diabetes was increasing in India and only 22 per cent were aware that diabetes could be prevented17. Knowledge about the role of obesity and physical inactivity in causing diabetes was even worse, with only about 12 per cent of study subjects reporting that these were the risk factors for diabetes. Knowledge regarding causes of diabetes, its prevention and the methods to improve health is especially poor among women18. These studies show that awareness and knowledge regarding diabetes is grossly inadequate in India and massive diabetes education programmes are urgently needed at the national level.

Lack of education about diabetes may also be common among the medical professionals. In one study, not only patients but also the healthcare providers displayed a lack of understanding for the need of constant monitoring and consistent tight glycaemic control in patients with diabetes4. In the Diabetes Attitudes, Wishes and Needs (DAWN)2 study, up to one third of healthcare professionals in some countries reported not having received any formal diabetes training19. In India, the majority of patients with diabetes, even those on insulin, lack knowledge about self-care of diabetes including food, exercise, hygiene, self monitoring of blood glucose or proper insulin injection technique20. The National Diabetes Educator Program initiated in 2011 was the first structured education programme for diabetes educators in India and it has reportedly trained 1032 diabetes educators all over the country21, a number grossly inadequate for the huge diabetic population of India.

Aim of education for prevention of diabetes should be achieving a healthy body weight through a combination of dietary modifications and physical activity. One should keep in mind that South Asians have more visceral fat and develop diabetes at relatively lower BMI and therefore, require different goal setting than other populations. Education should start early at the school level. In one study, following the intervention in schools, knowledge scores improved in all children especially in younger children, in females and in government schools because of their low baseline knowledge14. An education campaign should start by trying to break the age-old myths and replace them with scientifically accurate facts. To be successful, the campaign must be tailored to the local needs and culture. For example, in some societies, obesity is considered to be a sign of good health and prosperity. Finishing all food on the plate is another norm in some cultures. Festival eating and overeating in other social situations (for example, weddings) can result in a significant increase in total calorie intake and this practice needs further studies. Over time, society will need to change its attitude towards food so that food does not dominate social events. The head of the family and women should be the target of education about healthy grocery shopping and healthy cooking to reduce total caloric intake for the entire family. Western style diets need to be discouraged. Societal changes to encourage more physical activity at all levels are needed. About half an hour of moderate to high intensity physical activity should be emphasized.

Healthy lifestyle should be promoted at every possible opportunity but simply advising and educating people about diet and exercise is not enough. Simultaneously, attention should be paid to creating conditions conducive to a healthy lifestyle. The IDF population strategy requires the governments of all countries to develop and implement a National Diabetes Prevention Plan22. This programme needs integrated efforts of the government, local communities, media, healthcare services and education services, and would require financial support from government as well as from non-governmental organizations23. Workers belonging to the same socio-cultural group are likely to be more effective educators and interventions promoting culturally acceptable and financially affordable dietary and exercise changes are most likely to succeed in bringing meaningful changes24. Research should also be a part of the diabetes prevention programme. For example, research on alternative flour to make low glycaemic index flat bread can be directly relevant to the diabetes prevention programme25.

Successful implementation of some diabetes prevention programmes and their cost-effectiveness has already been demonstrated. Effect of lifestyle changes on diabetes incidence was reported in the Diabetes Prevention Programme, a large randomized controlled trial conducted in the United Sates26. This study showed that aggressive lifestyle changes can help to prevent or delay the onset of T2DM by about 50 per cent. A few other smaller studies including the Finish study27, the Da Qing (Chinese) study28 and the Indian Diabetes Prevention Programme (IDPP)29 confirm that diabetes prevention is possible by aggressive lifestyle changes across all ethnic groups. In the IDPP, progression from impaired glucose tolerance to diabetes was higher than anticipated based on data from other populations but lifestyle modification reduced the incidence of diabetes by 28.5 per cent29. IDPP also showed, that drug therapy with metformin or pioglitazone was unnecessary and did not offer any additional advantage if effective lifestyle changes could be implemented2930. Lifestyle changes were also shown to be cost-effective in the IDPP31. These studies provide compelling data to initiate a National Diabetes Prevention Programme focused on education to promote a healthy lifestyle.

In conclusion, while the prevalence of diabetes is increasing much faster in the developing countries, awareness and education about diabetes remains suboptimal. Aggressive lifestyle changes including healthy diet and physical activity can prevent diabetes. Education campaigns at all levels of society to reverse the trends of westernization, to get rid of many cultural myths and misconceptions and to promote a healthier lifestyle are needed to stem the rising tide of diabetes.