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EDITORIAL
Year : 2013  |  Volume : 138  |  Issue : 6  |  Page : 820-823

Diabetes education & prevention


Division of Endocrinology, Diabetes & Hypertension Brigham & Women's Hospital 221 Longwood Ave Boston, MA 02115, USA

Date of Web Publication11-Feb-2014

Correspondence Address:
Rajesh Garg
Division of Endocrinology, Diabetes & Hypertension Brigham & Women's Hospital 221 Longwood Ave Boston, MA 02115
USA
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Source of Support: None, Conflict of Interest: None


PMID: 24521619

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How to cite this article:
Garg R. Diabetes education & prevention. Indian J Med Res 2013;138:820-3

How to cite this URL:
Garg R. Diabetes education & prevention. Indian J Med Res [serial online] 2013 [cited 2019 Oct 19];138:820-3. Available from: http://www.ijmr.org.in/text.asp?2013/138/6/820/126817

The prevalence of diabetes mellitus, especially type 2 diabetes mellitus (T2DM) is increasing worldwide [1],[2],[3] . 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 2030 [1] . 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 2 nd 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 2030 [1] . If unchecked, this epidemic will not only affect the health and well-being of our population but can also impact our economy [4] . 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 earnings [5] . 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 activity [6],[7] . 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 India [8] . Along with these desirable changes, there was an increase in obesity and prevalence of diabetes [8] . In rural India, there was a three-fold increase in the prevalence of diabetes during this time period [8] . A significant increase in abdominal obesity and glucose levels was reported between 2003 and 2008 among adolescent children in north India [9] . While poverty in developing countries is still mostly associated with malnutrition [6] , urbanization is linked to high rates of obesity and diabetes even among the poor [10],[11] . 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 population [12] . 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 prevalence [12] . 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 unsatisfactory [13] . Children in private schools may have slightly better awareness than those in government schools [14] . Even among the affluent class, including the Indians living abroad, health awareness is lower than among the other populations [15] . 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 diabetes [16] . Individuals in the lower educational groups had lower levels of awareness even though they had a higher prevalence of T2DM [16] . In a study of the general population of Chennai, 25 per cent population was completely unaware of the condition called diabetes [17] . 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 prevented [17] . 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 women [18] . 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 diabetes [4] . 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 training [19] . 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 technique [20] . 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 country [21] , 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 knowledge [14] . 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 Plan [22] . 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 organizations [23] . 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 changes [24] . 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 programme [25] .

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 Sates [26] . 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 study [27] , the Da Qing (Chinese) study [28] 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 cent [29] . 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 implemented [29],[30] . Lifestyle changes were also shown to be cost-effective in the IDPP [31] . 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.

 
   References Top

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2.Yoon KH, Lee JH, Kim JW, Cho JH, Choi YH, Ko SH, et al. Epidemic obesity and type 2 diabetes in Asia. Lancet 2006; 368 : 1681-8.  Back to cited text no. 2
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19.Holt RI, Nicolucci A, Kovacs Burns K, Escalante M, Forbes A, Hermanns N, et al. Diabetes Attitudes, Wishes and Needs second study (DAWN2): Cross-national comparisons on barriers and resources for optimal care-healthcare professional perspective. Diabet Med 2013; 30 : 789-98.  Back to cited text no. 19
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20.Kaur K, Singh MM, Kumar, Walia I. Knowledge and self-care practices of diabetics in a resettlement colony of Chandigarh. Indian J Med Sci 1998; 52 : 341-7.  Back to cited text no. 20
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21.Joshi S, Joshi S, Mohan V. Methodology and feasibility of a structured education program for diabetes education in India: The National Diabetes Educator Program. Indian J Endocrinol Metab 2013; 17 : 396-401.  Back to cited text no. 21
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23.Ramachandran A, Snehalatha C, Samith Shetty A, Nanditha A. Primary prevention of Type 2 diabetes in South Asians - challenges and the way forward. Diabet Med 2013; 30 : 26-34.  Back to cited text no. 23
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25.Radhika G, Sumathi C, Ganesan A, Sudha V, Jeya Kumar Henry C, Mohan V. Glycaemic index of Indian flatbreads (rotis) prepared using whole wheat flour and ′atta mix′-added whole wheat flour. Br J Nutr 2010; 103 : 1642-7.  Back to cited text no. 25
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27.Lindstrom J, Louheranta A, Mannelin M, Rastas M, Salminen V, Eriksson J, et al. The Finnish Diabetes Prevention Study (DPS): Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 2003; 26 : 3230-6.  Back to cited text no. 27
    
28.Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997; 20 : 537-44.  Back to cited text no. 28
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29.Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006; 49 : 289-97.  Back to cited text no. 29
    
30.Ramachandran A, Snehalatha C, Mary S, Selvam S, Kumar CK, Seeli AC, et al. Pioglitazone does not enhance the effectiveness of lifestyle modification in preventing conversion of impaired glucose tolerance to diabetes in Asian Indians: results of the Indian Diabetes Prevention Programme-2 (IDPP-2). Diabetologia 2009; 52 : 1019-26.  Back to cited text no. 30
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