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Community-Based Diabetes Prevention and Management Education in Rural India

Principal Investigators:

Padmini Balagopal PHD CDE RD and N Kamalamma PHD,
Gandhigram Rural Institute, India

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Thakor G Patel MD, Chair Public Health Committee,
AAPI & Adjunct Associate Professor of Medicine,
Uniformed Services University of the Health Sciences

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Ranjita Misra PHD, CHES, Member Public Health Committee, AAPI & Professor, Texas A&M University, College Station Texas

Introduction

The World Health Organization predicts non communicable diseases (NCDs) will account for two-thirds of all deaths within the next 25 years in the South-East Asian countries.India is the diabetic capital of the world with 58 million individuals with type 2 diabetes mellitus.  Seventy percent of India’s population lives in resource-poor rural settings where a chronic disease like type 2 diabetes mellitus can rapidly deteriorate into a crisis due to low awareness, poor access to quality care, and increased diabetes-related complications.  Primary prevention is therefore critically important because it offers the most cost-effective strategy to prevent type 2 diabetes mellitus and sustain the changes long-term.  Studies suggest a community based participatory approach (CBPR) will enhance the effectiveness of such diabetes programs by engaging the participants in the planning and intervention processes.  Hence, this project used a 7-month non-pharmacological intervention was to evaluate the effectiveness of a CBPR based diabetes prevention and management program in rural Tamil Nadu in India.

Objective-

This project evaluated a 7-month community-based non-pharmacological lifestyle modification intervention to prevent/reduce the risk of developing diabetes and its complications in the resource-poor village in Tamilnadu, India.

Research Design and Methods -

The quasi-experimental study design used a collective population approach to provide intervention using trained individuals for a period of seven months. The village of Alamarathupatti, one of the field sites of Gandhigram Rural Institute (GRI), was selected. This hamlet with a population of 1150 residents (950 over 10 years of age) of mixed a religion and socio-economic strata, had only a elementary school and a primary health clinic. Recruitment of subjects’ ≥ 10 years of age was completed through door-to-door visitations.

Community Based Participatory Research Approach -

The CBPR method as described by Israel and his colleagues (10) was used to plan the project using a ‘from the ground up’ approach.  Community stakeholders (key formal and informal community leaders, village elders, local school staff, health professionals, and community members) were engaged in planning, implementation, and improving awareness.  Eight pre-planning meetings were conducted before launching the program to enhance understanding of health issues affecting the community. Community representatives identified chronic diseases, especially diabetes, as a major area of concern.

Educational Intervention -

Culturally-sensitive and linguistically appropriate (Tamil language) diabetes education and lifestyle modifications addressed diet, physical activity, stress relaxation and blood glucose management (for the core group with a pre-condition of T2DM or IFG). Ten face-to-face encounters were customized on an individual basis. These health messages were tailored for gender, age and socio-economic differences in the target population.  Reinforcement of education intervention was supported by group events.

Dietary education highlighted the intake of fiber and protein from local resources, low glycemic whole grains, and avoidance of empty calories from sweetened drinks and fried foods.  Reinforcement of dietary education was channeled through cooking demonstrations, recipe competitions, and model meals. Physical activity education focused on individual and group counseling, with demonstrations and dancercise events held to reach the younger respondents. The importance of physical activity was further reinforced through competitive fun events using peer influences and family support.  Stress relaxation included the importance of meditation and breathing exercises already familiar to many of the respondents. Education and counseling for blood glucose management to the core group included the importance of periodic blood glucose testing, weight control, portion controlled diet, regulated physical activity, and medication management (where applicable) and was provided by a certified diabetes educator on a one-on-one basis and periodically reinforced. Additionally a one-time sample of a low-cost, portion-controlled ‘model meal’ was served to demonstrate minor yet effective low-glycemic improvements to the current diet. The model meal included sprouted lentils and vegetables partly substituting enriched white rice that formed the prototype meal pattern. This served as a valuable interactive teaching tool.

Results-

The crude prevalence of diabetes and pre-diabetes among adults was 5.1% and 13.5%  respectively, while pre-diabetes  in youth 10-17 years of age was  of 5.1%.  Intervention reduced fasting blood glucose levels by 3% in the adults, 11%  in pre-diabetes adults , 17%  in pre-diabetes youth and 25%  among adults with type 2 diabetes mellitus.    Improvements in obesity parameters and dietary intake also occurred. There was a step-wise worsening of parameters   progressing from the normoglycemic state to the impaired levels of pre-diabetes and Diabetes mellitus  

Conclusions-

This study has charted the increasing prevalence of diabetes and pre-diabetes in rural India.   Educational intervention reduced obesity risk factors and improved diet in the target population   especially in the individuals with pre-diabetes and diabetes mellitus.

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