Economic evaluation of diabetes prevention interventions in Bangladesh: A modelling study.

BackgroundA cluster randomised trial of mHealth and participatory learning and action (PLA) community mobilisation interventions showed that PLA significantly reduced the prevalence of intermediate hyperglycaemia and type 2 diabetes mellitus...

BackgroundTo determine the association between triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C) for identifying subjects at risk of incident prediabetes and type 2 diabetes mellitus (T2DM).MethodsIn 5064 subjects (men = 2247) aged ≥ 20 years, using Cox proportional hazards regression analyses, the associations of TG/HDL-C with incident prediabetes and T2DM were examined among normoglycemic men and women. Furthermore, the association of this lipid ratio with incident T2DM was also assessed among prediabetic subjects (n = 1414). The multivariable analyses were adjusted for age, body mass index, waist-to-height ratio, wrist circumference, systolic blood pressure, family history of T2DM, education level, history of cardiovascular diseases, and fasting plasma glucose (FPG).ResultsDuring a median follow-up of 11.2 years, 2140 new cases of prediabetes (men = 1070) and 360 incident T2DM (men = 152) were identified among normoglycemic individuals. In the prediabetic population, 574 new cases of T2DM (men = 252) were developed. Among the whole population, compared to the first quartile (reference), higher quartiles of TG/HDL-C were significantly associated with higher risks of incident prediabetes and T2DM among normoglycemic individuals and incident T2DM in the prediabetic population (all P for trend < 0.001). The corresponding hazard ratios (HRs) and 95% confidence intervals (CIs) for the fourth quartiles were 1.37(1.20–1.58), 1.92(1.34–2.75), and 1.57(1.22–2.01), respectively. The sex-stratified analyses demonstrated similar significant associations in both sexes; however, TG/HDL-C lost its association with incident T2DM among prediabetic men. Among the normoglycemic population, 1 unit increase in TG/HDL-C was significantly associated with incident prediabetes and T2DM [1.02(1.00–1.03) and 1.06(1.03–1.08), respectively]. The corresponding value for incident T2DM in prediabetic individuals was 1.01(1.00–1.03). In a subgroup population having insulin data (n = 2897), the associations between TG/HDL-C and incident prediabetes and T2DM among normoglycemic individuals generally persisted even after replacing FPG with an index of insulin resistance (IR), i.e., homeostasis model assessment of IR (HOMA-IR) in the adjusted model.ConclusionsIn conclusion, in the normoglycemic population, the increasing value of TG/HDL-C was unfavorably associated with incident prediabetes and T2DM, especially among women. Similarly, TG/HDL-C was associated with incident T2DM in prediabetic individuals. Generally, we found that the correlation between TG/HDL-C and different states of dysglycemia is independent of HOMA-IR.

Diabetes is a rapidly growing non-communicable disease globally, with 360 million out of 537 million affected adults residing in urban centres in 2021. In Pakistan, the situation is alarming, with diabetes prevalence alone exceeding 28.3% in urban areas, placing significant strain on the healthcare system exacerbated by limited resources and high management costs. Due to these multidimensional challenges, there is a growing emphasis on large-scale community-based participatory interventions like Participatory Learning and Action (PLA) for the prevention and control of type 2 diabetes mellitus (T2DM) and to improve the health outcomes of people living with T2DM. Building on a successful rural intervention from Bangladesh (D-Magic), our study aims to adapt PLA for T2DM prevention and control in urban settings and assess its feasibility in the urban context of Pakistan. The EMPOWER-D feasibility trial is a two-arm cluster randomised control trial (cRCT) with embedded economic and process evaluation, to be conducted in the urban setting of Karachi, Pakistan. Six clusters, defined as blocks with a population of 1500, will be randomly allocated (1:1) to intervention and control arms. The intervention arm will participate in an 18-month PLA intervention, which includes monthly community meetings where group members will identify, prioritise, and address issues related to T2DM and its associated risk factors. Recruitment, appropriateness, and intervention fidelity will be assessed, alongside anthropometric, biochemical, and sociodemographic data collection. The trial data will be descriptively reported for the feasibility outcomes. This EMPOWER-D feasibility trial is among the first to implement a culturally tailored PLA intervention to prevent and control T2DM in urban low- and middle-income countries (LMICs). By conducting a feasibility cRCT trial, we aim to generate critical insights into this approach's feasibility in an urban setting, informing the implementation of a future definitive trial. Addressing T2DM aligns with the Sustainable Development Goals for 2030, exploring how community-based research can empower LMICs to tackle local health risks and targets. The trial is registered at Clinicaltrials.gov on 26th August 2024 [NCT06570057]. Engagement of coMmunity through Participatory learning and action for cOntrol and preVEntion of type 2 Diabetes and its Risk factors: UrbanFeasibility Trial (EMPOWER-D-UFT).

BackgroundAn estimated 463 million people globally have diabetes, with the prevalence growing in low-and middle-income settings, such as Bangladesh. Given the need for context-appropriate interventions to prevent type 2 diabetes mellitus (T2DM), the ‘Diabetes: Community-led Awareness, Response and Evaluation’ (D:Clare) trial will rigorously evaluate the replication and scale-up of a participatory learning and action (PLA) cycle intervention in Bangladesh, to inform policy on population-level T2DM prevention and control.MethodsThis is a stepped-wedge cluster randomised controlled trial, with integrated process and economic evaluations, conducted from March 2020 to September 2022. The trial will evaluate a community-based four-phase PLA cycle intervention focused on prevention and control of T2DM implemented over 18 months, against a control of usual care. Twelve clusters will be randomly allocated (1:1) to implement the intervention at project month 1 or 12. The intervention will be evaluated through three cross-sectional surveys at months 1, 12 and 24. The trial will be conducted in Alfadanga Upazila, Faridpur district, with an estimated population of 120,000. Clusters are defined as administrative geographical areas, with approximately equal populations. Each of the six unions in Alfadanga will be divided into two clusters, forming 12 clusters in total. Given the risk of inter-cluster contamination, evaluation surveys will exclude villages in border areas. Participants will be randomly sampled, independently for each survey, from a population census conducted in January 2020. The primary outcome is the combined prevalence of intermediate hyperglycaemia and T2DM, measured through fasting and 2-h post-glucose load blood tests. A total of 4680 participants provide 84% power to detect a 30% reduction in the primary outcome, assuming a baseline of 30% and an ICC of 0.07. The analysis will be by intention-to-treat, comparing intervention and control periods across all clusters, adjusting for geographical clustering.DiscussionThis study will provide further evidence of effectiveness for community-based PLA to prevent T2DM at scale in a rural Bangladesh setting. However, we encountered several challenges in applying the stepped-wedge design to our research context, with particular consideration given to balancing seasonality, timing and number of steps and estimation of partial versus full effect.Trial registrationISRCTN: ISRCTN42219712. Registered on 31 October 2019

Prospective observational studies uniformly link vitamin D deficiency with the incidence of type 2 diabetes mellitus (T2DM), yet trials supplementing participants at risk of T2DM with vitamin D to reduce progression to T2DM have yielded inconsistent results. Inconsistencies between supplementation trials may be due to insufficient dosing or small sample sizes. Observational studies may also have reported spurious associations due to uncontrolled confounding by lifestyle or genetic factors. Alternatively, observational and intervention studies may not be entirely comparable. Observational studies show an association between higher vitamin D status, which is predominantly derived from sun exposure, and decreased incidence of T2DM. Trials intervene with vitamin D supplementation, and therefore may be missing alternate causes of the effect of sun exposure, as seen in observational studies. We propose that sun exposure may be the driving force behind the associations seen in observational studies; sun exposure may have additional benefits beyond increasing serum 25-hydroxyvitamin D (25OHD) levels. We performed an electronic literature search to identify articles that examined associations between sun exposure and T2DM and/or glucose metabolism. A best evidence synthesis was then conducted using outcomes from analyses deemed to have high methodological quality. Ten eligible full-text articles were identified, yielding 19 T2DM-related outcomes. The best evidence analysis considered 11 outcomes which were grouped into six outcome types: T2DM, fasting glucose, glucose tolerance, fasting insulin, insulin secretion and insulin sensitivity. There was moderate evidence to support a role of recreational sun exposure in reducing odds of T2DM incidence. High-level evidence was lacking; evidence presented for other outcomes was of low or insufficient level. This review highlights significant gaps in research pertaining to sun exposure and T2DM-related outcomes. Further research is encouraged as we aim to identify novel preventative strategies for T2DM.

SummaryBackgroundStrategies are needed to prevent and control type 2 diabetes and intermediate hyperglycaemia, which together affect roughly a third of adults in Bangladesh. We aimed to assess the effects of mHealth and community mobilisation on the prevalence of intermediate hyperglycaemia and diabetes among the general adult population in rural Bangladesh, and to assess the effect of these interventions on the incidence of type 2 diabetes among people with intermediate hyperglycaemia within the study population.MethodsDMagic was a three-arm, cluster-randomised trial of participatory community mobilisation, mHealth mobile phone messaging, and usual care (control) in 96 villages (population roughly 125 000) in Bangladesh. Community mobilisation involved 18 monthly group meetings, led by lay facilitators, applying a participatory learning and action (PLA) cycle focused on diabetes prevention and control. mHealth involved twice-weekly voice messages over 14 months promoting behaviour change to reduce diabetes risk. The primary outcomes were the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the overall population at the end of the intervention implementation period, and 2-year cumulative incidence of type 2 diabetes in a cohort with intermediate hyperglycaemia at baseline. Primary outcomes were assessed through fasting blood glucose concentrations and 2-h oral glucose tolerance tests among a cross-section of adults aged 30 years and older and a cohort of individuals identified with intermediate hyperglycaemia. Prevalence findings are based on a cross-sectional survey at the end of the study; incidence findings are based on 2-year follow-up survey of a cohort of individuals identified with intermediate hyperglycaemia through a cross-sectional survey at baseline. We also assessed the cost-effectiveness of the interventions. This trial is registered with the ISRCTN registry, number ISRCTN41083256, and is completed.FindingsThe study took place between June 27, 2015, and June 28, 2018, with the PLA intervention running in 32 villages from June, 2016, to December, 2017, and the mHealth intervention running in 32 villages from Oct 21, 2016, to Dec 24, 2017. End-of study prevalence was assessed in 11 454 individuals and incidence in 2100 individuals. There was a large reduction in the combined prevalence of type 2 diabetes and intermediate hyperglycaemia in the PLA group compared with the control group at the end of the study (adjusted [for stratification, clustering, and wealth] odds ratio [aOR] 0·36 [0·27–0·48]), with an absolute reduction of 20·7% (95% CI 14·6–26·7). Among 2470 adults with intermediate hyperglycaemia at baseline, 2100 (85%) were followed-up at 2 years. The 2-year cumulative incidence of diabetes in this cohort was significantly lower in the PLA group compared with control (aOR 0·39, 0·24–0·65), representing an absolute incidence reduction of 8·7% (3·5–14·0). There was no evidence of effect of mHealth on combined prevalence of intermediate hyperglycaemia and diabetes (aOR 0·93, 0·74–1·16) or the incidence of diabetes (1·02, 0·73–1·43). The incremental cost-effectiveness ratios for PLA were INT$316 per case of intermediate hyperglycaemia or type 2 diabetes prevented and $6518 per case of type 2 diabetes prevented among individuals with intermediate hyperglycaemia.InterpretationOur data provide strong evidence to support the use of community mobilisation based on PLA to prevent type 2 diabetes in this rural Bangladeshi population. Despite raising knowledge and awareness of diabetes, the mHealth intervention did not change disease outcomes in our population. Replication studies in other populations should be a priority.FundingUK Medical Research Council.

BackgroundUndernutrition during pregnancy leads to low birthweight, poor growth and inter-generational undernutrition. We did a non-blinded cluster-randomised controlled trial in the plains districts of Dhanusha and Mahottari, Nepal to assess the impact on birthweight and weight-for-age z-scores among children aged 0–16 months of community-based participatory learning and action (PLA) women’s groups, with and without food or cash transfers to pregnant women.MethodsWe randomly allocated 20 clusters per arm to four arms (average population/cluster = 6150). All consenting married women aged 10–49 years, who had not had tubal ligation and whose husbands had not had vasectomy, were monitored for missed menses. Between 29 Dec 2013 and 28 Feb 2015 we recruited 25,092 pregnant women to surveillance and interventions: PLA alone (n = 5626); PLA plus food (10 kg/month of fortified wheat-soya ‘Super Cereal’, n = 6884); PLA plus cash (NPR750≈US$7.5/month, n = 7272); control (existing government programmes, n = 5310). 539 PLA groups discussed and implemented strategies to improve low birthweight, nutrition in pregnancy and hand washing. Primary outcomes were birthweight within 72 hours of delivery and weight-for-age z-scores at endline (age 0–16 months). Only children born to permanent residents between 4 June 2014 and 20 June 2015 were eligible for intention to treat analyses (n = 10936), while in-migrating women and children born before interventions had been running for 16 weeks were excluded. Trial status: completed.ResultsIn PLA plus food/cash arms, 94–97% of pregnant women attended groups and received a mean of four transfers over their pregnancies. In the PLA only arm, 49% of pregnant women attended groups. Due to unrest, the response rate for birthweight was low at 22% (n = 2087), but response rate for endline nutritional and dietary measures exceeded 83% (n = 9242). Compared to the control arm (n = 464), mean birthweight was significantly higher in the PLA plus food arm by 78·0 g (95% CI 13·9, 142·0; n = 626) and not significantly higher in PLA only and PLA plus cash arms by 28·9 g (95% CI -37·7, 95·4; n = 488) and 50·5 g (95% CI -15·0, 116·1; n = 509) respectively. Mean weight-for-age z-scores of children aged 0–16 months (average age 9 months) sampled cross-sectionally at endpoint, were not significantly different from those in the control arm (n = 2091). Differences in weight for-age z-score were as follows: PLA only -0·026 (95% CI -0·117, 0·065; n = 2095); PLA plus cash -0·045 (95% CI -0·133, 0·044; n = 2545); PLA plus food -0·033 (95% CI -0·121, 0·056; n = 2507). Amongst many secondary outcomes tested, compared with control, more institutional deliveries (OR: 1.46 95% CI 1.03, 2.06; n = 2651) and less colostrum discarding (OR:0.71 95% CI 0.54, 0.93; n = 2548) were found in the PLA plus food arm but not in PLA alone or in PLA plus cash arms.InterpretationFood supplements in pregnancy with PLA women’s groups increased birthweight more than PLA plus cash or PLA alone but differences were not sustained. Nutrition interventions throughout the thousand-day period are recommended.Trial registrationISRCTN75964374.

Overall prognosis of people with IH worsened over time. T2DM cumulative incidence generally increased over the course of follow-up but varied with IH definition. Regression from IH to normoglycaemia decreased over time but was observed even after 11 years of follow-up. The risk of developing T2DM when comparing IH with normoglycaemia at baseline varied by IH definition. Taking into consideration the uncertainty of the available evidence, as well as the fluctuating stages of normoglycaemia, IH and T2DM, which may transition from one stage to another in both directions even after years of follow-up, practitioners should be careful about the potential implications of any active intervention for people 'diagnosed' with IH.

Community mobilisation through Participatory Learning and Action (PLA) has been shown to be effective for a range of health outcomes, including diabetes. Using a cluster randomised controlled trial we evaluated the impact of a PLA community mobilisation intervention for diabetes prevention and control when implemented in rural Bangladesh in 2021-2022 and adapted to the evolving context of the COVID-19 pandemic. 108 PLA groups held a minimum of 13 meetings over a total implementation period of 20 months. Random cross-sectional samples of adults (aged ≥30 years) at baseline (pre-intervention, n = 1392) and at endline (post-intervention, n = 1343) were selected to evaluate intervention impact on the primary outcome of prevalence of intermediate hyperglycaemia and diabetes assessed through fasting blood glucose concentrations and two-hour oral glucose tolerance tests. Secondary outcomes included blood pressure, knowledge of diabetes, and behavioural outcomes, including diet, physical activity, and care-seeking. Results showed no evidence of an intervention effect on prevalence of intermediate hyperglycaemia and diabetes between study arms (adjusted difference -1.19% (95% CI -10.74, 8.36), p = 0.784). Large increases in diabetes knowledge were recorded and the intervention was associated with a significant reduction in mean diastolic blood pressure (-2.98 (-5.55, -0.41), p = 0.028) and possible reductions in the prevalence of hypertension (-7.40% (-16.03, 1.24), p = 0.0845) and abdominal obesity (-15.23% (-33.02, 2.56), p = 0.085). Although COVID-related interruptions and adaptations to implementation of PLA may have impacted effectiveness, the PLA approach to non-communicable disease prevention and control continues to show promise in resource-poor settings. Trial registration: ISRCTN42219712 - registered 31st October 2019. Status: complete.

BackgroundType 2 diabetes mellitus (T2DM) incidence is traditionally derived from cohort studies that are not always feasible, representative, or available. The present study estimates T2DM incidence in Fijian adults from T2DM prevalence estimates assembled from surveys of 25–64 year old adults conducted over 30 years (n = 14,288).MethodsT2DM prevalence by five-year age group from five population-based risk factor surveys conducted over 1980–2011 were variously adjusted for urban-rural residency, ethnicity, and sex to previous censuses (1976, 1986, 1996, 2009) to improve representativeness. Prevalence estimates were then used to calculate T2DM incidence based on birth cohorts from the age-period (Lexis) matrix following the Styblo technique, first used to estimate annual risk of tuberculosis infection (incidence) from sequential Mantoux population surveys. Poisson regression of year, age, sex, and ethnicity strata (n = 160) was used to develop projections of T2DM prevalence and incidence to 2020 based on various scenarios of population weight measured by body mass index (BMI) change.ResultsT2DM prevalence and annual incidence increased in Fiji over 1980–2011. Prevalence was higher in Indians and men than i-Taukei and women. Incidence was higher in Indians and women. From regression analyses, absolute reductions of 2.6 to 5.1% in T2DM prevalence (13–26% lower), and 0.5–0.9 per 1000 person-years in incidence (8–14% lower), could be expected in 2020 in adults if mean population weight could be reduced by 1–4 kg, compared to the current period trend in weight gain.ConclusionsThis is the first application of the Styblo technique to calculate T2DM incidence from population-based prevalence surveys over time. Reductions in population BMI are predicted to reduce T2DM incidence and prevalence in Fiji among adults aged 25–64 years.Electronic supplementary materialThe online version of this article (doi:10.1186/s12963-016-0114-0) contains supplementary material, which is available to authorized users.

Background: Type 2 Diabetes Mellitus (T2DM) and Impaired Glucose Tolerance (IGT) are major public health concerns globally, with increasing prevalence in India. The study assessed the prevalence of T2DM and IGT among, and to recognize key associated risk factors. Methods: 1050 persons were involved in the study selected by rigorous random sampling. To diagnose T2DM and IGT, data were gathered via in-person interviews using a pre-made questionnaire, which were then followed by clinical exams and blood testing. Results: The incidence of IGT was 12.48% and T2DM was 9.24%, respectively. In the 61–70 age range, the highest incidence of T2DM (20.86%) and IGT (21.58%) was noted. The incidence of T2DM was somewhat higher in men (9.87%) than in women (8.58%). The incidence rates of T2DM (21.84%) and IGT (36.78%) were considerably greater in those with a positive family record of diabetes. Additionally, there was a substantial correlation found between obesity and hypertension and a higher incidence of T2DM and IGT. Conclusion: The study reveals a considerable incidence of T2DM and IGT in the Sharifganj area of Katihar, with advanced age, male gender, family history of diabetes, obesity, and hypertension identified as key risk factors. Recommendations: Targeted public health interventions, including lifestyle modifications, regular screenings, and health education, are essential to manage and reduce the risk of diabetes in this community. Keywords: Prediabetes,T2DM, Impaired Glucose Tolerance, IGT, Impaired Fasting Glucose, IFG, Risk Factors, Katihar, Bihar.

Pioglitazone for prevention or delay of type 2 diabetes mellitus and its associated complications in people at risk for the development of type 2 diabetes mellitus.

AimsDespite more and more studies indicate that beverages play an important role in type 2 diabetes mellitus(T2DM), the efficacy of intaking different beverages for T2DM has not been clearly stated in one article. The meta-analysis was performed, which aims to assess the effects of beverages on mortality and cardiovascular complications in patients with type 2 diabetes and the incidence of T2DM.MethodPubMed, Embase, Web of Science and Cochrane Library databases were search up to March, 2023 to identify relevant studies, including studies researching beverage consumption, the incidence and mortality of T2DM and incidence of cardiovascular disease, a kind of complication of T2DM. The way to explore the source of heterogeneity is performing subgroup analyses and sensitivity analyses. Funnel plots and Egger’s regression test were performed to assess publication bias. The Hazard ratio (HR) and 95% confidence intervals (95% CIs) were used to analysis the results. Fifteen observational studies were included in our meta-analysis.ResultsFifteen eligible articles were included sugar-sweetened beverages(SSB) consumption increased the mortality and incidence of T2DM ( Hazard ratio (HR), 1.20; 95% confidence interval (CI), 1.05–1.38; P = 0.01 and HR, 1.15; 95% CI,1.06–1.24; P = 0.001), respectively. Artificially-sweetened beverages (ASB) consumption was not associated with the mortality and incidence of T2DM (HR,0.96;95%CI, 0.86–1.07; P = 0.464 and HR, 1.15; 95% CI,1.05–1.26; P = 0.003), respectively. Fruit juice consumption increased the incidence of T2DM (HR,1.08;95%CI,1.02–1.14, P = 0.296).Tea or coffee consumption can reduce the incidence of T2DM (HR, 0.89; 95%CI,0.81–0.98; P = 0.016). Tea or coffee consumption was associated with a lower risk of mortality of T2DM (HR,0.84; 95% Cl, 0.75–0.94; P = 0.002 and HR,0.75; 95% CI, 0.65–0.87; P < 0.001), respectively. Additionally, beverage consumption was not associated with cardiovascular disease in T2DM patients (HR,1.03; 95% Cl, 0.82–1.30, P > 0.05).ConclusionsHigh consumption of SSBs led to a higher risk and mortality of T2DM, while high consumption of coffee or tea showed significant associations with a lower risk of the incidence and mortality of T2DM.

ObjectivesResearch indicates the effectiveness of participatory interventions to address rapid rises in type 2 diabetes in low-income countries. Understanding their transferability to different contexts is a priority. We aimed to...

Associations between long-term exposure to ambient air pollution and risk of type 2 diabetes mellitus: A systematic review and meta-analysis