The complications of diabetes are rife among patients in developing countries. Ironically, many of these countries lack the wherewithal for adequate management of target-organ dysfunction. In most of sub-Saharan Africa, renal replacement therapy (either chronic dialysis or transplantation services), laser surgery for retinopathy, invasive cardiology and coronary rescue procedures are not routinely available, even in tertiary care centers. Limb amputation, however, is available and performed frequently on patients with gangrenous diabetic foot ulcers. Once the lower extremity has been amputated in a patient with diabetes in poorer countries, the economic contribution of that patient virtually ceases, because of poorly developed prosthetic and rehabilitation services. Under such a grim scenario, a stronger case cannot be made for an aggressive focus on diabetes prevention as a top national priority in every developing country.

Strategies for Primary Prevention of Type-2 Diabetes

Developing countries besieged by other existential priorities have so far not focused on diabetes prevention. [The few local examples, such as the Tanzanian World Health Organization InterHealth Project, need to be replicated and expanded considerably.] The looming diabetes pandemic mandates that timely action be taken to place diabetes prevention as a top national priority in the developing world. The situation is somewhat reminiscent of (but far more hopeful than) that of HIV/AIDS. A curious disorder, later characterized as HIV, emerged in the early 1980s. Despite a rapid growth in the understanding of the modes of transmission of HIV, little was done by way of preemptive community mobilization in Africa and Asia until two decades later, after the disease had afflicted and decimated large segments of the population in these regions. Developing countries currently have lower prevalence rates for type-2 diabetes than do developed countries, but the rate of increase is disproportionately greater among developing countries. As argued by Dr. King of the World Health Organization (WHO), “worldwide surveillance of diabetes is a necessary first step toward its prevention … which is now recognized as an urgent priority.”

Preventive Interventions

In several large studies (Table 3), nonpharmaco-logical approaches that focused on increased physical activity, reduction in caloric intake and modest weight loss have proved more efficacious in preventing type-2 diabetes than medications. Therefore, these approaches must be considered the interventions of choice for the prevention of type-2 diabetes, particularly in the developing world.

Table 3. Landmark diabetes prevention studies

Mean Age

Mean Mean Follow-Up

Diabetes

Study

N

(Years)

BMI*

Ethnicity

(Years)

Intervention

Reduction** (%)

Da Qing18

577

45

26

Chinese

6

Diet + exercise 33-47%

Finnish19

522

55

31

European

3.2

Diet + exercise 58%
Qpp20***

3,234

50.6

34

Multiethnic

2.8

Diet + exercise 58%
Metformin 31%

* BMI: body mass index; **

Percentage reduction in incidence of diabetes compared with control; *** DPP: Diabetes Prevention Program

The lifestyle intervention goal of the Diabetes Prevention Program (DPP) was to achieve and maintain a weight reduction of >7% of initial body weight through modest caloric restriction (500-700 fewer calories per day) and physical activity of moderate intensity, such as brisk walking, for >150 minutes per week. The study subjects, all of whom had impaired glucose tolerance (IGT) at baseline, met with case managers one-to-one as well as in group sessions at frequent intervals. After an average follow-up period of 2.8 years, the incidence of diabetes was reduced by 58% in the lifestyle intervention group compared with placebo. levitra plus

The beneficial effect of lifestyle intervention was seen in all age, gender, racial and ethnic subgroups of the DPP participants. Furthermore, reversion to normal glucose tolerance occurred in ~30% of subjects in the lifestyle intervention arm, as compared with ~18% in the placebo arm. Thus, caloric restriction and increased physical activity not only prevented progression from IGT to diabetes but were also effective in restoring normal glucose tolerance in a substantial proportion of subjects with initial IGT.

Category: Diseases / Tags: developing countries, Diabetes, prevention

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