The first task is the education of policymakers on the urgent need for action to prevent the looming epidemic of diabetes (Table 4). The WHO, practicing physicians, healthcare workers, civic organizations and academia should take the lead in this regard. Local diabetes organizations could be a rallying point for sensitizing governments to the importance of diabetes prevention. Once governments become convinced of its critical value, the translation of diabetes prevention through dietary modification and increased physical activity could be easier than anticipated in developing countries.
The central control of policy and polity in many developing countries may actually facilitate the dissemination of healthy propaganda. The ministries of health, information, agriculture and education in these countries can rapidly implement public education and nutritional programs centered around the theme of diabetes prevention. The role of ministries of education in the maintenance and expansion of existing physical education programs in schools cannot be overemphasized. Similarly, the initiation and dissemination of national nutritional guidelines (currently a rarity in the developing world) by ministries of agriculture and health, in collaboration with appropriate experts, would be integral to the overall translation process.
Table 4. Approach to translation of diabetes prevention in developing countries
|• Initial education of national and local policymakers on the need for primary prevention of diabetes|
|• Collaboration among ministries of health, information, education, agriculture and other stakeholders|
|• Incorporation of diabetes prevention information in school curriculum at elementary, secondary and|
|• Maintenance and expansion of existing physical education programs in schools|
|• Initiation and dissemination of national nutritional guidelines|
|• Involvement of healthcare community and civic organizations|
|• Formal launching of local pilot and feasibility programs on diabetes prevention|
|• Centrifugal spread of local diabetes prevention centers from metropolitan to rural areas|
To be successful, such programs must utilize culturally congruent methods for prevention of type-2 diabetes. With regard to the latter, pilot programs will be needed to validate the results of the published studies in several locations on the African continent, the West Indies, Asia, Pacific rim, South America and other developing regions. Relatives of persons with diabetes would seem an obvious initial target for enrollment in local pilot studies. The purpose of such studies would be to identify culturally and regionally specific approaches (and constraints) to the translation of the key elements of the lifestyle arm of the DPP, including a determination of the feasibility of and best models for the delivery of physical activity and dietary interventions. Following the conclusion of local pilot programs, full implementation of diabetes prevention programs can be attempted in the general population. A phased approach with “waves” of centers spreading outwards from a core group of metropolitan diabetes prevention centers is an appealing strategy.
Cost of Diabetes Prevention
The costs associated with societal translation of diabetes prevention could be substantial. Analysis of costs associated with the DPP indicate that diabetes prevention did not come cheap, although the overall expense to society was cost-effective. Over three years, the direct medical costs of the DPP interventions were $79 per participant in the placebo group, $2,542 in the metformin group and $2,780 in the lifestyle group. One of the challenges in sub-Saha-ran Africa will be for the communities to develop their own brand of diabetes prevention interventions at an affordable cost. Reduction in contact frequency and size of personnel would lead to substantially lower costs. However, the minimum effective frequency of interaction and the optimal size of lifestyle interventionists need to be determined for each community. Indeed, this information should be the focus of the pilot and feasibility studies in the various communities.
Clearly, the adaptation of diabetes prevention programs to developing countries would require creativity in fundraising, cost containment, and cost-sharing. Savings from cutting personnel and visits to local diabetes prevention centers may need to be ploughed back into the development of infrastructure for expansion of the program to wider segments of society. Realistically, the sparse gross domestic product for most developing countries predicts that even a minimally effective society-wide diabetes prevention program may be unaf-fordable. Therefore, external funding would be critical for the initiation and maintenance of local diabetes prevention programs. Foreign aid and grants from international philanthropic sources and nongovernmental organizations can be structured for specific health-related outcomes. prevacid 15 mg
Finally, debt-forgiveness programs in which the wealthy Group-of-Eight (G8) countries liquidate or commute debts owed to them by poorer nations can (and should) be linked to specific socioeconomic, political and health outcomes, in a paradigm that rewards poorer countries for excellence in the development and execution of programs in the aforementioned areas. There is already a precedent for debt forgiveness in the context of spreading democracy to societies emerging from dictatorial regimes. A clear and compelling case exists for extending the same consideration to developing nations, especially in sub-Saharan Africa, where debt forgiveness can become a potent foreign policy tool that drives national health policies and practices. It is envisioned that the proportion of debt forgiven can somehow be linked to demonstrable efforts in the areas of disease prevention and health promotion in diabetes and other specific areas (e.g., childhood immunization, HIV-AIDS awareness and prevention, etc.).