Evidence based review of type 2 diabetes prevention and management in low and middle income countries

Table 2 Diabetes management: Structured dietary change and exercise as main components (not lifestyle education)

Country	Ref.	Objective	Study design	Sample size/characteristics	Components of intervention	Measurements	Outcome measures	Conclusion
Brazil	Rodrigues Silva et al[60]	To evaluate effect of rice bran fiber diet	Single group	n = 11, 45-60 yr old, controlled diabetes by diet or oral hypoglycemic agents, T1DM + T2DM	1 wk low fiber diet, 2nd week low fiber diet + rice bran, cross over	Mean fasting and post prandial glucose	Daily fasting and postprandial glucose	Mean fasting and postprandial serumglucose levels were reduced, but values of high fiber diet were significantly lower (P < 0.001) than that of the lower fiber diet
China	Sun et al[71]	To evaluate effectiveness of structured integrated intervention program	RCT	n = 150, Intervention group 100 and control group 50, 18-70 yr, BMI > 23 kg/m2, T2DM	Nutritional counseling and meal replacement, physical activity instruction, education – monthly group lectures, sample meal plans with applications of meal exchanges and low glycemic index foods	FBG + insulin, HbA1c	0, 3 and 6 mo	An integrated intervention program can achieve improvements in glycemic control. Mean fasting blood glucose values at 24 wk were 7.4 ± 0.2 vs 8.9 ± 0.4 mmol/L (P < 0.001), intervention vs reference, respectively. No change in HbA1c in reference group, but a -0.8% change observed in intervention group (P < 0.001)
Costa Rica	Goldhaber-Fiebert et al[64]	To evaluate effectiveness of group-centered, community based public health intervention	RCT	n = 61, 33 in intervention group and 28 in control group, diagnosed T2DM	11 weekly nutrition classes 90 min each, triweekly walking physical activity sessions 60 min each	HbA1c, FBG	0 and 3 mo	Community-based, group-centered intervention including nutrition and exercise can improve glycemic control and is economically feasible. Change in FBG in intervention group change -19, control group 16 (P + 0.048). Change in HbA1c in intervention group -1.8, control group -0.4 (P = 0.028)
India	Pande et al[56]	To investigate effects of low/medium glycemic indexed Indian vegetarian snacks and meal plans on diabetics	Single group experimental	n = 15, 42-58 yr, diagnosed T2DM	Redesigned meal plan focusing on decreasing starches, lipids and increasing fiber	Blood glucose, HbA1c, lipid profile	0, 1, 2, 3 and 4 wk	Significant improvement in metabolic parameters was observed and can be improved if compliance to low/medium GI diet is continued. Blood glucose level of 173.6 mg% at baseline decreased to 137.8 mg% (P < 0.001), HbA1c of 8% at baseline decreased to 7.1% from baseline (P < 0.001)
India	Shenoy et al[62]	To evaluate effectiveness of aerobic walking program with pedometer and HRM	RCT	n = 40, 20 in control and 20 in intervention, 40-70 yr, diagnosed T2DM, Not enrolled in any other physical activity program	Timed walking schedule of target 150 min/wk to reach a 50%-70% maximum heart rate, pedometer, HRM	BMI, GWB	0 and 2 mo	Walking with a pedometer and HRM is more effective than walking alone and results in a better wellbeing for T2DM patients
India	Kosuri et al[70]	To evaluate effect of yoga on T2DM patients	Single group	n = 35, T2DM	40 d yoga camp with yoga exercises everyday	BMI, general well being	0 and 40 d	BMI decreased from 26.514 to 25.771 (P < 0.001) and there was also an improvement in total general well being
India	Agrawal et al[61]	To investigate effect of camel milk on glycemic control and insulin sensitivity	Two group experimental, crossover	n = 28, T2DM	Cow milk for non diabetic group, camel milk for diabetic group, followed by 3 mo washout period, with switch	FBS, HbA1c, HOMA-IR	0, 1 (run in period), 4 (camel milk period), 5 (washout period), 8 mo (cross over to cow milk)	HbAlc improved due to camel milk consumption (8.39 ± 0.64 to 7.27% ± 0.67%) whereas deteriorated in the case of cow milk (7.36 ± 0.66 to 8.26% ± 0.60%) in diabetic group
India	Misra et al[67]	To evaluate effectiveness of PRT	Single group	n = 30, diagnosed T2DM	Scheduled PRT training of six muscle groups (two sets, 10 repetitions each), 3 times/wk	HbA1c, blood glucose, lipid profile, BMI	0 and 3 mo	Moderate PRT is effective in improving metabolic parameters in T2DM patients and should be an integral part of their exercise regimen. HbA1c changed 0.54%, (P < 0.001), fasting blood glucose changed 2.7 mmol/L (P < 0.001)
India	Arora et al[68]	To evaluate effectiveness of PRT compared to aerobic exercise	RCT	n = 30, 10 in supervised PRT, 10 in control group and 10 in aerobic exercise group, 40-70 yr, diagnosed T2DM > 6 mo, inactive lifestyle	Scheduled PRT exercises of 3 sets of 10 repetitions for 2 times per week, aerobic exercise of walking 30 min/d three times a week	HbA1c, BP, BMI, lipid profile, GWB	0 and 2 mo	Metabolic parameters in T2DM patients improved more with PRT compared to aerobic exercise. HbA1c levels decreased (P < 0.05) both in the PRT group (7.57% to 6.23%) and in Aerobic Exercise group (8.11% to 6.66%)
Iran	Yazdanpanah et al[66]	To evaluate effectiveness of community based participatory diabetes care program	Single group, CBPR	n = 320, 30-65 yr, diagnosed T2DM, impaired fasting glucose	Nutrition classes 90 min each 2 d per week for 4 wk, structured physical activity 60 min sessions 3x a week for 13 wk	FBS, HbA1c, BP, lipid profile	0, 3 and 4.1 mo	Community-based participatory program is a feasible model for diabetes control. FBS decreased from 176 to 102 mg/dL (P < 0.01) and HbA1c decreased from 6.9 to 6.1 (P < 0.001)
Nigeria	Adeniyi et al[69]	To evaluate effect of 12 wk exercise program	Single group	n = 29, T2DM for min 6 mo, triglyceride levels > 1.7 mmol/L, waist circumference > 102 cm (men) or 88 cm (women) and BP > 130/85	Alternate day 45 min exercises (3 d in a week) for 12 wk, exercises included aerobic exercise, mobilization and resistance exercises	Fasting blood glucose, HbA1c	0, 2, 4, 6, 8, 12 wk	Improvement was observed in the fasting plasma glucose of both male (t = 8.059; P = 0.0001) and female groups (t = 13.007; P = 0.01)
Nigeria	Salau et al[57]	To evaluate effect of fruits and vegetables diet on selected hematological parameters	Single group	n = 30, T2DM	Two servings of diced fruit mix (100 g each) every day, 1 serving of edible green and leafy vegetables (100 g each) every day	ESR, hematocrit	0, 2, 4, 6, 8, 10 wk	ESR decreased from 49.40 to 32.8 (P < 0.05). Regular intake of fruits and vegetables can reduce cardiovascular risk factors in diabetic patients
Nigeria	Oli et al[55]	To evaluate effect of high carbohydrate diet	Single group	n = 160, weight not more than 10% above or below the mean weight for their age, sex and height, age at onset of diabetes > 30 yr, random blood glucose between 100 mL and 200 mg/100 mL, no ketonuria	250 g to 300 g of carbohydrate daily per patient depending on age and occupation	Mean fasting glucose	3 yr	Fifty-three patients (33.1%) achieved excellent control of their blood glucose (mean fasting blood glucose of 7.0 mmol/L or less); 38 patients (23.8%) achieved good control of their blood glucose (mean fasting blood glucose of 7.0-8.0 mmol/L); and 42 patients (26.3%) achieved fair control of their blood glucose (mean fasting blood, glucose of 8.0-9.0 mmol/L)
South Africa	van Rooijen et al[63]	To evaluate effectiveness of exercise intervention program vs a relaxation program	Single blind double intervention RCT	n = 149, 74 in relaxation group and 75 in exercise group, 40-65 yr, diagnosed T2DM for at least 1 yr	Home exercise program, fortnightly 45 min aerobics, 20 min tensing of muscles and relaxing for relaxation group, interactive group sessions, diet lectures	HbA1c, BMI, BP	0 and 3 mo	The exercise group did not impact the glycemic parameters greater than the relaxation group. HbA1c decreased -0.39 (P = 0.02) for exercise group
Thailand	Komindr et al[58]	To evaluate effect of long-term intake of Asian food with different glycemic indices	Single group cross over	n = 10, T2DM, b/w 32-60 yr	High glycemic diet or low glycemic diet was mainly glutinous rice or mungbean noodles, intermediate glycemic diet was solely white rice	HbA1c	2 mo	Ingestion of mungbean noodles (a low glycemic diet) without increasing fiber intake, can improve diabetic control and protein conservation in type 2 diabetes
Thailand	Chaiopanont[54]	To evaluate effect of a sitting and breathing exercise technique	Quasi-experiment, single group, pre and post-test	n = 50, 42-80 yr, diagnosed T2DM	Scheduled sitting and breathing techniques once a week for 30 min	Post Prandial glucose, FBS, BP	0, 1 and 2 wk	The somporn kantaradudsi-triamchaisri sitting and breathing techniques had a postprandial hypoglycemic effect in T2DM patients. Post prandial plasma glucose levels decreased from 19.26 mg/dL (P < 0.001) in the 2nd week to 17.64 mg/dL in the 3rd week (P < 0.001)
Turkey	Acik et al[65]	To evaluate effectiveness of education and lifestyle recommendations	Non-randomized cluster controlled trial	n = 80, 33 in standard diet, 28 in exercise + diet, 39 in control group, diagnosed T2DM	Nutritional counseling, structure physical activity schedule 3 times/wk	HbA1c, BMI, Blood Glucose	0, 1 and 2 mo	Diabetes education intervention program involving lifestyle modifications improves glycemic parameters. HbA1c in the diet + exercise group decreased from 9.9% to 7.9% (P = 0.001) and in the diet group, levels decreased from 7.8% to 7.5% (P = 0.001)
Mexico	Jimenez-Cruz et al[59]	To evaluate effectiveness of lower-higher-glycemic index mexican style diet	RCT crossover	n = 14, 35-75 yr, diagnosed T2DM	Pamphlets, detailed instructions on high-low GI foods, washout period of 6 wk with 6 wk periods of treatment alternating between low-GI period and high-GI period	FPG, HbA1c, BMI, lipid panel	0, 1.5 and 3 mo	A low-GI mexican style diet improves metabolic control in obese T2DM patients. HbA1c is lower in the low-GI period (8.1) than the high GI-period (8.6) P = 0.02

T2DM: Type 2 diabetes mellitus; RCT: Randomized control trial; BMI: Body mass index; GWB: General well being; PRT: Progressive resistance training; HbA1c: Hemoglobin A1c; GI: Gastrointestinal; PRT: Progressive resistance training.