A Sustainable Shield
From Indian villages to Korean cities, evidence proves that lifestyle modification can considerably reduce diabetes risk.
By Dr Subhash Wagnoo
The world is currently facing a metabolic crisis of unprecedented proportions. According to the International Diabetes Federation (IDF), approximately 537 million adults were living with diabetes in 2021, a figure projected to soar to 783 million by 2045. Perhaps most staggering is where this burden falls: nearly 81 per cent of individuals with diabetes now reside in low- and middle-income countries (LMICs). In these regions, the condition is often a “silent killer,” with nearly half of all cases remaining undiagnosed.
As healthcare systems in the Indian subcontinent, sub-Saharan Africa, and East Asia struggle to manage the rising tide of complications—ranging from cardiovascular disease to kidney failure—a consensus has emerged among global experts. The most effective, sustainable, and economically viable weapon we have is not a new pill, but a fundamental shift in how we live: Lifestyle Modification (LSM).
The Science of Vulnerability: Why Now?
The rapid increase in Type 2 Diabetes (T2DM) is driven by a complex interaction between genes and the environment. While genetic predisposition sets the stage, the modern environment—characterized by rapid urbanisation, globalisation, and sedentary behaviour—acts as the trigger.
In LMICs, socioeconomic transitions have led to dramatic changes in dietary patterns and physical activity. These shifts produce adverse biological effects, most notably obesity and insulin resistance, which, when superimposed on genetic susceptibility, lead to the expression of diabetes.
Certain populations are at even higher risk due to unique biological profiles. For instance, South Asian populations exhibit distinctive phenotypic characteristics, such as higher abdominal obesity and earlier onset of insulin resistance, often appearing in the first two decades of life. In Africa, malnutrition during pregnancy and early childhood can lead to “intrauterine programming,” resulting in low birthweight and a higher risk of dysglycemia later in life.
Lifestyle Modification: The Cornerstone of Prevention
Primary prevention aims to stop the disease before it starts. For T2DM, this means targeting individuals with prediabetes—those with Impaired Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT). Landmark clinical trials globally have proven that intensive LSM—incorporating healthy diets, consistent physical activity, and weight control—can reduce diabetes incidence by 30 per cent to 58 per cent in high-risk individuals.
Lessons from the Frontline: India and Korea
India has been a pioneer in testing these interventions. The Indian Diabetes Prevention Programme (IDPP) demonstrated that structured diet and physical activity were as effective as the drug metformin in preventing T2DM among Asian Indians with IGT.
A recent breakthrough study in Kerala focused on a specific, high-risk group: women with isolated Impaired Fasting Glucose (i-IFG). This community-based randomised controlled trial found that a structured 12-month LSM program led to prediabetes remission in 45.9 per cent of participants, compared to only 6.3 per cent in the control group. The women in the LSM group were seven times more likely to return to normal blood sugar levels. They also saw significant improvements in weight (average loss of 3.7 kg), waist circumference, and body fat mass.
While the efficacy of LSM is proven, high-intensity models from the US or Finland are often too expensive or resource-heavy for LMICs to implement at scale. To address this, the Korean Diabetes Prevention Study (KDPS) developed a culturally tailored, moderate-intensity model. The KDPS focuses on the “10 Habits” program, which uses simple, action-oriented messages like “Sib-si-il-gang” to promote sustainable change. These habits are delivered in a stepwise manner based on the Transtheoretical Model (TTM) of behaviour change, ensuring that participants receive the right encouragement whether they are just contemplating change or are ready for action. Interim results from the KDPS show that this moderate-intensity approach can still achieve a 30 per cent lower incidence of diabetes compared to standard management.
A Four-Step Roadmap for National Success
Implementing effective prevention programs requires a systematic approach. Experts suggest a four-step framework for LMICs:
Step 1: Awareness Creation
The first hurdle is the “knowledge gap.” It is imperative to sensitize not just the general public, but also healthcare personnel and government stakeholders. Public lectures, media campaigns, and health camps at worksites have proven effective in India and beyond. Awareness must focus on identifying the signs of diabetes early and understanding modifiable risk factors like diet and inactivity.
Step 2: Risk Stratification
Screening an entire population with expensive blood tests is unfeasible in many LMICs. Instead, programs should use non-invasive risk scores. These tools use simple metrics like age, waist circumference, and family history to identify high-risk individuals who then undergo biological testing. This approach is cost-effective, labour-saving, and highly scalable.
Step 3: Strategic Planning and mHealth
Planning must account for available resources. In under-resourced settings, community-based programs are preferred over hospital-based ones as they reduce travel costs and increase participation.
The explosion of mobile technology in LMICs offers a golden opportunity. mHealth (Mobile Health), such as using SMS text messages to encourage healthy behaviours, has shown remarkable results. An Indian study using mobile phone messaging showed a 36 per cent relative risk reduction in the development of diabetes among men with IGT.
Step 4: Outcome Evaluation and Sustainability
For a program to survive, it must be monitored and proven sustainable. This includes regular tracking of disease progression in high-risk groups and a clear analysis of cost-effectiveness.
The Economic Reality: Prevention is a Bargain
From a government perspective, the “best buy” is prevention. In the Indian IDPP trial, the cost to prevent one case of diabetes using LSM was approximately US$1,052. While this may seem significant, it is a fraction of the cost in the US (where it is roughly $15,700) and far less than the lifelong cost of treating diabetes complications like dialysis or heart surgery.
Furthermore, population-wide policies, such as taxing sugar-sweetened beverages (SSBs), have been shown to be cost-saving. A modelling study in South Africa suggested that a 20 per cent SSB tax could substantially reduce diabetes incidence and save over US$860 million in healthcare costs over 20 years.
Overcoming the Hurdles
Despite the clear benefits, challenges remain. Cultural and societal constraints, insufficient healthcare infrastructure, and the competing priority of communicable diseases often push non-communicable disease (NCD) prevention to the back burner.
However, the “Life Circle” approach suggests we cannot afford to wait. Prevention must be integrated into the entire continuum of life, from preconception through old age. This requires a joint effort:
Governments must provide policy support and funding for community health workers.
Healthcare providers must shift from a reactive “sick-care” model to a proactive “preventive-care” model.
Individuals must take ownership of their “10 habits,” focusing on 150 minutes of moderate exercise per week and a diet rich in whole grains and fibre.
A Call to Action
The evidence is undeniable: Type 2 diabetes is largely a preventable disorder. In the economically challenged regions of the world, where the burden is highest, lifestyle modification stands as the most practical, powerful, and cost-effective tool available. By combining culturally tailored education, smart technology, and community-led interventions, we can turn the tide of this global epidemic.
But awareness alone is not enough—action is required. Governments must prioritise NCD prevention in national health policies. Healthcare systems must train and deploy community health workers to deliver LSM programs at the grassroots level. And individuals must recognise that the power to prevent diabetes lies largely in their own hands—in the food they choose, the steps they take, and the habits they build.
The next decade will be decisive. With political will, community engagement, and personal commitment, we can ensure that future generations inherit not a legacy of chronic disease, but a foundation of lifelong health. The shield is within our reach. It is time to use it.
(The author is Senior Consultant Endocrinologist and Diabetologist, Apollo Centre for Obesity, Diabetes and Endocrinology (ACODE), New Delhi.