A pragmatic and scalable strategy using mobile technology to promote sustained lifestyle changes to prevent Type 2 diabetes in India and the UK

Type 2 diabetes is a major healthcare problem in the developed and developing world.
Recent clinical trials have demonstrated that it may be prevented in many instances by
lifestyle intervention focused on diet and physical activity. Translating these known
benefits to the population at large has been hampered by the intensive nature and
expense of the successful lifestyle modification programmes and by the difficulties and
expense involved in ascertaining those in the population who are at high risk. We
propose a randomised controlled trial (RCT) comparing intervention using mobile phone
technology versus conventional management to induce lifestyle modification in people
with impaired glucose regulation in both India and the UK. In India people at risk will be
ascertained using simply the Indian Diabetes Risk Score followed by measurement of
HbA1c in those with high risk scores. In the UK, high risk subjects will be ascertained
from the NHS Health Check Scheme and from routine screening in primary care. The
NHS Health Check scheme is a recently introduced government scheme in England
offered to people aged 40-74 years. UK recruitment will also be based on HbA1c
measurements. The mobile phone based intervention will use short messaging service
(SMS or text messaging) to deliver education, treatment targets, advice, support and
motivation. Subjects will be invited to participate and, once recruited, will be randomised
to usual care or the SMS intervention group. Usual care will consist of a one-to-one 30
minute interview, conducted by the research team, delivering personalised diet and
exercise advice. This will be supplemented by standardised written material and
education regarding IGR and diabetes. This will be delivered once at the beginning of the
study. The intervention group will undergo the same initial interview and, in addition, will
receive 3 times weekly text messaging with education, advice, support and motivation.
These messages will be personalised to individual targets set at the initial interview.
Lifestyle modification will be achieved by physical activity and dietary means. The
primary outcome will be progression to diabetes, as defined by HbA1c, with and without
SMS intervention. Secondary outcomes will be improvements in objectively measured
physical activity, body weight and other cardiovascular risk factors (blood pressure, total
and HDL cholesterol and serum triglycerides). The study programme is compatible with
major initiatives in both the UK and India for the prevention of diabetes and
cardiovascular disease (CVD).

Diabetes is a major healthcare problem in the developed and developing world. Clinical trials have shown diabetes prevention by lifestyle intervention focused on diet and physical activity. Translating these benefits to the population has been hampered by the intensive nature and expense of the lifestyle modification programmes and by the difficulties and expense involved in ascertaining high risk subjects. We propose a randomised controlled trial comparing intervention using mobile phone technology versus conventional management to induce lifestyle modification in people with impaired glucose regulation in both India and the UK. In India people at risk will be ascertained using the Indian Diabetes Risk Score followed by measurement of HbA1c in those with high risk scores. In the UK, subjects will be ascertained from the NHS Health Check Scheme and from routine screening in primary care. The NHS Health Check scheme in England is offered to people aged 40-74 years. UK recruitment will also be based on HbA1c measurements. The mobile phone intervention will use text messaging to deliver education, treatment targets, advice, support and motivation. Subjects will be invited to participate and, once recruited, will be randomised to usual care or the SMS intervention group. Usual care will consist of a 30 minute interview, delivering personalised diet and exercise advice. This will be supplemented by standardised written material and will be delivered once at the beginning of the study. The intervention group will undergo the same initial interview and will receive 3 times weekly text messaging with education, advice, support and motivation. These messages will be personalised to individual targets set at the initial interview. Lifestyle modification will be achieved by physical activity and diet. The primary outcome is progression to diabetes. Secondary outcomes will be improvements in measured physical activity, body weight and other cardiovascular risk factors.

The results of this project will inform public health policies in both India and the UK. In the UK, for example, the government has introduced an NHS Health Check scheme aimed at reducing cardiovascular disease and Diabetes in the middle aged and older population. Diabetes is a major cardiovascular disease risk factor and the results from this project will inform future practice in cardiovascular disease and prevention. Worldwide, diabetes care consumes between 5 and 15% of total health care budgets. Its prevention would have major economic, social and personal benefits.