Co-DiRECT Nepal: a community-based diet programme for remission of type 2 diabetes and amelioration of non-communicable disease risks
Lead Research Organisation:
University of Glasgow
Department Name: College of Medical, Veterinary, Life Sci
Abstract
Layperson Summary
Many Low and Middle Income Countries, such as Nepal, have massive and growing 'double burdens' of ill-health, as the chronic non-communicable diseases (NCD) associated with Western diets and lifestyles, most notably type 2 diabetes (T2D), are added to still-high levels of infectious diseases. Health services, except for relatively privileged people living near to private hospitals, are rudimentary. In the large peri-urban communities which have arisen from recent urban migration, modern diabetes care is inaccessible and unaffordable, and national budgets are unlikely ever to provide it.
A Nepal charity, PHASE-Nepal, has pioneered community empowerment approaches to help with social welfare, education and health. Recognising the devastating effects of T2D in younger adults for families and communities, and the dramatic results of the diet intervention in our Diabetes Remission Clinical Trial (DiRECT), PHASE-Nepal invited the applicants to meet in Nepal, to consider adapting the DiRECT method as a low-cost sustainable diet programme which could be delivered within the communities to combat T2D, related NCDs and the adult weight gain which drives them. A diet plan based on DiRECT but using only traditional, local Nepali food and meals has been designed to be nutritionally complete, and pilot research has found it to be acceptable and to produce remissions of T2D in over 40% of people.
The present project is built on concepts of community empowerment, community engagement and community-focused implementation. It will first test this diet approach in the real-life setting of Nepal's peri-urban communities, in larger numbers and over a 12-month period. People with undiagnosed, and untreated diabetes will be identified by a simple finger-prick screening test. Importantly, to maximise uptake and minimise costs, the screening and diet treatment will be delivered by 'Women Community Health Volunteers', members of the same communities who help with vaccination, screening and health promotion programmes.
The project will document how effective the intervention is in this new setting, and explore in detail its implementation, ensuring no-one is disadvantages because of sex, wealth, caste etc. It uses surveys and interviews to identify barriers and incentives, among people with T2D, in their environment and services, and in local and national government policies. With strong local management for training and capacity-building, input from the DiRECT research team, and engagement with stakeholders and people living with T2D, we aim to make the programme attractive, affordable, effective, sustainable and widely transferable in Nepal and elsewhere. As well as conventional presentations and publication of results, a local film company will make a documentary about the project, to help spread the word and exert influence over policy-makers.
Many Low and Middle Income Countries, such as Nepal, have massive and growing 'double burdens' of ill-health, as the chronic non-communicable diseases (NCD) associated with Western diets and lifestyles, most notably type 2 diabetes (T2D), are added to still-high levels of infectious diseases. Health services, except for relatively privileged people living near to private hospitals, are rudimentary. In the large peri-urban communities which have arisen from recent urban migration, modern diabetes care is inaccessible and unaffordable, and national budgets are unlikely ever to provide it.
A Nepal charity, PHASE-Nepal, has pioneered community empowerment approaches to help with social welfare, education and health. Recognising the devastating effects of T2D in younger adults for families and communities, and the dramatic results of the diet intervention in our Diabetes Remission Clinical Trial (DiRECT), PHASE-Nepal invited the applicants to meet in Nepal, to consider adapting the DiRECT method as a low-cost sustainable diet programme which could be delivered within the communities to combat T2D, related NCDs and the adult weight gain which drives them. A diet plan based on DiRECT but using only traditional, local Nepali food and meals has been designed to be nutritionally complete, and pilot research has found it to be acceptable and to produce remissions of T2D in over 40% of people.
The present project is built on concepts of community empowerment, community engagement and community-focused implementation. It will first test this diet approach in the real-life setting of Nepal's peri-urban communities, in larger numbers and over a 12-month period. People with undiagnosed, and untreated diabetes will be identified by a simple finger-prick screening test. Importantly, to maximise uptake and minimise costs, the screening and diet treatment will be delivered by 'Women Community Health Volunteers', members of the same communities who help with vaccination, screening and health promotion programmes.
The project will document how effective the intervention is in this new setting, and explore in detail its implementation, ensuring no-one is disadvantages because of sex, wealth, caste etc. It uses surveys and interviews to identify barriers and incentives, among people with T2D, in their environment and services, and in local and national government policies. With strong local management for training and capacity-building, input from the DiRECT research team, and engagement with stakeholders and people living with T2D, we aim to make the programme attractive, affordable, effective, sustainable and widely transferable in Nepal and elsewhere. As well as conventional presentations and publication of results, a local film company will make a documentary about the project, to help spread the word and exert influence over policy-makers.
Technical Summary
The project addresses UN Sustainable Development Goal-3.4, to reduce premature mortality from non-communicable diseases (NCD). Partly via related NCD risks, Type 2 diabetes (T2D) reduces life expectancy by 6 years on average, >10 years if under age 40. Recent urbanisation, under-served communities, and heavily-marketed high-fat/sugar/salt foods, coupled with greater Asian predisposition to T2D at lower age and lower body weight, generates very high disease burdens. Western treatments are inaccessible and unaffordable to most peri-urban communities.
Our Diabetes Remission Clinical Trial (DiRECT) showed that T2D is reversible, into remission for 2 years, for >70% by losing >10kg, and 36% overall. 5-year results suggest protection against medical events, despite imperfect weight loss maintenance. Collaborating with a Nepal community empowerment charity, we designed a culturally-adapted diet programme, based on DiRECT but using only low-cost traditional local foods. Pilot studies (n=70) found high acceptability and 42% T2D remissions in hospital patients. This 'Type-1 hybrid Effectiveness & Implementation' project will yield 4m RCT and 12m observational data for prevention, remission or amelioration of T2D and related NCD risks. The programme will be delivered by training existing community health volunteers with minimal call on healthcare professionals, employing validated portable HbA1c analysers. Impacts from potentially influential socio-cultural, environmental and policy factors will be explored using mixed-methods approaches developing a merged Implementation Framework to optimise programme content, delivery and policy support. Strong project management, stakeholder involvement and community engagement and empowerment will promote capacity-building and generate policy support for future scalability and sustainability. Impacts in Nepal and wider in LMICs will be enhanced by making a documentary film about the project.
Our Diabetes Remission Clinical Trial (DiRECT) showed that T2D is reversible, into remission for 2 years, for >70% by losing >10kg, and 36% overall. 5-year results suggest protection against medical events, despite imperfect weight loss maintenance. Collaborating with a Nepal community empowerment charity, we designed a culturally-adapted diet programme, based on DiRECT but using only low-cost traditional local foods. Pilot studies (n=70) found high acceptability and 42% T2D remissions in hospital patients. This 'Type-1 hybrid Effectiveness & Implementation' project will yield 4m RCT and 12m observational data for prevention, remission or amelioration of T2D and related NCD risks. The programme will be delivered by training existing community health volunteers with minimal call on healthcare professionals, employing validated portable HbA1c analysers. Impacts from potentially influential socio-cultural, environmental and policy factors will be explored using mixed-methods approaches developing a merged Implementation Framework to optimise programme content, delivery and policy support. Strong project management, stakeholder involvement and community engagement and empowerment will promote capacity-building and generate policy support for future scalability and sustainability. Impacts in Nepal and wider in LMICs will be enhanced by making a documentary film about the project.
