Diabetes RP

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SYSTEMATIC REVIEW OF NON-PHARMACOLOGICAL INTERVENTIONS FOR TYPE 2 DIABETES IN LOW AND MIDDLE-INCOME COUNTRIES: A QUALITATIVE EXPLORATION

Introduction: Diabetes, one of the most pervasive non-communicable diseases (NCDs) worldwide, represents a formidable public health challenge. Characterized by the body's inability to use insulin effectively or the insufficient production of insulin by the pancreas, diabetes has been on the rise in recent years. In 2014, a staggering 422 million individuals received diagnoses of diabetes globally, marking a concerning trend (World Health Organization, 2016). The prevalence of diabetes has surged from 4.7% to 8.5% between 1980 and 2012, with a total of 1.5 million new cases during this period. Notably, low- and middle-income countries (LMICs) experience a disproportionate burden of diabetes, with higher mortality rates and prevalence (Roglic, 2016). The primary objective of diabetes management involves lifestyle modifications that encompass dietary improvements, physical activity, and weight management. These interventions are paramount in reducing the prevalence of diabetes and its associated complications. A kilogram of weight loss is associated with a 16% reduction in the risk of developing Type 2 Diabetes (T2D) (Hamman et al., 2006). In a clinical study conducted in Daqing, China, a combination of diet and exercise was correlated with a significant reduction in diabetes risk by 42%, underlining the efficacy of non-pharmacological interventions (Hamman et al., 2006). Furthermore, physical exercise enhances glucose tolerance and lowers the risk of T2D, irrespective of an individual's weight. Non-pharmacological treatments have demonstrated their potential in lowering the risk of T2D, even in individuals with poor glucose tolerance, offering an effective alternative to pharmaceutical interventions (Sarker et al., 2020).

Review of literature: Type 2 diabetes (T2D) constitutes a major global health challenge, with a particularly high burden in low- and middle-income countries (LMICs). Given the potential limitations in access to pharmaceutical treatments within these regions, non-pharmacological interventions have garnered increasing attention as pragmatic approaches to managing T2D (Heissel et al., 2023). In this literature review, we delve into various non-pharmacological treatments commonly employed in LMICs to provide a comprehensive evaluation of their effectiveness and their potential impact on patient outcomes. Non-pharmacological interventions, particularly lifestyle modifications, have become indispensable in the management of T2D within LMICs. Numerous studies have illuminated the transformative effects of lifestyle changes, encompassing dietary adjustments, increased physical activity, and weight management, on glycemic control and overall health (Bodhini et al., 2023). Research findings consistently highlight the potential for lowering blood glucose levels and achieving weight loss through regular exercise and the adoption of well-balanced diets rich in fruits, vegetables, and whole grains. These revelations underscore the significance of promoting healthy lifestyles, especially in resource-constrained settings, to curb the T2D epidemic (Sarker et al., 2020). In contexts where access to healthcare services is frequently limited, telemedicine and mobile health initiatives have emerged as promising tools in LMICs. Remote monitoring, smartphone applications, and text message reminders have exhibited the capacity to enhance patients' self-management and treatment adherence (Diez Alvarez et al., 2023). The utilization of telemedicine holds the potential to bridge the communication gap between patients and healthcare providers, resulting in improved disease management and superior health outcomes (Diez Alvarez et al., 2023).

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Additionally, traditional medicine has emerged as a compelling avenue for the management of T2D, especially given its strong cultural underpinnings in many LMICs. Practices such as acupuncture, herbal remedies, and other traditional therapies have demonstrated their potential in reducing blood glucose levels and enhancing overall well-being (Tang et al., 2023). However, it is imperative to approach traditional medicine with caution due to the paucity of robust scientific evidence substantiating their safety and efficacy (Tang et al., 2023). The potential for improved diabetes outcomes in LMICs is further exemplified through community-based efforts. Peer support groups and health education initiatives provide a safe platform for individuals to share their experiences, knowledge, and coping mechanisms (Sarker et al., 2020). These initiatives facilitate more effective disease management and foster a sense of community and support, enhancing participants' motivation and overall health (Fullman et al., 2023). Despite significant research in the field of non-pharmacological T2D management within LMICs, certain gaps warrant attention. Long-term efficacy and sustainability of lifestyle changes in LMICs remain an underexplored area in the literature (Fullman et al., 2023). A deeper understanding of the cultural, sociological, and economic factors influencing the adoption and maintenance of lifestyle changes is necessary. Furthermore, while telemedicine and mobile health demonstrate promise, few studies have addressed their scalability, cost- effectiveness, and accessibility within resource-constrained settings, thus necessitating tailored approaches to these technologies within LMICs' healthcare systems (Sarker et al., 2020). Intriguingly, the safety, efficacy, and treatment criteria associated with traditional medicine in T2D management remain largely unexamined. Robust scientific validation is needed to

establish evidence-based practices that ensure the safety and effectiveness of traditional treatments within LMICs (Fullman et al., 2023). Similarly, while community-based interventions and diabetes education initiatives exhibit potential, further investigation is required to assess their impact on LMIC populations, along with considerations of scalability and sustainability. Implementing and adapting these practices to diverse cultural contexts holds the promise of improving diabetes control in resource-limited environments (Sarker et al., 2020). Research Aim: This systematic review seeks to comprehensively evaluate non-pharmacological interventions for type 2 diabetes (T2D) within low- and middle-income countries (LMICs). The aim is to synthesize and analyze existing research to provide a detailed understanding of the effectiveness, feasibility, and impact of these interventions on T2D management in resource- constrained settings. Research Objectives:  Population (P): To investigate the non-pharmacological interventions used in LMICs for individuals with T2D.  Interventions (I): To assess a range of non-pharmacological interventions, including dietary modifications, exercise programs, traditional medicine, community-based initiatives, telemedicine, and mobile health interventions.  Outcomes (O): To evaluate the impact of these interventions on patient outcomes, such as glycemic control, quality of life, and disease management. Research Questions: 1. Quantitative Systematic Review:

 What is the comparative effectiveness of non-pharmacological interventions for managing type 2 diabetes in LMICs?  How do these interventions impact key patient outcomes, including glycemic control, weight management, and overall health?  Are there variations in the efficacy of these interventions based on different LMIC settings, cultural contexts, or socioeconomic factors? 2. Qualitative Systematic Review:  What are the common experiences, perceptions, and challenges faced by individuals with type 2 diabetes in LMICs when engaging in non- pharmacological interventions?  How do cultural, social, and economic factors influence the feasibility and adoption of these interventions in LMICs?  What are the key facilitators and barriers associated with non-pharmacological interventions for type 2 diabetes within the context of LMICs? By structuring the research aim, objectives, and questions using the PIO (Population, Interventions, Outcomes) format, this systematic review will distinctly address either quantitative or qualitative aspects while ensuring clarity and specificity in defining the research focus. Methodology: This systematic review follows a qualitative deductive research approach to investigate non- pharmacological treatments for type 2 diabetes in low- and middle-income countries

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(LMICs). This research design has been chosen for its suitability in comprehensively synthesizing and analyzing existing literature to answer the research question effectively (Tenny, Brannan, & Brannan, 2022). Systematic Review Process: 1. Search Strategy: A comprehensive search of relevant electronic databases, including but not limited to PubMed and Google Scholar, will be conducted. The search strategy will involve using medical subject headings (MeSH) and related phrases specific to the research topic (Richter & Austin, 2012). 2. Inclusion and Exclusion Criteria: Eligible studies will be selected based on the predefined PEO (Population, Exposure, Outcomes) criteria, as outlined in the "Inclusion and Exclusion Criteria" section. This systematic review will exclusively focus on non-pharmacological interventions for type 2 diabetes in LMICs. 3. Data Extraction: Pertinent data from selected studies will be systematically extracted, including information on the study population, exposure (non- pharmacological treatments), outcomes, and other relevant findings. 4. Quality Assessment: To ensure the robustness of included studies, a quality assessment will be conducted to evaluate the methodological quality and risk of bias in each study. 5. Synthesis and Analysis: A qualitative synthesis will be performed to consolidate the findings and insights from the selected studies. This process will enable the identification of trends, common themes, and knowledge gaps.

6. Reporting: The findings will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure clarity and transparency in presenting the systematic review results (Shamseer et al., 2015). By adopting a qualitative deductive research approach, this systematic review aims to provide a comprehensive understanding of the effectiveness and feasibility of non-pharmacological treatments for type 2 diabetes in LMICs. This approach allows for the synthesis of both quantitative and qualitative data to offer a holistic view of the research topic. The following keywords will be used to search for pertinent data: KEYWORDS Type 2 Diabetes Middle-Income Countries Non-Insulin-Dependent Diabetes Mellitus Developing Countries T2D LMICs Low-Income Countries Non-Pharmacological Interventions Inclusion Criteria: Population (P): Research involving individuals with type 2 diabetes (T2D) living in low- and middle-income countries (LMICs). Exposure (E): Studies exploring non-pharmacological interventions for managing T2D, including but not limited to dietary modifications, physical activity, traditional medicine, telemedicine, mobile health interventions, and community-based programs. Outcomes (O): Studies that report relevant patient outcomes such as glycemic control, weight management, quality of life, disease management, and patient experiences. Additional Inclusion Criteria:

1. Study Types: Original research studies, systematic reviews, meta-analyses, and literature reviews that have undergone peer-review. 2. Language: Studies published in the English language. 3. Geographic Location: Studies conducted in nations classified as low- and middle- income by the World Bank. Exclusion Criteria: 1. Geographic Location: Studies conducted in high-income countries and regions not classified as low- and middle-income by the World Bank will be excluded. 2. Focus on Pharmacological Treatments: Research primarily centered on pharmacological interventions for T2D management will not be included. 3. Non-Type 2 Diabetes: Studies that do not specifically target type 2 diabetes or involve other diabetes types will be excluded. 4. Unclear Data: Studies with incomplete or unclear data, inadequately reported non- pharmacological treatment details, or uncertain outcomes will not be considered. Data Extraction and Interpretations: The interpretation of the synthesized results will be determined by the study's question and aims. The quality of the included studies and potential bias sources will be taken into account as the strengths and weaknesses of the evidence are examined (Snyder, 2019). On the basis of the findings, recommendations for clinical practices, policy implications, and potential future research fields will be suggested (Snyder, 2019).

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In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta- Analyses) guidelines, the systematic review's findings must be reported in an understandable way. The data extraction table, analytical results, and a data interpretation will all be included in the study report's final version (Shamseer et al., 2015). References: 1. Bodhini, D., Morton, R. W., Santhakumar, V., Nakabuye, M., Pomares-Millan, H., Clemmensen, C., Fitzpatrick, S. L., Guasch-Ferre, M., Pankow, J. & Ried-Larsen, M. 2023. Role of sociodemographic, clinical, behavioral, and molecular factors in precision prevention of type 2 diabetes: a systematic review. medRxiv, 2023.05. 03.23289433. 2. Diez Alvarez, S., Fellas, A., Santos, D., Sculley, D., Wynne, K., Acharya, S., Navathe, P., Girones, X. & Coda, A. 2023. The Clinical Impact of Flash Glucose Monitoring— a Digital Health App and Smartwatch Technology in Patients With Type 2 Diabetes: Scoping Review. JMIR diabetes, 8, e42389. 3. Fullman, N., Cowling, K., Flor, L. S., Wilson, S., Bhatt, P., Bryant, M. F., Camarda, J. N., Colombara, D. V., Daly, J. & Gabert, R. K. 2023. Assessing the impact of community-based interventions on hypertension and diabetes management in three Minnesota communities: Findings from the prospective evaluation of US Health Rise programs. PloS one, 18, e0279230. 4. Hamman, R. F., Wing, R. R., Edelstein, S. L., Lachin, J. M., Bray, G. A., Delahanty, L., Hoskin, M., Kriska, A. M., Mayer-Davis, E. J. & Pi-Sunyer, X. 2006. Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes care, 29, 2102- 2107. 5. Heissel, A., Heinen, D., Brokmeier, L. L., Skarabis, N., Kangas, M., Vancampfort, D., Stubbs, B., Firth, J., Ward, P. B. & Rosenbaum, S. 2023. Exercise as medicine for

depressive symptoms? A systematic review and meta-analysis with meta-regression. British Journal of Sports Medicine. 6. Organization, W. H. 2016. Global report on diabetes: executive summary. World Health Organization. 7. Roglic, G. 2016. WHO Global report on diabetes: A summary. International Journal of Noncommunicable Diseases, 1, 3. 8. Sarker, A., Das, R., Ether, S. & Saif-Ur-Rahman, K. 2020. Non-pharmacological interventions for the prevention of type 2 diabetes mellitus in low and middle-income countries: protocol for a systematic review and meta-analysis of randomized controlled trials. Systematic Reviews, 9, 1-7. 9. Tang, C., Bao, T., Zhang, Q., Qi, H., Huang, Y., Zhang, B., Zhao, L. & Tong, X. 2023. Clinical potential and mechanistic insights of mulberry (Morus alba L.) leaves in managing type 2 diabetes mellitus: Focusing on gut microbiota, inflammation, and metabolism. Journal of Ethno pharmacology, 116143. 10. Richter, R.R. and Austin, T.M. (2012). Using MeSH (Medical Subject Headings) to Enhance PubMed Search Strategies for Evidence-Based Practice in Physical Therapy. Physical Therapy , 92(1), pp.124–132. doi:https://doi.org/10.2522/ptj.20100178. 11. Shamseer, L., Moher, D., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P. and Stewart, L.A. (2015). Preferred reporting items for systematic review and meta- analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ , 349(jan02 1), pp.g7647–g7647. doi:https://doi.org/10.1136/bmj.g7647. 12. Snyder, H. (2019). Literature Review as a Research methodology: an Overview and Guidelines. Journal of Business Research , [online] 104(1), pp.333–339. doi:https://doi.org/10.1016/j.jbusres.2019.07.039. 13. Tenny, S., Brannan, J. and Brannan, G. (2022). Qualitative study . [online] National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470395/.

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