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Effects of dietary and physical activity interventions on the risk of type 2 diabetes in South Asians: meta-analysis of individual participant data from randomised controlled trials

  • Anne Karen JenumEmail author
  • Idunn Brekke
  • Ibrahimu Mdala
  • Mirthe Muilwijk
  • Ambady Ramachandran
  • Marte Kjøllesdal
  • Eivind Andersen
  • Kåre R. Richardsen
  • Anne Douglas
  • Genevieve Cezard
  • Aziz Sheikh
  • Carlos A. Celis-Morales
  • Jason M. R. Gill
  • Naveed Sattar
  • Raj S. Bhopal
  • Erik Beune
  • Karien Stronks
  • Per Olav Vandvik
  • Irene G. M. van Valkengoed



Individuals of South Asian origin have a high risk of type 2 diabetes and of dying from a diabetes-attributable cause. Lifestyle modification intervention trials to prevent type 2 diabetes in high-risk South Asian adults have suggested more modest effects than in European-origin populations. The strength of the evidence of individual studies is limited, however. We performed an individual participant data meta-analysis of available RCTs to assess the effectiveness of lifestyle modification in South Asian populations worldwide.


We searched PubMed, EMBASE, Cochrane Library and Web of Science (to 24 September 2018) for RCTs on lifestyle modification interventions incorporating diet and/or physical activity in South Asian adults. Reviewers identified eligible studies and assessed the quality of the evidence. We obtained individual participant data on 1816 participants from all six eligible trials (four from Europe and two from India). We generated HR estimates for incident diabetes (primary outcome) and mean differences for fasting glucose, 2 h glucose, weight and waist circumference (secondary outcomes) using mixed-effect meta-analysis overall and by pre-specified subgroups. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system to rate the quality of evidence of the estimates. The study is registered with the International Prospective Register of Systematic Reviews ([PROSPERO] CRD42017078003).


Incident diabetes was observed in 12.6% of participants in the intervention groups and in 20.0% of participants in the control groups. The pooled HR for diabetes incidence was 0.65 (95% CI 0.51, 0.81; I2 = 0%) in intervention compared with control groups. The absolute risk reduction was 7.4% (95% CI 4.0, 10.2), with no interactions for the pre-specified subgroups (sex, BMI, age, study duration and region where studies were performed). The quality of evidence was rated as moderate. Mean difference for lifestyle modification vs control groups for 2 h glucose was −0.34 mmol/l (95% CI −0.62, −0.07; I2 = 50%); for weight −0.75 kg (95% CI −1.34, −0.17; I2 = 71%) and for waist −1.16 cm (95% CI −2.16, −0.16; I2 = 75%). No effect was found for fasting glucose. Findings were similar across subgroups, except for weight for European vs Indian studies (−1.10 kg vs −0.08 kg, p = 0.02 for interaction).


Despite modest changes for adiposity, lifestyle modification interventions in high-risk South Asian populations resulted in a clinically important 35% relative reduction in diabetes incidence, consistent across subgroups. If implemented on a large scale, lifestyle modification interventions in high-risk South Asian populations in Europe would reduce the incidence of diabetes in these populations.


Diet Individual participant data meta-analysis Lifestyle intervention Physical activity Prevention RCT South Asians Type 2 diabetes 



Academic Medical Center


Diabetes Intervention Study in Hindustani Surinamese


Grading of Recommendations, Assessment, Development and Evaluation


Number needed to treat


Prevention of Diabetes and Obesity in South Asians


International Prospective Register of Systematic Reviews



We thank F.S. van Etten-Jamaludin (clinical librarian, Amsterdam UMC, location Academic Medical Center [AMC]) for her help with the development of the search strategy for the different databases. We also thank M. Nicolaou (AMC) and S. Quereshi (Norwegian Centre for Migration and Minority Health, Norwegian Institute of Public Health, Oslo, Norway) for their contribution to the systematic review data collection on which the present study builds [27].

Some of the data were presented as an abstract at the 54th Annual Meeting of the EASD in Berlin, 2018 (S160, Abstract 317).

Contribution statement

The present study builds on a previous systematic review in which the corresponding author was involved. RSB, KS and IGMvV conceived and initiated the meta-analysis and AKJ and IGMvV designed the current study. All authors (except RSB) involved in designing, and agreed on, the protocol for analysis. MM and IGMvV screened abstracts and later full-text studies for eligibility. MM, IGMvV and CAC-M assessed the quality of eligible studies. Data were acquired by IB and IM. IGMvV, KS, AR, MK, EA, AD, GC and AS contributed data to the study and verified preliminary results for their respective studies. IB, IM and KRR analysed the data and, together with AKJ, POV and IGMvV, interpreted the initial results. AKJ and IGMvV drafted the manuscript, with input from MM, IB, IM and POV. All authors contributed to the interpretation of data, critically revised the manuscript and approved the last version for publication. IB, IM, KRR and AKJ had full access to all the data in the study. AKJ is responsible for the integrity of the work as a whole.


The work was sponsored by the Health Program 2014-2020 from the European Union, grant number 664609 HPPJ-2014, set up to improve the prevention of diabetes in South Asians, and by the authors’ institutions: University of Oslo, Oslo, Norway (AKJ, IM, POV); Oslo Metropolitan University, Oslo, Norway (IB, KRR); and Amsterdam UMC, location AMC, University of Amsterdam, the Netherlands (MM, EB, KS, IGMvV). The funders had no role in study design, data collection, analysis, data interpretation or writing of the paper. No pharmaceutical companies or representatives have been involved.

Duality of interest

The authors declare that there is no duality of interest associated with this manuscript. Some authors contributed to studies that were included in this systematic review. JMRG, NS, RSB, AD and AS were co-authors on the Prevention of Diabetes and Obesity in South Asians (PODOSA) trial but were not involved in its evaluation in the present study. IGMvV and KS contributed to the Diabetes Intervention Study in Hindustani Surinamese (DHIAAN), and were therefore not involved in the quality assessment in the present study. Similarly, no other co-authors who contributed their data (AR, MK, EA) were involved in the quality assessment in the present study.

Supplementary material

125_2019_4905_MOESM1_ESM.pdf (850 kb)
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  1. 1.
    Sattar N, Gill JMR (2015) Type 2 diabetes in migrant south Asians: mechanisms, mitigation, and management. Lancet Diabetes Endocrinol 3(12):1004–1016. CrossRefGoogle Scholar
  2. 2.
    Jenum AK, Diep LM, Holmboe-Ottesen G, Holme IM, Kumar BN, Birkeland KI (2012) Diabetes susceptibility in ethnic minority groups from Turkey, Vietnam, Sri Lanka and Pakistan compared with Norwegians - the association with adiposity is strongest for ethnic minority women. BMC Public Health 12(1):150. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Gholap N, Davies M, Patel K, Sattar N, Khunti K (2011) Type 2 diabetes and cardiovascular disease in South Asians. Prim Care Diabetes 5(1):45–56. CrossRefPubMedGoogle Scholar
  4. 4.
    Raymond NT, Varadhan L, Reynold DR et al (2009) Higher prevalence of retinopathy in diabetic patients of South Asian ethnicity compared with white Europeans in the community: a cross-sectional study. Diabetes Care 32(3):410–415. CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Gulati S, Misra A (2017) Abdominal obesity and type 2 diabetes in Asian Indians: dietary strategies including edible oils, cooking practices and sugar intake. Eur J Clin Nutr 71(7):850–857. CrossRefPubMedGoogle Scholar
  6. 6.
    Krishnaveni GV, Yajnik CS (2017) Developmental origins of diabetes-an Indian perspective. Eur J Clin Nutr 71(7):865–869. CrossRefPubMedGoogle Scholar
  7. 7.
    Ikram UZ, Kunst AE, Lamkaddem M, Stronks K (2014) The disease burden across different ethnic groups in Amsterdam, the Netherlands, 2011-2030. Eur J Pub Health 24(4):600–605. CrossRefGoogle Scholar
  8. 8.
    Tuomilehto J, Lindström J, Eriksson JG et al (2001) Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344(18):1343–1350. CrossRefPubMedGoogle Scholar
  9. 9.
    Knowler WC, Barrett-Connor E, Fowler SE et al (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346(6):393–403. CrossRefPubMedGoogle Scholar
  10. 10.
    Pan XR, Li GW, Hu YH et al (1997) Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and diabetes study. Diabetes Care 20(4):537–544. CrossRefGoogle Scholar
  11. 11.
    Kosaka K, Noda M, Kuzuya T (2005) Prevention of type 2 diabetes by lifestyle intervention: a Japanese trial in IGT males. Diabetes Res Clin Pract 67(2):152–162. CrossRefGoogle Scholar
  12. 12.
    Ramachandran A, Snehalatha C, Mary S et al (2006) The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 49(2):289–297. CrossRefGoogle Scholar
  13. 13.
    Haw JS, Galaviz KI, Straus AN et al (2017) Long-term sustainability of diabetes prevention approaches: a systematic review and meta-analysis of randomized clinical trials. JAMA Intern Med 177(12):1808–1817. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Galaviz KI, Weber MB, Straus A, Haw JS, Narayan KMV, Ali MK (2018) Global diabetes prevention interventions: a systematic review and network meta-analysis of the real-world impact on incidence, weight, and glucose. Diabetes Care 41(7):1526–1534. CrossRefPubMedGoogle Scholar
  15. 15.
    Admiraal WM, Vlaar EM, Nierkens V et al (2013) Intensive lifestyle intervention in general practice to prevent type 2 diabetes among 18 to 60-year-old South Asians: 1-year effects on the weight status and metabolic profile of participants in a randomized controlled trial. PLoS One 8(7):e68605. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Bhopal RS, Douglas A, Wallia S et al (2014) Effect of a lifestyle intervention on weight change in south Asian individuals in the UK at high risk of type 2 diabetes: a family-cluster randomised controlled trial. Lancet Diabetes Endocrinol 2(3):218–227. CrossRefGoogle Scholar
  17. 17.
    Telle-Hjellset V, Kjollesdal MKR, Bjorge B et al (2013) The InnvaDiab-DE-PLAN study: a randomised controlled trial with a culturally adapted education programme improved the risk profile for type 2 diabetes in Pakistani immigrant women. Br J Nutr 109(3):529–538. CrossRefPubMedGoogle Scholar
  18. 18.
    Andersen E, Burton NW, Anderssen SA (2012) Physical activity levels six months after a randomised controlled physical activity intervention for Pakistani immigrant men living in Norway. Int J Behav Nutr Phys Act 9(1):47. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Brown T, Smith S, Bhopal R, Kasim A, Summerbell C (2015) Diet and physical activity interventions to prevent or treat obesity in South Asian children and adults: a systematic review and meta-analysis. Int J Environ Res Public Health 12(1):566–594. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Chapman J, Qureshi N, Kai J (2013) Effectiveness of physical activity and dietary interventions in south Asian populations: a systematic review. Br J Gen Pract 63(607):e104–e114. CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Riley RD, Lambert PC, Abo-Zaid G (2010) Meta-analysis of individual participant data: rationale, conduct, and reporting. BMJ 340:c221. CrossRefGoogle Scholar
  22. 22.
    Shamseer L, Moher D, Clarke M et al (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 349:g7647. CrossRefGoogle Scholar
  23. 23.
    Thomas H (2003) Quality assessment tool for quantitative studies: effective public health practice project. McMaster University, Hamilton, ON, CanadaGoogle Scholar
  24. 24.
    Chowdhury TA, Hitman GA (2007) Type 2 diabetes in people of South Asian origin: potential strategies for prevention. Br J Diabetes Vasc Dis 7(6):279–282. CrossRefGoogle Scholar
  25. 25.
    Ramachandran A, Snehalatha C, Samith Shetty A, Nanditha A (2013) Primary prevention of Type 2 diabetes in South Asians—challenges and the way forward. Diabet Med 30(1):26–34. CrossRefPubMedGoogle Scholar
  26. 26.
    Ramachandran A, Snehalatha C, Ram J et al (2013) Effectiveness of mobile phone messaging in prevention of type 2 diabetes by lifestyle modification in men in India: a prospective, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol 1(3):191–198. CrossRefPubMedGoogle Scholar
  27. 27.
    Muilwijk M, Nicolaou M, Qureshi SA et al (2018) Dietary and physical activity recommendations to prevent type 2 diabetes in South Asian adults: a systematic review. PLoS One 13(7):e0200681. CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    WHO Expert Consultation (2004) Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 363(9403):157–163Google Scholar
  29. 29.
    Koopman L, van der Heijden GJ, Grobbee DE, Rovers MM (2008) Comparison of methods of handling missing data in individual patient data meta-analyses: an empirical example on antibiotics in children with acute otitis media. Am J Epidemiol 167(5):540–545. CrossRefPubMedGoogle Scholar
  30. 30.
    Carpenter JR, Goldstein H, Michael G, Kenward MG (2011) REALCOM-IMPUTE software for multilevel multiple imputation with mixed response types. J Stat Softw 45(5):1–14CrossRefGoogle Scholar
  31. 31.
    Royston P, White IR (2011) Multiple imputation by chained equations (MICE): implementation in Stata. J Stat Softw 45(5):1–20Google Scholar
  32. 32.
    Guyatt GH, Oxman AD, Vist GE et al (2008) GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 336(7650):924–926. CrossRefGoogle Scholar
  33. 33.
    Thankappan KR, Sathish T, Tapp RJ et al (2018) A peer-support lifestyle intervention for preventing type 2 diabetes in India: a cluster-randomized controlled trial of the Kerala Diabetes Prevention Program. PLoS Med 15(6):e1002575. CrossRefGoogle Scholar
  34. 34.
    Mayer-Davis EJ, Sparks KC, Hirst K et al (2004) Dietary intake in the diabetes prevention program cohort: baseline and 1-year post randomization. Ann Epidemiol 14(10):763–772. CrossRefPubMedGoogle Scholar
  35. 35.
    Snehalatha C, Mary S, Joshi VV, Ramachandran A (2008) Beneficial effects of strategies for primary prevention of diabetes on cardiovascular risk factors: results of the Indian Diabetes Prevention Programme. Diab Vasc Dis Res 5(1):25–29. CrossRefPubMedGoogle Scholar
  36. 36.
    Snehalatha C, Mary S, Selvam S et al (2009) Changes in insulin secretion and insulin sensitivity in relation to the glycemic outcomes in subjects with impaired glucose tolerance in the Indian Diabetes Prevention Programme-1 (IDPP-1). Diabetes Care 32(10):1796–1801. CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Ramachandran A, Arun N, Shetty AS, Snehalatha C (2010) Efficacy of primary prevention interventions when fasting and postglucose dysglycemia coexist: analysis of the Indian Diabetes Prevention Programmes (IDPP-1 and IDPP-2). Diabetes Care 33(10):2164–2168. CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Patel JV, Hughes EA, Lip GY, Gill PS (2011) Diabetes Health, Residence & Metabolism in Asians: the DHRMA study, research into foods from the Indian subcontinent - a blinded, randomised, placebo controlled trial. BMC Cardiovasc Disord 11(1):70. CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Ram J, Selvam S, Snehalatha C et al (2014) Improvement in diet habits, independent of physical activity helps to reduce incident diabetes among prediabetic Asian Indian men. Diabetes Res Clin Pract 106(3):491–495. CrossRefPubMedGoogle Scholar
  40. 40.
    Weber MB, Ranjani H, Staimez LR et al (2016) The stepwise approach to diabetes prevention: results from the D-CLIP randomized controlled trial. Diabetes Care 39(10):1760–1767. CrossRefGoogle Scholar
  41. 41.
    Willis A, Roshan M, Patel N et al (2016) A community faith centre based screening and educational intervention to reduce the risk of type 2 diabetes: a feasibility study. Diabetes Res Clin Pract 120:73–80. CrossRefGoogle Scholar
  42. 42.
    Patel RM, Misra R, Raj S, Balasubramanyam A (2017) Effectiveness of a group-based culturally tailored lifestyle intervention program on changes in risk factors for type 2 diabetes among Asian Indians in the United States. J Diabetes Res 2017:2751980CrossRefGoogle Scholar
  43. 43.
    Wijesuriya M, Fountoulakis N, Guess N et al (2017) A pragmatic lifestyle modification programme reduces the incidence of predictors of cardio-metabolic disease and dysglycaemia in a young healthy urban South Asian population: a randomised controlled trial. BMC Med 15(1):146. CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Yates T, Davies M, Gorely T, Bull F, Khunti K (2009) Effectiveness of a pragmatic education programme aimed at promoting walking activity in individuals with impaired glucose tolerance: a randomized controlled trial. Diabetes Care 32(8):1404–1410. CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Hamman RF, Wing RR, Edelstein SL et al (2006) Effect of weight loss with lifestyle intervention on risk of diabetes. Diabetes Care 29(9):2102–2107. CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Engberg S, Glumer C, Witte DR, Jorgensen T, Borch-Johnsen K (2010) Differential relationship between physical activity and progression to diabetes by glucose tolerance status: the Inter99 Study. Diabetologia. 53(1):70–78. CrossRefPubMedGoogle Scholar
  47. 47.
    Patel S, Bhopal R, Unwin N, White M, Alberti KG, Yallop J (2001) Mismatch between perceived and actual overweight in diabetic and non-diabetic populations: a comparative study of South Asian and European women. J Epidemiol Community Health 55(5):332–333. CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Hussain A, Bjorge B, Hjellset VT, Holmboe-Ottesen G, Wandel M (2010) Body size perceptions among Pakistani women in Norway participating in a controlled trial to prevent deterioration of glucose tolerance. Ethn Health 15(3):237–251. CrossRefPubMedGoogle Scholar
  49. 49.
    Williams RL, Wood LG, Collins CE, Callister R (2015) Effectiveness of weight loss interventions—is there a difference between men and women: a systematic review. Obes Rev 16(2):171–186. CrossRefPubMedGoogle Scholar
  50. 50.
    Davidson EM, Liu JJ, Bhopal R et al (2013) Behavior change interventions to improve the health of racial and ethnic minority populations: a tool kit of adaptation approaches. The Milbank Quarterly 91(4):811–851. CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Kreuter MW, Lukwago SN, Bucholtz RD, Clark EM, Sanders-Thompson V (2003) Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Educ Behav 30(2):133–146. CrossRefPubMedGoogle Scholar
  52. 52.
    Nierkens V, Hartman MA, Nicolaou M et al (2013) Effectiveness of cultural adaptations of interventions aimed at smoking cessation, diet, and/or physical activity in ethnic minorities. a systematic review. PLoS One 8(10):e73373. CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Iliodromiti S, Ghouri N, Celis-Morales CA, Sattar N, Lumsden MA, Gill JM (2016) Should physical activity recommendations for South Asian adults be ethnicity-specific? Evidence from a cross-sectional study of South Asian and White European men and women. PLoS One 11(8):e0160024. CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Bhopal RS (2019) Epidemic of cardiovascular disease and diabetes. Explaining the phenomenon in South Asians worldwide. Oxford University Press, Oxford. CrossRefGoogle Scholar
  55. 55.
    Lean ME, Leslie WS, Barnes AC et al (2018) Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet 391(10120):541–551. CrossRefGoogle Scholar
  56. 56.
    Huttunen-Lenz M, Hansen S, Christensen P et al (2018) PREVIEW study-influence of a behavior modification intervention (PREMIT) in over 2300 people with pre-diabetes: intention, self-efficacy and outcome expectancies during the early phase of a lifestyle intervention. Psychol Res Behav Manag 11:383–394. CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Anne Karen Jenum
    • 1
    Email author
  • Idunn Brekke
    • 2
    • 3
  • Ibrahimu Mdala
    • 1
  • Mirthe Muilwijk
    • 4
  • Ambady Ramachandran
    • 5
    • 6
  • Marte Kjøllesdal
    • 7
  • Eivind Andersen
    • 8
  • Kåre R. Richardsen
    • 9
  • Anne Douglas
    • 10
  • Genevieve Cezard
    • 10
    • 11
  • Aziz Sheikh
    • 10
  • Carlos A. Celis-Morales
    • 12
  • Jason M. R. Gill
    • 12
  • Naveed Sattar
    • 12
  • Raj S. Bhopal
    • 10
  • Erik Beune
    • 4
  • Karien Stronks
    • 4
  • Per Olav Vandvik
    • 13
  • Irene G. M. van Valkengoed
    • 4
  1. 1.General Practice Research Unit (AFE), Department of General Practice, Institute of Health and Society, Faculty of MedicineUniversity of OsloOsloNorway
  2. 2.Centre for Welfare and Labour Research, Norwegian Social ResearchOsloMet – Oslo Metropolitan UniversityOsloNorway
  3. 3.Faculty of Health Sciences, Department of Nursing and Health PromotionOsloMet – Oslo Metropolitan UniversityOsloNorway
  4. 4.Department of Public Health, Amsterdam Public Health Research InstituteUniversity of AmsterdamAmsterdamthe Netherlands
  5. 5.India Diabetes Research FoundationChennaiIndia
  6. 6.Dr. A. Ramachandran’s Diabetes HospitalsChennaiIndia
  7. 7.Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of MedicineUniversity of OsloOsloNorway
  8. 8.Faculty of Humanities, Sports and Educational ScienceUniversity of South-Eastern NorwayBorreNorway
  9. 9.Department of Physiotherapy, Faculty of Health SciencesOsloMet – Oslo Metropolitan UniversityOsloNorway
  10. 10.Usher Institute of Population Health Sciences and InformaticsUniversity of EdinburghEdinburghUK
  11. 11.Population and Health Research Group, School of Geography and Sustainable DevelopmentUniversity of St AndrewsFifeUK
  12. 12.Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
  13. 13.Department of MedicineInnlandet Hospital TrustGjøvikNorway

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