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Diabetes: scaling up solutions for a global problem

The Emory Global Diabetes Research Center seeks to strengthen efforts to combat diabetes and hypertension in India. Training of local health care workers will be a key element.

Photo courtesy of EGDRC/Courtney Peters


When the United States first launched November as a month dedicated to diabetes in the early 1980s, it was considered a disease of adults in affluent countries. Today, with economic development and changing lifestyles, diabetes has spread worldwide in epidemic proportions.

The number of people with diabetes has quadrupled in the last 35 years, and more than 460 million adults in the world now have diabetes. The majority of people with diabetes now live in low- and middle-income countries. It afflicts the poor as much as the rich and strikes children and teens as well as adults, in both urban and rural areas.

"In the years since I began working in this field, diabetes has grown to become one of the biggest public health and development threats we face," says K.M. Venkat Narayan, who is Ruth and O.C. Hubert Professor of Global Health at Emory University’s Rollins School of Public Health. "The spread of some of the ills of a modern lifestyle — sedentary behaviors, a diet of processed and unhealthy foods, and an increase in obesity — has made diabetes a worldwide crisis. In its most common form, diabetes is mostly preventable."

Narayan and his team of researchers at the Emory Global Diabetes Research Center (EGDRC) are looking at what needs to be done for a world free of diabetes. This was the focus of the team’s entry to the MacArthur Foundation’s 100&Change competition, which is currently underway. The grant proposal highlighted Emory’s culture of collaboration with multiple teams across the university engaging in its development. Building upon expertise in global health, public health leadership training, community outreach, computer science and data analytics, the Emory team included members from Rollins, the schools of nursing and medicine, Emory College, the Office of the Provost, Advancement and Alumni Engagement, and Communications and Public Affairs, among others.  

In the application, titled “Destination Zero,” the team proposed scaling up the diabetes and hypertension prevention and management program they have developed and tested in India over many years. They are currently testing the scale-up in a pilot program in India. The pilot program, conducted in partnership with leading Indian institutions such as the All India Institutes of Medical Sciences and the Public Health Foundation of India, harnesses existing government infrastructure to deliver the interventions.

The World Health Organization’s recent announcement about certifying generic insulin production could increase access to the drug for the 80 million people around the world who need it, half of whom can’t afford it. The scarcity has long been a concern of Narayan’s.

“It’s not uncommon for a poor family in rural India to face a terrible choice: should they send one child off to school or make sure that the other child has insulin?” he told Scientific American.

In developing countries, Narayan says increasing access to medications has to go hand in hand with strengthening primary care infrastructure, and prevention, especially diet and exercise. "We have gotten very good at caring for and controlling diabetes, especially in high-income countries, but we are lagging in prevention," he says.

Narayan and his team plan to leverage some of the lessons learned from their programs here in Georgia. They know that knowledge of the disease and how to prevent it, while necessary, is not enough to promote sustained adoption of behavior changes. In other areas of public health such as tobacco cessation and vaccination promotion, technologies such as text messaging apps have proven helpful in providing needed reminders and motivation. The center plans to deploy similar strategies, together with training nurses and community health workers, to fight diabetes in India.

The project in India has a community-based component and a clinic-based component. The community portion includes training programs and apps – developed with Indian partners – to allow health care workers to educate patients with videos or text messaging, and to connect them to affordable medications and care. There is a media campaign component as well to raise awareness about lifestyle changes that can prevent diabetes and hypertension. Existing community health workers will be trained as patient advocates.

Hypertension is even more prevalent than diabetes in Indian cities, Narayan and his India-based partners have learned from their research. In a two-year period, one in six adults they studied developed hypertension. Diabetes and hypertension, as risk factors for heart disease and stroke, can and must be dealt with together, he says.

Lifestyle education can deliver concrete results. Mary Beth Weber, assistant professor of global health and on the EGDRC team, partnered with the Madras Diabetes Research Foundation in India on a study that showed interventions that succeeded in preventing diabetes in the U.S. and elsewhere can work in India with some people. They saw that after three years, the group that got the recommended intervention — lifestyle education plus the glucose-lowering drug metformin if needed — was 30 percent less likely to develop diabetes than the control group.

Narayan recalls a participant in the Chennai study, who had become almost hopeless because of the amount of weight he had gained. He feared his high glucose levels would cause him to go blind. But after the program, he became a transformation agent, Narayan says.

“He was one of the most effective members of the community to make the study successful,” he says. “We’ve seen several examples of people whose livelihoods depended on good health, such as taxi drivers and fruit vendors, come into the program and become much healthier.”

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