***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Almost three decades ago the Finnish led the way for prevention of coronary heart disease by successfully implementing the community based North Karelia project.1 With the recent publication of their r and omised controlled clinical trial of prevention of type 2 diabetes , Tuomilehto et al have now shown that effective lifestyle changes can prevent another major chronic disease of our time . 2 3 Type 2 diabetes has long been linked with behavioural and environmental factors such as overweight , physical inactivity , and dietary habits.4 The findings from the Finnish trial confirm this link . Major lifestyle changes result ing from industrialisation are contributing to a rapid rise in diabetes worldwide , but especially in industrialising countries . An estimated 135 million people worldwide had diagnosed diabetes in 1995 , and this number is expected to rise to at least 300 million by 2025.4 Between 1995 and 2025 the number of people with diabetes will increase by 42 % ( from 51 to 72 million ) in industrialised countries and by 170 % ( from 84 to 228 million ) in industrialising countries . Diabetes exerts a huge OBJECTIVE Only a few prospect i ve studies have examined the relationship between the frequency of cigarette smoking and the incidence of diabetes mellitus .  The purpose of this study was to determine whether greater frequency of cigarette smoking accelerated the development of diabetes mellitus , and whether quitting reversed the effect . METHODS Data were collected in the Cancer Prevention Study I , a prospect i ve cohort study conducted from 1959 through 1972 by the American Cancer Society where volunteers recruited more than one million acquaintances in 25 US states . From these over one million original participants , 275,190 men and 434,637 women aged > or = 30 years were selected for the primary analysis using predetermined criteria . RESULTS As smoking increased , the rate of diabetes increased for both men and women . Among those who smoked > or = 2 packs per day at baseline , men had a 45 % higher diabetes rate than men who had never smoked ; the comparable increase for women was 74 % . Quitting smoking reduced the rate of diabetes to that of non-smokers after 5 years in women and after 10 years in men . CONCLUSIONS A dose-response relationship seems likely between smoking and incidence of diabetes . Smokers who quit may derive substantial benefit from doing so . Confirmation of these observations is needed through additional epidemiological and biological research BACKGROUND AND OBJECTIVE R and omized clinical trials have documented that lifestyle changes through physical activity can prevent diabetes . However there is no data whether such strategies are applicable at community level , that is , in a real life setting . This study demonstrates the first attempt in India , to our knowledge , of increasing physical activity through community empowerment in an attempt at primary prevention of non communicable diseases . METHODS The Chennai Urban Population Study [ CUPS ] was conducted in the year 1996 in two residential areas : a middle income group the Asiad colony at Tirumangalam , and a low income group at Bharathi Nagar in T. Nagar . The Asiad colony was selected for this study . Of the 524 eligible individuals available at baseline in 1998 [ age > or = 20 years ] , 479 individuals consented for the study ( response rate : 91.4 % ) . After seven years , in 2004 , the number of eligible individuals increased to 712 of whom 705 consented for the study ( response rate:99 % ) . Education regarding the benefits of physical activity was provided by mass awareness programmes like public lectures and video clippings . Both at baseline and during follow-up , details about the physical activity were collected using a vali date d question naire , which included job related and leisure time activities , and specific questions on exercise . Study individuals were then grade d as having light , moderate and heavy physical activity using a scoring system . RESULTS In response to the awareness programmes given by our research team , the colony residents constructed a unique public park with their own funds . Though the occupation grade s did not change , there was a significant change in the pattern of physical activity . At baseline , only 14.2 % of the residents did some form of exercise . more than three times a week , which presently increased to 58.7 % [ p < 0.001 ] . The number of subjects who walked more than three times a week increased from 13.8 % at baseline to 52.1 % during follow-up [ p < 0.001 ] . CONCLUSION This study is a demonstration of how community empowerment with increased physical activity could possibly lead to prevention of diabetes and other non communicable diseases at the community level . This study also highlights the importance of sharing the results of research studies with the community Prevention of type 2 diabetes by intensive lifestyle intervention design ed to achieve and maintain ideal body weight was assessed in subjects with impaired glucose tolerance ( IGT ) . Male subjects with IGT recruited from health-screening examinees were r and omly assigned in a 4:1 ratio to a st and ard intervention group ( control group ) and intensive intervention group ( intervention group ) . The final numbers of subjects were 356 and 102 , respectively . The subjects in the control group and in the intervention group were advised to maintain body mass index ( BMI ) of < 24.0 kg/m2 and of < 22.0 kg/m2 , respectively , by diet and exercise . In the intervention group , detailed instructions on lifestyle were repeated every 3 - 4 months during hospital visits . Diabetes was judged to have developed when two or more consecutive fasting plasma glucose ( FPG ) values exceeded 140 mg/dl . A 100 g oral glucose tolerance test was performed every 6 months to detect improvement of glucose tolerance . The subjects were seen in an ordinary outpatient clinic . The cumulative 4-year incidence of diabetes was 9.3 % in the control group , versus 3.0 % in the intervention group , and the reduction in risk of diabetes was 67.4 % ( P < 0.001 ) . Body weight decreased by 0.39 kg in the control group and by 2.18 kg in the intervention group ( P < 0.001 ) . The control group was subclassified according to increase and decrease in body weight . The incidence of diabetes was positively correlated with the changes in body weight , and the improvement in glucose tolerance was negatively correlated . Subjects with higher FPG at baseline developed diabetes at a higher rate than those with lower FPG . Higher 2h plasma glucose values and higher BMI values at baseline were also associated with a higher incidence of diabetes , but the differences were not significant . Subjects with a low insulinogenic index ( DeltaIRI/DeltaPG 30 min after an oral glucose load ) developed diabetes at a significantly higher rate than those with a normal insulinogenic index . Comparison of the BMI data and incidence of diabetes in five diabetes prevention studies by lifestyle intervention revealed a linear correlation between the incidence of diabetes and the BMI values , with the exception of the DaQing Study . However , the slope of the reduction in incidence of diabetes in the intensive intervention groups was steeper than expected simply on the basis of the reduction of BMI , suggesting that the effect of lifestyle intervention can not be solely ascribed to the body weight reduction . We conclude that lifestyle intervention aim ed at achieving ideal body weight in men with IGT  is effective and can be conducted in an outpatient clinic setting BACKGROUND & OBJECTIVE Cardiovascular and other chronic diseases are becoming the major causes of morbidity and mortality in most of the third world countries including India , especially in the southern Indian States , like Kerala , where most of the health indicators match closely with those of any developed country . Various behavioural risk factors ( BRF ) namely smoking , unhealthy diet , stress at home and work place , consumption of alcohol , sedentary life style , etc . , are known to be risk factors for many such diseases . The present study was carried out to estimate the prevalence of various behavioural risk factors for chronic diseases , and to identify their biosocial correlates . METHODS A cross-sectional study was done in which the data were collected from a sample of 6579 individuals of age 30 to 74 yr , r and omly selected following a stratified multi-stage cluster sampling design covering Kerala State . The important factors investigated include various behavioural risk factors , presenting chronic diseases and family histories among close relatives . The data were analysed using both univariate and multivariate analyses . RESULTS The two major risk factors observed among males were smoking and alcohol consumption . About two fifths ( 40 % ) of them were current smokers as well as current users of alcohol ( 41 % ) . The median age at initiation was 21 yr for both smoking habits and for alcohol consumption . Nearly a quarter of the target population were inactive ( 23 % males and 22 % females ) based on work and leisure time activities . More than one-fifth of them ( 23 % ) reported stress . Obesity was found more among females ( 33 % ) than males ( 17 % ) . Low socio-economic background was found to be a high predictor ( high risk group ) for habit of smoking , alcohol consumption , stress and unhealthy diet . INTERPRETATION & CONCLUSION Substantially high levels of the various behavioural risk factors among adults in Kerala suggests an urgent need for adopting healthy life style modifications among the population in general . The increased risk observed among the younger generation for behavioural risk factors such as smoking and alcohol consumption calls for urgent corrective steps and measures for long-term monitoring of all major risk factors as well as the major chronic disease conditions Population Registry of Lifestyle Diseases ( PROLIFE ) is a prospect i ve cohort study aim ed at the long-term follow-up of the residents of seven contiguous villages in Kerala , India . There were 161 942 subject enrolments as of 1 July 2002 . The study was initiated by Health Action by People ( HAP ) , a non-profit public health research organization . Kerala , with a population of 431 million in 2001 , has the best health indicators in India . The ‘ Kerala health experience ’ has been much discussed in academic circles . The dramatic declines in fertility and mortality in the state have result ed in a rapid epidemiological transition characterized by high morbidity and mortality from chronic diseases . However , valid epidemiological information on the burden of chronic diseases in the population does not exist . We have to rely on secondary data from hospitals . HAP decided to bridge the data gap by setting up PROLIFE Context The Diabetes Prevention Program ( DPP ) showed that lifestyle changes or metformin effectively decreased the development of  type 2 diabetes in adults with impaired glucose tolerance . The economics of these interventions is important to policymakers . Contribution This cost-effectiveness model estimates that the DPP life-style intervention would cost society about $ 8800 and metformin would cost about $ 29900 per quality -adjusted life-year saved . While lifestyle intervention had a favorable cost-effectiveness profile at any adult age , metformin was not cost-effective after age 65 years . Implication s The cost-effectiveness of lifestyle intervention to prevent type 2 diabetes  in high-risk individuals is within the range that American society typically finds acceptable for health care interventions . The Editors During the past half century , the number of persons with diagnosed diabetes in the United States has increased 4- to 6-fold ( 1 ) . Recent large clinical trials from Asia , Europe , and North America have demonstrated that behavioral and medication interventions can delay or prevent the development of type 2 diabetes in persons with impaired glucose tolerance , which is defined by a plasma glucose level between 7.77 mmol/L ( 140 mg/dL ) and 11.04 mmol/L ( 199 mg/dL ) 2 hours after a 75-g oral glucose load ( 2 - 6 ) . The Diabetes Prevention Program ( DPP ) r and omly assigned 3234 nondiabetic persons 25 years of age or older with impaired glucose tolerance and fasting glucose levels between 5.27 mmol/L ( 95 mg/dL ) and 6.94 mmol/L ( 125 mg/dL ) to placebo ; a lifestyle-modification program with the goals of at least a 7 % weight loss and 150 minutes of physical activity per week ; or metformin , 850 mg twice daily ( 4 ) . The mean age of participants was 51 years , and the mean body mass index was 34.0 kg/m2 ; 68 % were women and 45 % were members of minority groups ( 4 ) . The average follow-up was 2.8 years . Compared with the placebo intervention , the lifestyle intervention reduced the incidence of type 2 diabetes by 58 % and the metformin intervention reduced the incidence of type 2 diabetes by 31 % ( 4 ) . We have previously described the costs of the DPP interventions and their cost-effectiveness within the 3-year trial period ( 7 , 8) . In this analysis , we project the costs , health outcomes , and cost-effectiveness of the DPP lifestyle and metformin interventions over a lifetime relative to the placebo intervention . Methods Clinical Trial The lifestyle intervention involved a healthy , low-calorie , low-fat diet and moderate physical activity , such as brisk walking . The lifestyle intervention was implemented with a 16-lesson core curriculum covering diet , exercise , and behavior modification that was taught by case managers on a one-on-one basis , followed by individual sessions ( usually monthly ) and group sessions with case managers ( 9 ) 
    Output:
    
Results Prevalence of risk factors for diabetes is very high and increasing in Kerala .
This situation is largely attributable to rapid changes in the lifestyle of people living in this state of India .
The findings from the systematic review and focus groups identified many environmental and personal determinants of these unhealthy lifestyle changes , including : less than ideal accessibility to and availability of health services ; cultural values and norms ; optimistic bias and other misconceptions related to risk ; and low expectations regarding one ’s ability to make lifestyle changes in order to influence health and disease outcomes .
On the other h and , there are existing intervention trials conducted in India which suggests that risk reduction is possible .
India ’s national programme for the prevention and control of major non-communicable diseases ( NCD ) also provide a supportive environment for further community-based efforts to prevent diabetes .