Lifestyle and Metformin Interventions Cost-Effective for Preventing Diabetes

New research indicates that the The Diabetes Prevention Program (DPP) approach is cost-effective, in delaying or preventing the development of Type 2 diabetes, involving lifestyle and metformin interventions.

Meanwhile, in a similar study, lifestyle modifications were found to decrease the risk of diabetes in nonsmokers without impaired glucose tolerance, echoing what was seen previously in patients with impaired tolerance.

Both reports appear in the Annals of Internal Medicine for March 1.

In the first study, Dr. William H. Herman, from the University of Michigan in Ann Arbor, and colleagues used a Markov simulation model to assess the cost-effectiveness of the DPP interventions among subjects 25 years of age or older with impaired glucose tolerance.

The lifestyle intervention of the DPP involved a healthy, low-calorie/low-fat diet and moderate physical activity reinforced on a one-to-one basis and in group sessions. The metformin intervention involved a twice-daily dose of 850 mg with adherence support by a case manager.

The lifestyle and metformin interventions delayed the onset of diabetes by 11 and 3 years, respectively, compared with placebo, the authors note. The corresponding reductions in the absolute incidence of diabetes were 20% and 8%. In addition, both interventions reduced the occurrence of diabetic complications and improved survival.

Compared with placebo, the cost per quality-adjusted life-years (QALYs) for the lifestyle and metformin interventions was $1100 and $31,300, respectively, the researchers found. The corresponding costs per QALY, from a societal perspective, were $8800 and $29,900. In both analyses, the metformin intervention was dominated by the lifestyle intervention.

In the second study, Dr. George Davey Smith, from the University of Bristol in the UK, and colleagues assessed the incidence of diabetes among 11,827 men without impaired glucose tolerance who participated in the Multiple Risk Factor Intervention Trial (MRFIT). As part of the trial, the subjects were randomized to receive a lifestyle intervention, similar to that used in the DPP, or usual care.

In the overall analysis, the rate of diabetes in the intervention group — 11.5% — was actually slightly higher than the rate in the usual care group — 10.8%. Further analysis revealed that the lifestyle intervention raised the risk of diabetes among smokers by 26%, but lowered the risk among nonsmokers by 18% (p = 0.0003).

As to why this occurred, the authors believe that the smoking cessation encouraged by the intervention may have resulted in weight gain among smokers that counterbalanced the beneficial effects seen. By contrast, this would not have occurred in patients who were nonsmokers at baseline.

In a related editorial, Dr. Jaakko Tuomilehto, from the National Public Health Institute in Helsinki, Finland, comments that while these reports show that lifestyle interventions can delay or prevent diabetes and are cost effective, the question remains of "what should be done with smokers?" It is possible that switching from diuretics and beta-blockers to drugs that interfere with the renin-angiotensin system may help cut the risk of diabetes in smokers with hypertension.
Ann Intern Med 2005;142:313-332,381-383.

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