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For the first time, clinical research shows that reducing health risks through weight control, a balanced diet, and physical activity is a cost-effective way to delay the development of type 2 diabetes.
Two studies published in the March 2005 issue of Annals of Internal Medicine are apparently the first to demonstrate the value of lifestyle intervention among nondiabetic patients.
"Intuitively, we've always thought that these things made sense," says William Herman, MD, MPH, of the University of Michigan, Ann Arbor. "We've had the efficacy data, but we didn't have the cost-effectiveness data."
LIFESTYLE VS. DRUGS
The Diabetes Prevention Program (DPP) estimated the cost-effectiveness of lifestyle modification and metformin therapy in delaying or preventing the development of type 2 diabetes.1
A cohort of 3,234 people 25 years of age or older who had impaired glucose intolerance and fasting glucose levels of 95–125 mg/dl were randomly assigned to receive placebo, follow a lifestyle modification program aimed at achieving 150 minutes of physical activity a week and a 7% weight loss (see sidebar), or receive 850 mg of metformin twice a day. Participants were followed for an average of 3 years.
Compared with placebo, lifestyle intervention delayed the development of diabetes by 11 years and reduced the incidence of the disease by more than 20% in high-risk participants. Metformin therapy was estimated to delay the onset of type 2 diabetes by 3 years and reduce the incidence of the disease by 9%.
According to investigators, lifestyle modifications cost about $1,100 (per year adjusted for quality of life), while metformin therapy costs $31,300. "Lifestyle interventions are clearly more cost-effective," says Herman.
Although lifestyle intervention is cost-effective for all age-groups, the value of metformin therapy drops off after age 65, according to the research. Metformin therapy becomes "cost-prohibitive when people get over 50 or 60, probably because the intervention is simply not as effective," Herman says.
MRFIT STUDY
Similar results were reported from the Multiple Risk Factor Intervention Trial (MRFIT).2
One of the largest randomized clinical trials of lifestyle intervention ever undertaken, MRFIT involved 12,866 men aged 35 to 57 who were followed for 6 to 7 years at 22 medical centers.
The intervention for participants with normal glucose levels included advice to reduce intake of saturated fats and increase intake of polyunsaturated fats, to reduce weight if the participant was overweight or obese, and to increase physical activity.
Lifestyle intervention reduced the incidence of type 2 diabetes by 18% over a 6-year period among nonsmokers. In smokers, the same strategy increased diabetes by 26%. Investigators say the adverse result among smokers may be due to weight gain from smoking cessation. Also, because smokers received cessation counseling, they may have been shortchanged on other lifestyle modification efforts.
PAYER ACCEPTANCE
Because of the higher up-front costs and intensive attention required to achieve lifestyle changes, risk reduction remains a hard sell among payers and clinicians alike, says Herman.
"The response in the trenches is, `Yeah, lifestyle intervention works, but it's easier to write a prescription,'" he says. "Our health system pays for pharmacologic intervention, but generally not for lifestyle intervention."
The tide may be changing slowly, as studies like these provide further evidence that improving health makes economic sense. Large payers such as Medicare and managed-care plans are becoming more open to dietary intervention to reduce diabetes risk, along with other lifestyle modifications.
"What we'd like to see is the health care system embrace lifestyle
intervention and offer it to people at risk of type 2 diabetes," Herman
says. "As these studies come out, they add ammunition [for the argument]
that the health system should consider covering them."
LIFESTYLE INTERVENTION AT A GLANCE
Results from the Diabetes Prevention Program (DPP) show that lifestyle intervention is a cost-effective way to delay development of type 2 diabetes.
The goal of the lifestyle intervention used by DPP was to achieve 150 minutes of physical activity per week and a 7% weight loss.
Lifestyle modifications included a healthy, low-fat, low-calorie diet and moderate physical activity such as brisk walking.
Participants followed a 16-lesson core curriculum covering diet, exercise, and behavioral modification taught one-on-one by a case manager, supplemented by regular individual and group sessions.
Clearly it's important to stress to every patient the importance of a healthy lifestyle that includes good nutrition and exercise. Initiating conversations about recent findings, including those of the DPP, helps to educate patients about the degree to which behavioral modification can help ward off ill health.
References
2. Davey Smith G, Bracha Y, Svendsen KH: Incidence of type 2 diabetes
in the randomized Multiple Risk Factor Intervention Trial. Ann
Intern Med 142:313–322, 2005.
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