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Economic Evaluation of Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among Persons at Increased Risk: A Systematic Review for the Community Preventive Services Task ForceEconomics of Lifestyle Prevention of Type 2 Diabetes FREE

Rui Li, PhD; Shuli Qu, MPH; Ping Zhang, PhD; Sajal Chattopadhyay, PhD; Edward W. Gregg, PhD; Ann Albright, PhD; David Hopkins, MD; and Nicolaas P. Pronk, PhD
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This article was published online first at www.annals.org on 14 July 2015.


From Centers for Disease Control and Prevention, Atlanta, Georgia, and HealthPartners Research Foundation, Minneapolis, Minnesota.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Acknowledgment: The authors thank William Thomas, MLIS, from the Library Science Branch at the Centers for Disease Control and Prevention for doing the literature search; Verughese Jacob, PhD, from the Community Guide Branch at the Centers for Disease Control and Prevention for his assistance in the study design, data abstraction, and graphical support; and Kate W. Harris, BA, for her help in editing the manuscript. They also thank Elizabeth Luman, PhD, from the Division of Diabetes Translation; Lawrence E. Barker, PhD, from the Division of Community Health; and the other internal reviewers from the Center for Surveillance, Epidemiology and Laboratory Services for their insightful comments on revising the manuscripts, as well as Tao Ran, PhD, from the Community Guide Branch for graphical support. In addition, the authors thank the Community Preventive Services Task Force for its contributions to this evidence review.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0469.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol, statistical code, and data set: Available from Dr. Li (e-mail, eok8@cdc.gov).

Requests for Single Reprints: Rui Li, PhD, Division of Diabetes Translation, Centers for Disease Control and Prevention, 4770 Buford Highway Northeast, MS F-75, Atlanta, GA 30341; e-mail, eok8@cdc.gov.

Current Author Addresses: Drs. Li, Zhang, Gregg, and Albright: Centers for Disease Control and Prevention, 4770 Buford Highway Northeast, MS F-75, Atlanta, GA 30341.

Ms. Qu and Drs. Chattopadhyay and Hopkins: Centers for Disease Control and Prevention, 4770 Buford Highway Northeast, MS E-69, Atlanta, GA 30341.

Dr. Pronk: HealthPartners Research Foundation, 70 33rd Avenue South, Mailstop HBG/21111H, Minneapolis, MN 55425.

Author Contributions: Conception and design: R. Li, S. Qu, P. Zhang, S. Chattopadhyay, D. Hopkins, N.P. Pronk.

Analysis and interpretation of the data: R. Li, S. Qu, P. Zhang, S. Chattopadhyay, A. Albright, D. Hopkins, N.P. Pronk.

Drafting of the article: R. Li, S. Qu, S. Chattopadhyay, A. Albright.

Critical revision of the article for important intellectual content: R. Li, S. Qu, P. Zhang, S. Chattopadhyay, E.W. Gregg, A. Albright, D. Hopkins, N.P. Pronk.

Final approval of the article: R. Li, S. Qu, P. Zhang, S. Chattopadhyay, E.W. Gregg, A. Albright, D. Hopkins, N.P. Pronk.

Provision of study materials or patients: R. Li.

Statistical expertise: R. Li, S. Qu, S. Chattopadhyay.

Administrative, technical, or logistic support: R. Li, S. Qu, S. Chattopadhyay, E.W. Gregg, D. Hopkins.

Collection and assembly of data: R. Li.


Ann Intern Med. 2015;163(6):452-460. doi:10.7326/M15-0469
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Background: Diabetes is a highly prevalent and costly disease. Studies indicate that combined diet and physical activity promotion programs can prevent type 2 diabetes among persons at increased risk.

Purpose: To systematically evaluate the evidence on cost, cost-effectiveness, and cost–benefit estimates of diet and physical activity promotion programs.

Data Sources: Cochrane Library, EMBASE, MEDLINE, PsycINFO, Sociological Abstracts, Web of Science, EconLit, and CINAHL through 7 April 2015.

Study Selection: English-language studies from high-income countries that provided data on cost, cost-effectiveness, or cost–benefit ratios of diet and physical activity promotion programs with at least 2 sessions over at least 3 months delivered to persons at increased risk for type 2 diabetes.

Data Extraction: Dual abstraction and assessment of relevant study details.

Data Synthesis: Twenty-eight studies were included. Costs were expressed in 2013 U.S. dollars. The median program cost per participant was $653. Costs were lower for group-based programs (median, $417) and programs implemented in community or primary care settings (median, $424) than for the U.S. DPP (Diabetes Prevention Program) trial and the DPP Outcomes Study ($5881). Twenty-two studies assessed the incremental cost-effectiveness ratios (ICERs) of the programs. From a health system perspective, 16 studies reported a median ICER of $13 761 per quality-adjusted life-year (QALY) saved. Group-based programs were more cost-effective (median, $1819 per QALY) than those that used individual sessions (median, $15 846 per QALY). No cost–benefit studies were identified.

Limitation: Information on recruitment costs and cost-effectiveness of translational programs implemented in community and primary care settings was limited.

Conclusion: Diet and physical activity promotion programs to prevent type 2 diabetes are cost-effective among persons at increased risk. Costs are lower when programs are delivered to groups in community or primary care settings.

Primary Funding Source: None.


Diabetes is a highly prevalent, severe, and costly disease in the United States. Approximately 29 million Americans (9.3% of the U.S. population) had diabetes in 2012, and that number is projected to increase (12). Diabetes is the leading cause of kidney failure, blindness, and amputation, as well as a major cause of heart disease and stroke (2). In the United States in 2012, the total medical cost of diagnosed diabetes was estimated at $176 billion, and the cost of productivity loss due to diabetes was another $69 billion (3).

Type 2 diabetes accounts for 90% to 95% of all cases of diagnosed diabetes. Common risk factors for type 2 diabetes include obesity, family history of diabetes, physical inactivity, hypertension, hypercholesterolemia, and elevated glucose level. In addition, approximately 37% of the U.S. population aged 20 years or older and 51% of those aged 65 years or older had prediabetes in 2012, meaning that they were at increased risk for type 2 diabetes (2). However, only about 10% of at-risk persons knew their risk status (4).

Randomized clinical trials around the world have shown that combined diet and physical activity promotion programs could prevent or delay progression to type 2 diabetes among persons at increased risk (58). Studies have also demonstrated the feasibility and effectiveness of such programs when they are implemented in primary care or community settings (9). In 2014, a systematic review done for the Community Preventive Services Task Force found that programs implemented in health care or community settings effectively reduced the risk for diabetes in persons at increased risk; increased the likelihood of reversion to normoglycemia; and reduced weight and other risk factors for cardiovascular disease, such as elevated blood pressure and lipid levels (10).

Given the potentially large population that is eligible for diet and physical activity promotion programs and the resources needed for implementation, information on program cost and cost-effectiveness is critical for policy decisions, such as benefit coverage for payers, as well as planning for program design and implementation. As a companion to the aforementioned effectiveness review, we did this systematic economic review for the Community Preventive Services Task Force to estimate the cost associated with diet and physical activity promotion programs and the cost-effectiveness and cost–benefit ratios of these programs.

Data Sources and Searches

We searched the Cochrane Library, EMBASE, MEDLINE, PsycINFO, Sociological Abstracts, Web of Science, EconLit, and CINAHL for English-language articles published between January 1985 and 7 April 2015. Details of the search strategy are available on the Guide to Community Preventive Services (Community Guide) Web site (www.thecommunityguide.org) and in Appendix Table 1 (11). We also screened reference lists of relevant studies and reviews and considered studies identified by the parallel review of the effectiveness of diet and physical activity promotion programs (10).

Table Jump PlaceholderAppendix Table 1. Search Strategy: Combined Diet and Physical Activity Promotion Programs Among Persons at Increased Risk—Economic Review* 
Study Selection

We included studies that provided information on program cost; cost–benefit ratio; or incremental cost-effectiveness ratio (ICER), which is measured as dollars per life-year gained (LYG), quality-adjusted life-year (QALY) saved, or disability-adjusted life-year (DALY) averted. Included studies on program cost had to evaluate the actual program implementation cost. Included cost-effectiveness or cost–benefit studies had to meet published criteria for conducting and reporting economic evaluation analysis (12).

We used the same inclusion criteria as the aforementioned effectiveness review for study population, intervention, comparison population, and publication language (10). Criteria included a population at increased risk for type 2 diabetes, based on glycemic measures or risk scores for diabetes, presence of cardiovascular disease, or presence of the metabolic syndrome; intervention with both diet and physical activity components delivered in at least 2 contact sessions over at least 3 months; comparison with a similar population receiving either usual care (standard lifestyle advice) or no intervention for the cost-effectiveness studies; and publication in English. We further restricted our review to studies in high-income countries to provide economic estimates relevant to U.S. settings and populations.

Data Extraction and Quality Assessment

Two authors extracted data from each article according to the Cochrane systematic review protocol (13) and the Community Guide protocol for economic evaluations (14).

Data Synthesis and Analysis

Intervention costs are reported as program costs per participant, including costs to identify eligible participants (through recruitment in the community, referral from providers, or screening and referral in study settings) and to implement the diet and physical activity promotion program (staff time, training materials, and other costs). We also generated program costs per participant per session, calculated by dividing program costs per participant by the total number of core and maintenance sessions delivered. Medians and interquartile intervals (IQIs) of study estimates were reported as summary measures. If there were 4 data points, we reported the range; if there were 3 or fewer data points, all were reported.

Subgroup analyses of intervention costs were done to explore potential factors affecting costs. For delivery setting, we grouped each study into those based on the U.S. DPP (Diabetes Prevention Program) study, in which the intervention was delivered in a clinical trial setting following rigorous procedures as described in study protocols (5), and those done in real-world settings, in which diet and physical activity promotion programs were translated to community or primary care settings, with (translational DPP programs) or without (translational non-DPP programs) explicit adaptation of DPP training materials.

For delivery method, we categorized each study into 1 of the following groups: individual-based programs, in which a participant met 1-on-1 with the program provider at each core session; group-based programs, in which the participants met as a group with the program provider at each core session; or mixed programs, in which the core sessions included both individual and group sessions.

For the type of personnel delivering the program, we grouped each study by whether the program was delivered by health professionals (such as medical staff, physicians, nurses, physiotherapists, case managers, or dietitians), trained laypersons (such as certified diabetes educators, lay health educators, trained community health workers, or trained volunteers with type 2 diabetes), or a mix of health professionals and trained laypersons.

Cost-effectiveness estimates were measured as ICERs, with medians and IQIs provided as summary measures. To improve comparability of ICERs across the studies, we reported them separately by the outcome measures used in different studies: QALYs saved, LYGs, or DALYs averted. For studies found to be cost-saving, we calculated the negative net cost per QALY saved, LYG, or DALY averted whenever possible to calculate the median ICER.

Two economic perspectives were considered: the health system perspective, in which only medical costs and benefits relevant to health systems were considered, and the societal perspective, in which direct nonmedical and indirect costs were also considered. When studies provided sufficient data, we calculated ICERs for perspectives beyond those reported.

As with cost estimates, subgroup analysis of ICERs was done by delivery method. We examined cost-effectiveness estimates by type of analysis: within-trial analysis, in which ICERs were calculated from data on actual costs and benefits; modeling of a trial or extension of trials, in which studies used simulation models to estimate program cost and effectiveness during or beyond the trial period; or modeling of the national effect, in which studies estimated ICERs for programs delivered by scaling up programs to the entire country in which the study was conducted.

Because time horizon is important in program planning and budget allocation, we reported ICERs by length of follow-up (short-term [<10 years] or long-term [≥10 years]). In addition, we reported ICERs stratified by country setting (U.S.- or non–U.S.-based) to better inform programs in the United States.

All costs were adjusted to 2013 U.S. dollars by using the Consumer Price Index for medical care services (15) and annual foreign exchange rates from the Federal Reserve Bank for conversion of other currencies (16). If a study did not mention the year used in cost calculations, we assumed costs to be as of 1 year before the study publication year. Interventions were considered cost-effective if the ICER was less than $50 000 per QALY saved, less than $50 000 per LYG (17), or less than the per capita gross domestic product of the relevant country for cost per DALY averted, as recommended by the World Health Organization (18).

Role of the Funding Source

This study was done by employees of the U.S. government as part of their official duties and received no external funding.

After screening, 28 studies met our inclusion criteria and were included in our final review (Figure 1) (1946). Of these, 6 cost-only studies (2023, 2627) and 6 cost-effectiveness studies (19, 2425, 2830) provided information on the actual cost of diet and physical activity promotion programs, and 22 contributed cost-effectiveness estimates of the programs (19, 2425, 2846). Fourteen studies were U.S.-based (1924, 2627, 31, 3538, 46). No cost–benefit studies were identified.

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Figure 1.

Summary of evidence search and selection.

* Studies had abstracts only, were irrelevant, or did not meet inclusion criteria.

† Did not meet inclusion criteria (for example, included persons with diabetes or had physical activity or diet component but not both). Two studies were conducted in low- or middle-income countries, and 1 did not follow a rigorous cost–benefit analysis.

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Intervention Costs

Of the 12 studies that reported the actual costs of implementing the program (2031), only 4 included costs for identifying persons at increased risk (22, 24, 27, 29). The major cost driver was staff time to deliver the intervention. Most studies provided program cost information embedded in an evaluation of program effectiveness or cost-effectiveness without doing a formal cost analysis (Appendix Table 2).

Table Jump PlaceholderAppendix Table 2. Summary Evidence Table of Included Studies Providing Cost of Combined Diet and Physical Activity Promotion Programs to Reduce Type 2 Diabetes Among Persons at Increased Risk 

Program costs per participant ranged from $191 to $5881 (median, $653 [IQI, $383 to $1160]). The most expensive program was the 10-year DPP/DPPOS (Diabetes Prevention Program Outcomes Study), which cost $5881 per participant (19). The cost from the first 3 years (the trial period for DPP, which was based on individual sessions delivered by health professionals) was $4687; the remaining maintenance and follow-up period, called the DPPOS period, was group-based and accounted for only $1194. The translational programs were less intense than the DPP trial and usually had fewer sessions and shorter duration. Most of them were group-based or had a mixture of group and individual sessions and were delivered by either trained laypersons or a mix of health professionals and trained laypersons (Appendix Table 2). They were also less costly than the DPP trial. The median program cost per participant was $424 (IQI, $340 to $793) for the 8 translational DPP programs (2027) and $1160 (range, $427 to $1416; 4 data points) for the 3 translational non-DPP programs (2830) (Table 1).

Table Jump PlaceholderTable 1. Comparison of Program Costs, by Program Delivery Setting, Method, and Personnel 

The median cost per participant per session was $30. The cost per session of the DPP/DPPOS was $102. The median costs per participant per session for the 8 translational DPP programs and the 3 translational non-DPP programs were $25 (IQI, $16 to $48) and $27 (range, $4 to $64), respectively (Table 1).

The median cost per participant was lower in the group-based programs ($417 [IQI, $341 to $600]) (2025, 2829) than in the DPP/DPPOS ($5881) (19) and the translational non-DPP program ($1242) (29) (Appendix Table 2), both of which used individual sessions. It was also lower than the median cost of programs with a mix of individual and group sessions (median, $918 [range, $839 to $1416]) (2627, 30) (Table 1). The median cost per participant for translational programs delivered by trained laypersons (median, $357 [range, $191 to $839]) (2122, 26) was lower than that for those delivered by health professionals (median, $1077 [IQI, $381 to $1329]; 4 programs; 5 data points) (20, 2830); however, there was large variation within personnel type, possibly due to a mixture of delivery settings and methods (Table 1).

Cost-Effectiveness of the Programs

Of 22 studies reporting the cost-effectiveness of the programs, 8 were U.S.-based (19, 24, 31, 3538, 46). Seventeen studies reported the outcome measure as cost per QALY saved (19, 2425, 2831, 3540, 4244, 46), 6 reported cost per LYG (3234, 3940, 43), and 2 reported cost per DALY averted (41, 45). All studies except 1 (42) reported ICERs from a health system perspective. Eight studies (19, 28, 31, 36, 3839, 42, 44) reported ICERs from a societal perspective, and 7 (19, 28, 31, 36, 3839, 44) reported both health system and societal perspectives. However, only 1 study included all of the costs and benefits from society as a whole (44). Eighteen studies used modeling techniques (24, 28, 30, 3246), 2 of which modeled the cost-effectiveness of nationwide community-based programs (4546). Fourteen studies were based on data from the DPP trial or the Finnish Diabetes Prevention Study, which used individual sessions (19, 3136, 3841, 4344, 46). Most modeling studies considered the health and cost consequences of the program for at least 10 years (28, 30, 3243, 4546). Appendix Table 3 provides estimates of cost-effectiveness or cost–utility ratios from individual studies, which served as the basis for the summary measure of ICERs.

Table Jump PlaceholderAppendix Table 3. Summary Evidence Table of Included Studies Providing Cost-Effectiveness of Combined Diet and Physical Activity Promotion Programs to Reduce Type 2 Diabetes Among Persons at Increased Risk 

Of the 16 studies that included cost per QALY saved from the health system perspective, all but 1 (35) reported ICERs below the cost-effectiveness threshold of $50 000 per QALY saved (Figure 2). Three studies reported cost savings (36, 43, 46). The median ICER from the 16 studies was $13 761 per QALY saved (IQI, $3067 to $21 899).

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Figure 2.

Scatterplot of ICERs from 16 cost-effectiveness or cost–utility analyses that reported cost per QALY saved from the health system perspective.

DPP = Diabetes Prevention Program; ICER = incremental cost-effectiveness ratio; IQI = interquartile interval; QALY = quality-adjusted life-year.

* $13 761 per QALY saved (IQI, $3067 to $21 899).

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From the health system perspective, subgroup analyses were done with 5 studies that reported ICERs for both individual- and group-based programs (19, 31, 3536, 38). The medians were $15 846 (IQI, $7980 to $72 723) and $1819 (IQI, −$5027 to $16 443) per QALY, respectively. Six studies (2425, 2830, 46) that evaluated the cost-effectiveness of translational programs found a median ICER of $7115 per QALY (IQI, $2252 to $27 582). Two of them were conducted in the United States (24, 46); 1 reported an ICER of $5494 per QALY, and the other reported cost savings.

Studies in the United States reported a median ICER of $9824 per QALY (IQI, $1930 to $41 982; 8 studies), and non-U.S. studies reported a median ICER of $13 860 per QALY (IQI, $6203 to $21 899; 8 studies). By method, the median ICER of the 4 within-trial analyses was $28 097 per QALY (range, $5359 to $50 694) (19, 25, 29, 31). Twelve modeling studies reported a median ICER of $13 367 per QALY (IQI, $2303 to $17 614). By time horizon, the median ICERs were $17 614 per QALY (IQI, $5427 to $45 521; 5 studies) for studies that considered the benefits and costs of the program over less than 10 years and $13 367 per QALY (IQI, $1805 to $15 846; 11 studies) for studies that extended 10 years or beyond (Table 2).

Table Jump PlaceholderTable 2. Comparison of Costs per QALY Saved, by Dimension 

Two studies conducted in Australia (41, 45) reported cost per DALY averted from the health system perspective and used the Australian 2013 per capita gross domestic product of $67 468 as the cost-effectiveness threshold (47). Both studies found the programs to be cost-effective ($21 195 and $50 707 per DALY).

Six other studies reported ICERs as cost per LYG (3234, 3940, 43); all were below the $50 000 threshold. Two studies showed negative costs per LYG, which indicated cost savings (34, 43). The median ICER was $2684 per LYG (IQI, −$2444 to $17 410).

Our review found a median ICER for diet and physical activity promotion programs of $13 761 per QALY saved. The 25th and 75th percentiles of the ICERs from the 16 studies that reported cost per QALY saved from the health system perspective were both under $50 000 per QALY, which is a conventional cost-effectiveness threshold (17). The ICERs of diet and physical activity promotion programs measured by cost per LYG or DALY averted were also all under commonly used cost-effectiveness thresholds (18). Thus, we conclude that diet and physical activity promotion programs are cost-effective and involve an efficient use of health care resources.

Our evidence search identified 4 pertinent systematic or narrative reviews evaluating the evidence on cost-effectiveness of diet and physical activity promotion programs for participants at increased risk for type 2 diabetes (4851). Results from these reviews also suggested that such programs were either cost-effective or cost-saving, independent of country or delivery setting. Previous reviews did not synthesize evidence on costs of diet and physical activity promotion programs. Our systematic review includes 18 additional studies; supports the overall finding of cost-effectiveness; and provides comparative economic estimates by delivery method, setting, and staffing to inform program planning and implementation.

Given the current evidence base, we cannot definitively conclude that the programs are cost-saving. Only 3 studies that reported cost per QALY saved found the program to be cost-saving (36, 43, 46). For the 2 U.S. studies, 1 (36) reported that the DPP program was cost-saving over a lifetime horizon when delivered in group sessions, and the other (46) reported that a nationwide diabetes prevention program became cost-saving in its 11th year, implying that the programs may not save costs in the short term. However, few health care interventions have been found to be cost-saving, and many medical services that are typically covered by insurance have much higher ICERs than the diet and physical activity promotion programs (52). In a 2010 review of the cost-effectiveness of interventions for diabetes prevention and control, the median ICER for lifestyle interventions was at the low end of the spectrum, and the interventions were much more cost-effective than many diabetes treatment interventions, such as intensive glycemic control (48).

Most cost-effectiveness studies in our review were model-based because most trials lasted 3 years or less, but both the health and economic effects of the program were expected to last beyond the trial period. Estimated long-term ICERs of the programs from those modeling studies provided valuable information for decision makers in forecasting the health and economic effects of the program. One common critique of model-based studies is a lack of transparency of the models. To ensure the validity of the estimates, we explicitly abstracted studies in which information on program cost and effectiveness was clearly described in the model. Most studies used either a previously validated model or a model used in previous peer-reviewed publications, and all studies explicitly stated important assumptions used to predict future health and economic outcomes of the program. Model-based ICER estimates varied widely, which could have been due to different model structures and health assumptions, such as the rates of progression of diabetes and its complications beyond the trial period. Despite this variation in the derivation of ICERs with the use of modeling, all but 1 study showed that the ICERs of the programs were far below conventional cost-effectiveness thresholds. The 1 study that reported a much higher ICER used a model with a structure that differed greatly from the other studies and assumed a much slower rate of progression to diabetes in the model (35). However, even for this study, when the intervention was delivered in a group setting, the ICER was below the threshold of $50 000 per QALY.

Our findings have several important implications for programs implemented in the field, such as the National Diabetes Prevention Program, a public–private partnership led by the Centers for Disease Control and Prevention to implement a low-cost intervention adapted from the DPP in communities across the country (53). Group-based programs were less costly and more cost-effective than individual-based programs. In group-based programs, several participants could be counseled in the same session; thus, the cost per participant was lower. Evidence also showed that group-based programs may achieve effectiveness similar to that for individual-based programs (10). To reduce cost and achieve higher cost-effectiveness of diet and physical activity promotion programs, it seems that group-based programs should be used when the programs are implemented in real-world settings.

The cost of these programs may present a barrier to implementation despite the evidence on program cost-effectiveness. The original DPP trial was individual-based and resource-intensive. However, the program cost was much lower when it was implemented in a group format in primary care clinics and communities or translational DPP programs and was lower than or similar to currently reimbursable medical practices. For example, the annual per capita expenditure (in 2012 U.S. dollars) on prescription medications for persons with diabetes was $1423 (3), and Medicare currently pays $25.52 per counseling session for weight-loss programs (54). Further, program scale-up is expected to create economies of scale, further reducing the cost. Programs were found to be more cost-effective in longer-term follow-up studies, given that health benefits often last beyond the program period. In addition, many diabetes-related complications do not appear immediately after a person develops diabetes, which limits the ability of short-term studies to capture the full range of health benefits and medical costs avoided by the intervention.

We identified several limitations of the evidence base that future research should address. First, few studies estimated the cost associated with recruiting and engaging eligible persons to participate in the programs, which may generate additional costs when the programs are scaled up. Second, only 2 studies provided a rigorous cost analysis, and there is a lack of information to better understand the cost of scaling up the programs, such as the cost of programs delivered by trained laypersons (27). Third, only 2 studies evaluated the cost-effectiveness of programs implemented in primary care and community settings in the United States. Fourth, although the societal perspective is often preferred, of the 22 cost-effectiveness studies identified, only 8 reported this perspective and only 1 included all cost and benefit components (12). In addition, 1 study reported an ICER from a health plan (payer) perspective. Fifth, no cost–benefit analyses were identified in the review. Finally, although we attempted to stratify ICERs by program features, these characteristics were so intertwined that formal statistical testing of the effect of a single feature was not feasible.

In summary, the available economic evidence indicates that combined diet and physical activity promotion programs are cost-effective when delivered to persons at increased risk for type 2 diabetes. Evidence further suggests that programs using group sessions delivered by trained diabetes educators or laypersons are an economically efficient approach for communities and health care systems, especially those faced with limited resources and an increasing demand for services.

Health care providers have an essential role in the prevention of type 2 diabetes among patients at increased risk. In most cases, clinicians will be involved in identifying at-risk patients, delivering initial or ongoing behavioral counseling (55), and arranging referrals to available services. Our findings, combined with the findings from the concurrent effectiveness review (10), add to the growing body of evidence that diet and physical activity promotion programs using group sessions delivered by trained personnel are both effective and cost-effective. As national, state, and local efforts to implement evidence-based programs expand, health care providers will have additional, effective intervention options for patients identified as being at increased risk for type 2 diabetes.

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Alderson P, Green S, Higgins JPT. Cochrane Reviewers' Handbook 4.2.2. The Cochrane Library. Chichester, United Kingdom: J Wiley; 2004.
 
Economic Evaluation Abstraction Form. 2010. Accessed at www.thecommunityguide.org/about/EconAbstraction_v5.pdf on 19 April 2015.
 
Bureau of Labor Statistics.  Consumer Price Index: All Urban Consumers. 2014. Accessed at http://data.bls.gov/cgi-bin/surveymost?cu on 21 April 2015.
 
Board of Governors of the Federal Reserve System.  Foreign Exchange Rate. 2015. Accessed at www.federalreserve.gov/releases/g5a/current on 19 April 2015.
 
Grosse SD. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert Rev Pharmacoecon Outcomes Res. 2008; 8:165-78.
PubMed
CrossRef
 
World Health Organization.  Macroeconomics and Health: Investing in Health for Economic Development. Geneva: World Health Organization; 2001. Accessed at http://whqlibdoc.who.int/publications/2001/924154550x.pdf on 19 April 2015.
 
Diabetes Prevention Program Research Group. The 10-year cost-effectiveness of lifestyle intervention or metformin for diabetes prevention: an intent-to-treat analysis of the DPP/DPPOS. Diabetes Care. 2012; 35:723-30.
PubMed
CrossRef
 
Kramer MK, Kriska AM, Venditti EM, Miller RG, Brooks MM, Burke LE, et al. Translating the Diabetes Prevention Program: a comprehensive model for prevention training and program delivery. Am J Prev Med. 2009; 37:505-11.
PubMed
CrossRef
 
Kramer MK, McWilliams JR, Chen HY, Siminerio LM. A community-based diabetes prevention program: evaluation of the group lifestyle balance program delivered by diabetes educators. Diabetes Educ. 2011; 37:659-68.
PubMed
CrossRef
 
Krukowski RA, Pope RA, Love S, Lensing S, Felix HC, Prewitt TE, et al. Examination of costs for a lay health educator-delivered translation of the Diabetes Prevention Program in senior centers. Prev Med. 2013; 57:400-2.
PubMed
CrossRef
 
Vadheim LM, Brewer KA, Kassner DR, Vanderwood KK, Hall TO, Butcher MK, et al. Effectiveness of a lifestyle intervention program among persons at high risk for cardiovascular disease and diabetes in a rural community. J Rural Health. 2010; 26:266-72.
PubMed
CrossRef
 
Smith KJ, Hsu HE, Roberts MS, Kramer MK, Orchard TJ, Piatt GA, et al. Cost-effectiveness analysis of efforts to reduce risk of type 2 diabetes and cardiovascular disease in southwestern Pennsylvania, 2005–2007. Prev Chronic Dis. 2010; 7:A109.
PubMed
 
Irvine L, Barton GR, Gasper AV, Murray N, Clark A, Scarpello T, et al. Cost-effectiveness of a lifestyle intervention in preventing type 2 diabetes. Int J Technol Assess Health Care. 2011; 27:275-82.
PubMed
CrossRef
 
Ockene IS, Tellez TL, Rosal MC, Reed GW, Mordes J, Merriam PA, et al. Outcomes of a Latino community-based intervention for the prevention of diabetes: the Lawrence Latino Diabetes Prevention Project. Am J Public Health. 2012; 102:336-42.
PubMed
CrossRef
 
Lawlor MS, Blackwell CS, Isom SP, Katula JA, Vitolins MZ, Morgan TM, et al. Cost of a group translation of the Diabetes Prevention Program: Healthy Living Partnerships to Prevent Diabetes. Am J Prev Med. 2013; 44:S381-9.
PubMed
CrossRef
 
Feldman I, Hellström L, Johansson P. Heterogeneity in cost-effectiveness of lifestyle counseling for metabolic syndrome risk groups—primary care patients in Sweden. Cost Eff Resour Alloc. 2013; 11:19.
PubMed
CrossRef
 
Sagarra R, Costa B, Cabré JJ, Solà-Morales O, Barrio F, el Grupo de Investigación DE-PLAN-CAT/PREDICE. Lifestyle interventions for diabetes mellitus type 2 prevention. Rev Clin Esp (Barc). 2014; 214:59-68.
PubMed
CrossRef
 
Jacobs-van der Bruggen MA, Bos G, Bemelmans WJ, Hoogenveen RT, Vijgen SM, Baan CA. Lifestyle interventions are cost-effective in people with different levels of diabetes risk: results from a modeling study. Diabetes Care. 2007; 30:128-34.
PubMed
CrossRef
 
Diabetes Prevention Program Research Group. Within-trial cost-effectiveness of lifestyle intervention or metformin for the primary prevention of type 2 diabetes. Diabetes Care. 2003; 26:2518-23.
PubMed
CrossRef
 
Segal L, Dalton AC, Richardson J. Cost-effectiveness of the primary prevention of non-insulin dependent diabetes mellitus. Health Promot Int. 1998; 13:197-209.
CrossRef
 
Caro JJ, Getsios D, Caro I, Klittich WS, O'Brien JA. Economic evaluation of therapeutic interventions to prevent type 2 diabetes in Canada. Diabet Med. 2004; 21:1229-36.
PubMed
CrossRef
 
Palmer AJ, Roze S, Valentine WJ, Spinas GA, Shaw JE, Zimmet PZ. Intensive lifestyle changes or metformin in patients with impaired glucose tolerance: modeling the long-term health economic implications of the diabetes prevention program in Australia, France, Germany, Switzerland, and the United Kingdom. Clin Ther. 2004; 26:304-21.
PubMed
CrossRef
 
Eddy DM, Schlessinger L, Kahn R. Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes. Ann Intern Med. 2005; 143:251-64.
CrossRef
 
Herman WH, Hoerger TJ, Brandle M, Hicks K, Sorensen S, Zhang P, et al, Diabetes Prevention Program Research Group. The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med. 2005; 142:323-32.
CrossRef
 
Ackermann RT, Marrero DG, Hicks KA, Hoerger TJ, Sorensen S, Zhang P, et al. An evaluation of cost sharing to finance a diet and physical activity intervention to prevent diabetes. Diabetes Care. 2006; 29:1237-41.
PubMed
CrossRef
 
Hoerger TJ, Hicks KA, Sorensen SW, Herman WH, Ratner RE, Ackermann RT, et al. Cost-effectiveness of screening for pre-diabetes among overweight and obese U.S.adults. Diabetes Care. 2007; 30:2874-9.
PubMed
CrossRef
 
Lindgren P, Lindström J, Tuomilehto J, Uusitupa M, Peltonen M, Jönsson B, et al, DPS Study Group. Lifestyle intervention to prevent diabetes in men and women with impaired glucose tolerance is cost-effective. Int J Technol Assess Health Care. 2007; 23:177-83.
PubMed
CrossRef
 
Gillies CL, Lambert PC, Abrams KR, Sutton AJ, Cooper NJ, Hsu RT, et al. Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis. BMJ. 2008; 336:1180-5.
PubMed
CrossRef
 
Bertram MY, Lim SS, Barendregt JJ, Vos T. Assessing the cost-effectiveness of drug and lifestyle intervention following opportunistic screening for pre-diabetes in primary care. Diabetologia. 2010; 53:875-81.
PubMed
CrossRef
 
Neumann A, Schwarz P, Lindholm L. Estimating the cost-effectiveness of lifestyle intervention programmes to prevent diabetes based on an example from Germany: Markov modelling. Cost Eff Resour Alloc. 2011; 9:17.
PubMed
CrossRef
 
Palmer AJ, Tucker DM. Cost and clinical implications of diabetes prevention in an Australian setting: a long-term modeling analysis. Prim Care Diabetes. 2012; 6:109-21.
PubMed
CrossRef
 
Png ME, Yoong JS. Evaluating the cost-effectiveness of lifestyle modification versus metformin therapy for the prevention of diabetes in Singapore. PLoS One. 2014; 9:e107225.
PubMed
CrossRef
 
Colagiuri S, Walker AE. Using an economic model of diabetes to evaluate prevention and care strategies in Australia. Health Aff (Millwood). 2008; 27:256-68.
PubMed
CrossRef
 
Zhuo X, Zhang P, Gregg EW, Barker L, Hoerger TJ, Tony Pearson-Clarke, et al. A nationwide community-based lifestyle program could delay or prevent type 2 diabetes cases and save $5.7 billion in 25 years. Health Aff (Millwood). 2012; 31:50-60.
PubMed
CrossRef
 
The World Bank.  GDP per capita (current US$). 2014. Accessed at http://data.worldbank.org/indicator/NY.GDP.PCAP.CD on 15 April 2015.
 
Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review. Diabetes Care. 2010; 33:1872-94.
PubMed
CrossRef
 
Radl K, Ianuale C, Boccia S. A systematic review of the cost-effectiveness of lifestyle modification as primary prevention intervention for diabetes mellitus type 2. Epidemology Biostatistics and Public Health. 2013; 10:8.
 
Vijgen SM, Hoogendoorn M, Baan CA, deWit GA, Limburg W, Feenstra TL. Cost effectiveness of preventive interventions in type 2 diabetes mellitus: a systematic literature review. Pharmacoeconomics. 2006; 24:425-41.
PubMed
CrossRef
 
Wylie-Rosett J, Herman WH, Goldberg RB. Lifestyle intervention to prevent diabetes: intensive and cost effective. Curr Opin Lipidol. 2006; 17:37-44.
PubMed
CrossRef
 
Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. N Engl J Med. 2008; 358:661-3.
PubMed
CrossRef
 
Albright AL, Gregg EW. Preventing type 2 diabetes in communities across the U.S.: the National Diabetes Prevention Program. Am J Prev Med. 2013; 44:S346-51.
PubMed
CrossRef
 
Centers for Medicare & Medicaid Services.  Physician fee schedule. 2014. Accessed at www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=1&T=4&HT=0&CT=0&H1=G0447&M=1 on 19 April 2015.
 
Lin JS, O'Connor EA, Evans CV, Senger CA, Rowland MG, Groom HC. Behavioral Counseling to Promote a Healthy Lifestyle for Cardiovascular Disease Prevention in Persons With Cardiovascular Risk Factors: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence synthesis no. 113. AHRQ publication no. 13-05179-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
 

Figures

Grahic Jump Location
Figure 1.

Summary of evidence search and selection.

* Studies had abstracts only, were irrelevant, or did not meet inclusion criteria.

† Did not meet inclusion criteria (for example, included persons with diabetes or had physical activity or diet component but not both). Two studies were conducted in low- or middle-income countries, and 1 did not follow a rigorous cost–benefit analysis.

Grahic Jump Location
Grahic Jump Location
Figure 2.

Scatterplot of ICERs from 16 cost-effectiveness or cost–utility analyses that reported cost per QALY saved from the health system perspective.

DPP = Diabetes Prevention Program; ICER = incremental cost-effectiveness ratio; IQI = interquartile interval; QALY = quality-adjusted life-year.

* $13 761 per QALY saved (IQI, $3067 to $21 899).

Grahic Jump Location

Tables

Table Jump PlaceholderAppendix Table 1. Search Strategy: Combined Diet and Physical Activity Promotion Programs Among Persons at Increased Risk—Economic Review* 
Table Jump PlaceholderAppendix Table 2. Summary Evidence Table of Included Studies Providing Cost of Combined Diet and Physical Activity Promotion Programs to Reduce Type 2 Diabetes Among Persons at Increased Risk 
Table Jump PlaceholderTable 1. Comparison of Program Costs, by Program Delivery Setting, Method, and Personnel 
Table Jump PlaceholderAppendix Table 3. Summary Evidence Table of Included Studies Providing Cost-Effectiveness of Combined Diet and Physical Activity Promotion Programs to Reduce Type 2 Diabetes Among Persons at Increased Risk 
Table Jump PlaceholderTable 2. Comparison of Costs per QALY Saved, by Dimension 

References

Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metr. 2010; 8:29.
PubMed
CrossRef
 
Centers for Disease Control and Prevention.  National Diabetes Statistics Report, 2014. Accessed at www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf on 19 April 2015.
 
American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013; 36:1033-46.
PubMed
CrossRef
 
Centers for Disease Control and Prevention (CDC). Awareness of prediabetes—United States, 2005–2010. MMWR Morb Mortal Wkly Rep. 2013; 62:209-12.
PubMed
 
Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al, Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002; 346:393-403.
PubMed
CrossRef
 
Lindström J, Louheranta A, Mannelin M, Rastas M, Salminen V, Eriksson J, et al, Finnish Diabetes Prevention Study Group. The Finnish Diabetes Prevention Study (DPS): lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care. 2003; 26:3230-6.
PubMed
CrossRef
 
Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance.The Da Qing IGT and Diabetes Study. Diabetes Care. 1997; 20:537-44.
PubMed
CrossRef
 
Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V, Indian Diabetes Prevention Programme (IDPP). The Indian Diabetes Preventiaon Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia. 2006; 49:289-97.
PubMed
CrossRef
 
Ali MK, Echouffo-Tcheugui J, Williamson DF. How effective were lifestyle interventions in real-world settings that were modeled on the Diabetes Prevention Program? Health Aff (Millwood). 2012; 31:67-75.
PubMed
CrossRef
 
Balk EM, Earley A, Raman G, Avendano EA, Pittas AG, Remington PL. Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: a systematic review for the Community Preventive Services Task Force. Ann Intern Med. 2015; 163:437-51.
 
The Community Guide.  Diabetes Prevention and Control: Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among People at Increased Risk. Atlanta, GA: Community Preventive Services Task Force; 2014. Accessed at www.thecommunityguide.org/diabetes/supportingmaterials/SScombineddietandpa-econ.html on 19 April 2015.
 
Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ Economic Evaluation Working Party. BMJ. 1996; 313:275-83.
PubMed
CrossRef
 
Alderson P, Green S, Higgins JPT. Cochrane Reviewers' Handbook 4.2.2. The Cochrane Library. Chichester, United Kingdom: J Wiley; 2004.
 
Economic Evaluation Abstraction Form. 2010. Accessed at www.thecommunityguide.org/about/EconAbstraction_v5.pdf on 19 April 2015.
 
Bureau of Labor Statistics.  Consumer Price Index: All Urban Consumers. 2014. Accessed at http://data.bls.gov/cgi-bin/surveymost?cu on 21 April 2015.
 
Board of Governors of the Federal Reserve System.  Foreign Exchange Rate. 2015. Accessed at www.federalreserve.gov/releases/g5a/current on 19 April 2015.
 
Grosse SD. Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold. Expert Rev Pharmacoecon Outcomes Res. 2008; 8:165-78.
PubMed
CrossRef
 
World Health Organization.  Macroeconomics and Health: Investing in Health for Economic Development. Geneva: World Health Organization; 2001. Accessed at http://whqlibdoc.who.int/publications/2001/924154550x.pdf on 19 April 2015.
 
Diabetes Prevention Program Research Group. The 10-year cost-effectiveness of lifestyle intervention or metformin for diabetes prevention: an intent-to-treat analysis of the DPP/DPPOS. Diabetes Care. 2012; 35:723-30.
PubMed
CrossRef
 
Kramer MK, Kriska AM, Venditti EM, Miller RG, Brooks MM, Burke LE, et al. Translating the Diabetes Prevention Program: a comprehensive model for prevention training and program delivery. Am J Prev Med. 2009; 37:505-11.
PubMed
CrossRef
 
Kramer MK, McWilliams JR, Chen HY, Siminerio LM. A community-based diabetes prevention program: evaluation of the group lifestyle balance program delivered by diabetes educators. Diabetes Educ. 2011; 37:659-68.
PubMed
CrossRef
 
Krukowski RA, Pope RA, Love S, Lensing S, Felix HC, Prewitt TE, et al. Examination of costs for a lay health educator-delivered translation of the Diabetes Prevention Program in senior centers. Prev Med. 2013; 57:400-2.
PubMed
CrossRef
 
Vadheim LM, Brewer KA, Kassner DR, Vanderwood KK, Hall TO, Butcher MK, et al. Effectiveness of a lifestyle intervention program among persons at high risk for cardiovascular disease and diabetes in a rural community. J Rural Health. 2010; 26:266-72.
PubMed
CrossRef
 
Smith KJ, Hsu HE, Roberts MS, Kramer MK, Orchard TJ, Piatt GA, et al. Cost-effectiveness analysis of efforts to reduce risk of type 2 diabetes and cardiovascular disease in southwestern Pennsylvania, 2005–2007. Prev Chronic Dis. 2010; 7:A109.
PubMed
 
Irvine L, Barton GR, Gasper AV, Murray N, Clark A, Scarpello T, et al. Cost-effectiveness of a lifestyle intervention in preventing type 2 diabetes. Int J Technol Assess Health Care. 2011; 27:275-82.
PubMed
CrossRef
 
Ockene IS, Tellez TL, Rosal MC, Reed GW, Mordes J, Merriam PA, et al. Outcomes of a Latino community-based intervention for the prevention of diabetes: the Lawrence Latino Diabetes Prevention Project. Am J Public Health. 2012; 102:336-42.
PubMed
CrossRef
 
Lawlor MS, Blackwell CS, Isom SP, Katula JA, Vitolins MZ, Morgan TM, et al. Cost of a group translation of the Diabetes Prevention Program: Healthy Living Partnerships to Prevent Diabetes. Am J Prev Med. 2013; 44:S381-9.
PubMed
CrossRef
 
Feldman I, Hellström L, Johansson P. Heterogeneity in cost-effectiveness of lifestyle counseling for metabolic syndrome risk groups—primary care patients in Sweden. Cost Eff Resour Alloc. 2013; 11:19.
PubMed
CrossRef
 
Sagarra R, Costa B, Cabré JJ, Solà-Morales O, Barrio F, el Grupo de Investigación DE-PLAN-CAT/PREDICE. Lifestyle interventions for diabetes mellitus type 2 prevention. Rev Clin Esp (Barc). 2014; 214:59-68.
PubMed
CrossRef
 
Jacobs-van der Bruggen MA, Bos G, Bemelmans WJ, Hoogenveen RT, Vijgen SM, Baan CA. Lifestyle interventions are cost-effective in people with different levels of diabetes risk: results from a modeling study. Diabetes Care. 2007; 30:128-34.
PubMed
CrossRef
 
Diabetes Prevention Program Research Group. Within-trial cost-effectiveness of lifestyle intervention or metformin for the primary prevention of type 2 diabetes. Diabetes Care. 2003; 26:2518-23.
PubMed
CrossRef
 
Segal L, Dalton AC, Richardson J. Cost-effectiveness of the primary prevention of non-insulin dependent diabetes mellitus. Health Promot Int. 1998; 13:197-209.
CrossRef
 
Caro JJ, Getsios D, Caro I, Klittich WS, O'Brien JA. Economic evaluation of therapeutic interventions to prevent type 2 diabetes in Canada. Diabet Med. 2004; 21:1229-36.
PubMed
CrossRef
 
Palmer AJ, Roze S, Valentine WJ, Spinas GA, Shaw JE, Zimmet PZ. Intensive lifestyle changes or metformin in patients with impaired glucose tolerance: modeling the long-term health economic implications of the diabetes prevention program in Australia, France, Germany, Switzerland, and the United Kingdom. Clin Ther. 2004; 26:304-21.
PubMed
CrossRef
 
Eddy DM, Schlessinger L, Kahn R. Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes. Ann Intern Med. 2005; 143:251-64.
CrossRef
 
Herman WH, Hoerger TJ, Brandle M, Hicks K, Sorensen S, Zhang P, et al, Diabetes Prevention Program Research Group. The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose tolerance. Ann Intern Med. 2005; 142:323-32.
CrossRef
 
Ackermann RT, Marrero DG, Hicks KA, Hoerger TJ, Sorensen S, Zhang P, et al. An evaluation of cost sharing to finance a diet and physical activity intervention to prevent diabetes. Diabetes Care. 2006; 29:1237-41.
PubMed
CrossRef
 
Hoerger TJ, Hicks KA, Sorensen SW, Herman WH, Ratner RE, Ackermann RT, et al. Cost-effectiveness of screening for pre-diabetes among overweight and obese U.S.adults. Diabetes Care. 2007; 30:2874-9.
PubMed
CrossRef
 
Lindgren P, Lindström J, Tuomilehto J, Uusitupa M, Peltonen M, Jönsson B, et al, DPS Study Group. Lifestyle intervention to prevent diabetes in men and women with impaired glucose tolerance is cost-effective. Int J Technol Assess Health Care. 2007; 23:177-83.
PubMed
CrossRef
 
Gillies CL, Lambert PC, Abrams KR, Sutton AJ, Cooper NJ, Hsu RT, et al. Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis. BMJ. 2008; 336:1180-5.
PubMed
CrossRef
 
Bertram MY, Lim SS, Barendregt JJ, Vos T. Assessing the cost-effectiveness of drug and lifestyle intervention following opportunistic screening for pre-diabetes in primary care. Diabetologia. 2010; 53:875-81.
PubMed
CrossRef
 
Neumann A, Schwarz P, Lindholm L. Estimating the cost-effectiveness of lifestyle intervention programmes to prevent diabetes based on an example from Germany: Markov modelling. Cost Eff Resour Alloc. 2011; 9:17.
PubMed
CrossRef
 
Palmer AJ, Tucker DM. Cost and clinical implications of diabetes prevention in an Australian setting: a long-term modeling analysis. Prim Care Diabetes. 2012; 6:109-21.
PubMed
CrossRef
 
Png ME, Yoong JS. Evaluating the cost-effectiveness of lifestyle modification versus metformin therapy for the prevention of diabetes in Singapore. PLoS One. 2014; 9:e107225.
PubMed
CrossRef
 
Colagiuri S, Walker AE. Using an economic model of diabetes to evaluate prevention and care strategies in Australia. Health Aff (Millwood). 2008; 27:256-68.
PubMed
CrossRef
 
Zhuo X, Zhang P, Gregg EW, Barker L, Hoerger TJ, Tony Pearson-Clarke, et al. A nationwide community-based lifestyle program could delay or prevent type 2 diabetes cases and save $5.7 billion in 25 years. Health Aff (Millwood). 2012; 31:50-60.
PubMed
CrossRef
 
The World Bank.  GDP per capita (current US$). 2014. Accessed at http://data.worldbank.org/indicator/NY.GDP.PCAP.CD on 15 April 2015.
 
Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review. Diabetes Care. 2010; 33:1872-94.
PubMed
CrossRef
 
Radl K, Ianuale C, Boccia S. A systematic review of the cost-effectiveness of lifestyle modification as primary prevention intervention for diabetes mellitus type 2. Epidemology Biostatistics and Public Health. 2013; 10:8.
 
Vijgen SM, Hoogendoorn M, Baan CA, deWit GA, Limburg W, Feenstra TL. Cost effectiveness of preventive interventions in type 2 diabetes mellitus: a systematic literature review. Pharmacoeconomics. 2006; 24:425-41.
PubMed
CrossRef
 
Wylie-Rosett J, Herman WH, Goldberg RB. Lifestyle intervention to prevent diabetes: intensive and cost effective. Curr Opin Lipidol. 2006; 17:37-44.
PubMed
CrossRef
 
Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. N Engl J Med. 2008; 358:661-3.
PubMed
CrossRef
 
Albright AL, Gregg EW. Preventing type 2 diabetes in communities across the U.S.: the National Diabetes Prevention Program. Am J Prev Med. 2013; 44:S346-51.
PubMed
CrossRef
 
Centers for Medicare & Medicaid Services.  Physician fee schedule. 2014. Accessed at www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=1&T=4&HT=0&CT=0&H1=G0447&M=1 on 19 April 2015.
 
Lin JS, O'Connor EA, Evans CV, Senger CA, Rowland MG, Groom HC. Behavioral Counseling to Promote a Healthy Lifestyle for Cardiovascular Disease Prevention in Persons With Cardiovascular Risk Factors: An Updated Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence synthesis no. 113. AHRQ publication no. 13-05179-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2014.
 

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