title: Non-pharmacological interventions to reduce the risk of diabetes in people with impaired glucose regulation: a systematic review and economic evaluation.
abstract: BACKGROUND
  The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the UK and worldwide. Before the onset of T2DM, there are two conditions characterised by blood glucose levels that are above normal but below the threshold for diabetes. If screening for T2DM in introduced, many people with impaired glucose tolerance (IGT) will be found and it is necessary to consider how they should be treated. The number would depend on what screening test was used and what cut-offs were chosen.
  
  
  OBJECTIVE
  To review the clinical effectiveness and cost-effectiveness of non-pharmacological interventions, including diet and physical activity, for the prevention of T2DM in people with intermediate hyperglycaemia.
  
  
  METHODS
  Electronic databases, MEDLINE (1996-2011), EMBASE (1980-2011) and all sections of The Cochrane Library, were searched for systematic reviews, randomised controlled trials (RCTs) and other relevant literature on the effectiveness of diet and/or physical activity in preventing, or delaying, progression to T2DM.The databases were also searched for studies on the cost-effectiveness of interventions.
  
  
  METHODS
  The review of clinical effectiveness was based mainly on RCTs, which were critically appraised. Subjects were people with intermediate hyperglycaemia, mainly with IGT. Interventions could be diet alone, physical activity alone, or the combination. For cost-effectiveness analysis, we updated the Sheffield economic model of T2DM. Modelling based on RCTs may not reflect what happens in routine care so we created a 'real-life' modelling scenario wherein people would try lifestyle change but switch to metformin after 1 year if they failed.
  
  
  RESULTS
  Nine RCTs compared lifestyle interventions (predominantly dietary and physical activity advice, with regular reinforcement and frequent follow-up) with standard care. The primary outcome was progression to diabetes. In most trials, progression was reduced, by over half in some trials. The best effects were seen in participants who adhered best to the lifestyle changes; a scenario of a trial of lifestyle change but a switch to metformin after 1 year in those who did not adhere sufficiently appeared to be the most cost-effective option.
  
  
  CONCLUSIONS
  Participants in the RCTs were volunteers and their results may have been better than in general populations. Even among the volunteers, many did not adhere. Some studies were not long enough to show whether the interventions reduced cardiovascular mortality as well as diabetes. The main problem is that we know what people should do to reduce progression, but not how to persuade most to do it.
  
  
  CONCLUSIONS
  In people with IGT, dietary change to ensure weight loss, coupled with physical activity, is clinically effective and cost-effective in reducing progression to diabetes.
  
  
  BACKGROUND
  The National Institute for Health Research Health Technology Assessment programme.
authors.affiliation: School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
authors.forename: M
authors.initials: M
authors.lastname: Gillett
authors.forename: P
authors.initials: P
authors.lastname: Royle
authors.forename: A
authors.initials: A
authors.lastname: Snaith
authors.forename: G
authors.initials: G
authors.lastname: Scotland
authors.forename: A
authors.initials: A
authors.lastname: Poobalan
authors.forename: M
authors.initials: M
authors.lastname: Imamura
authors.forename: C
authors.initials: C
authors.lastname: Black
authors.forename: M
authors.initials: M
authors.lastname: Boroujerdi
authors.forename: S
authors.initials: S
authors.lastname: Jick
authors.forename: L
authors.initials: L
authors.lastname: Wyness
authors.forename: P
authors.initials: P
authors.lastname: McNamee
authors.forename: A
authors.initials: A
authors.lastname: Brennan
authors.forename: N
authors.initials: N
authors.lastname: Waugh
mesh_terms: D000328:Adult; D000368:Aged; D001786:Blood Glucose / Q000032:analysis*; D002648:Child; D003362:Cost-Benefit Analysis; D003924:Diabetes Mellitus, Type 2 / Q000453:epidemiology / Q000517:prevention & control*; D015444:Exercise; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000178:diet therapy*; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000517:prevention & control; D040242:Risk Reduction Behavior; D006113:United Kingdom / Q000453:epidemiology
chemical_list: D001786:Blood Glucose