BOSTON – Adults with prediabetes who took part in an intensive lifestyle intervention program at YMCAs across the United States lost weight and spent less on health care over 3 years than did those who did not participate, according to results from a large nationwide study.
The findings, presented at the annual scientific sessions of the American Diabetes Association, represent the first evidence that a lifestyle intervention rolled out on a national scale can result in both clinical benefit – in this case, weight loss – and potential health care savings in people considered at risk for developing type 2 diabetes.
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Previously, the Diabetes Prevention Program (DPP), a large randomized trial that compared an intensive lifestyle intervention with metformin treatment and placebo, established that focused training in diet, exercise, and behavior modification could result in a sharp reduction of progress to type 2 diabetes (T2D) in at-risk individuals. People randomized to the lifestyle intervention reduced their risk of progressing to T2D by 58% over placebo, compared with 31% for those randomized to metformin (N. Engl. J. Med. 2002;346:393-403).
But the risk reduction was achieved at a high intervention cost, and though smaller studies implementing DPP-like interventions in community health care settings saw meaningful results much more cheaply, questions lingered about cost-effectiveness when such interventions were scaled up, said Dr. Ronald T. Ackermann, director of the Center for Community Health-Institute for Public Health and Medicine and professor of medicine and geriatrics at the Northwestern University in Chicago.
Dr. Ackermann, principal investigator of the new study, presented findings from a nonrandomized “natural experiment” by which commercial health plan enrollees first identified and later clinically confirmed as having prediabetes (n = 11,737) by UnitedHealth Group, a large national insurer, were given the option to participate in the YMCA program at no cost.
Of this cohort with confirmed prediabetes, 4,064 people participated at least once in a diet and physical activity program, adapted from the DPP, involving weekly group counseling meetings lasting at least an hour for the first 4-6 months, then monthly maintenance sessions delivered by YMCA wellness instructors who were trained in the intervention protocol.
During the 3-year study period, participants lost a mean 3.6% of their body weight. Compared with a group of nonparticipating health plan enrollees who were matched for age, sex, comorbidities, metabolic markers including hemoglobin A1c, and patterns of health care spending, the participants experienced a statistically significant lower rate of health care expenditures over a 3-year period after starting the program. The 3-year sum of total per-person health care expenditures was estimated to be $364 lower for participants than for the matched nonparticipants.
UnitedHealth Group’s coverage policy for this program directs higher payments to the YMCA for participants who attend the program more often and who reach weight goals. No payments were made for enrollees who never attended. On average, UnitedHealth paid the YMCA approximately $234 per person participating. Subtracting this cost from the estimated $364 in reduced health care expenses, “the best estimate is about $129 of savings per person” to the insurer after intervention costs were subtracted, Dr. Ackermann said.
One of the key questions the study hoped to resolve, he noted, was what proportion of high-risk adults would participate in such a program. Some 35% of those encouraged to try the program by their insurer did, and of these, more than 70% were considered highly compliant, with at least nine sessions attended in the first year, he said.
The YMCA offers its diabetes prevention intervention at sites nationwide and currently has about 30,000 participants under various public and private insurance programs, including UnitedHealth, Dr. Ackermann said.
The insurer found the study results “very encouraging” and continues to pay for the program. “If an individual is identified as at risk of diabetes by a primary care doctor or endocrinologist, UnitedHealth will pay for them to take part in the program,” he said.
Dr. Ackermann’s research was carried out under the auspices of the NEXT-D study network, a multi-institution effort investigating population-targeted measures to improve diabetes prevention and outcomes. The Centers for Disease Control and Prevention and the National Institute of Diabetes and Digestive and Kidney Diseases fund NEXT-D. Dr. Ackermann disclosed no conflicts of interest.