Cost-effectiveness of DiabetesPrevention InterventionsTargeting High-risk Individualsand Whole Populations: ASystematic ReviewDiabetes Care 2020;43:1593–1616 | https://doi.org/10.2337/dci20-0018

OBJECTIVE

We conducted a systematic review of studies evaluating the cost-effectiveness (CE)of interventions to prevent type 2 diabetes (T2D) among high-risk individuals andwhole populations.

RESEARCH DESIGN AND METHODS

Interventions targeting high-risk individuals are those that identify people at highrisk of developing T2D and then treat them with either lifestyle or metformininterventions. Population-based prevention strategies are those that focus on thewhole population regardless of the level of risk, creating public health impactthrough policy implementation, campaigns, and other environmental strategies.We systematically searched seven electronic databases for studies published inEnglish between 2008 and 2017.We grouped lifestyle interventions targeting high-risk individuals by delivery method and personnel type. We used the medianincremental cost-effectiveness ratio (ICER), measured in cost per quality-adjustedlife year (QALY) or cost saved to measure the CE of interventions. We used the$50,000/QALY threshold to determine whether an intervention was cost-effectiveor not. ICERs are reported in 2017 U.S. dollars.

RESULTS

Our review included 39 studies: 28 on interventions targeting high-risk individualsand 11 targeting whole populations. Both lifestyle and metformin interventions inhigh-risk individuals were cost-effective from a health care system or a societalperspective, with median ICERs of $12,510/QALY and $17,089/QALY, respectively,compared with no intervention. Among lifestyle interventions, those thatfollowed a Diabetes Prevention Program (DPP) curriculum had a median ICER of$6,212/QALY,while those that did not followaDPP curriculumhadamedian ICERof$13,228/QALY. Compared with lifestyle interventions delivered one-on-one orbyahealthprofessional, thoseoffered inagroup settingorprovidedbya combination ofhealth professionals and lay health workers had lower ICERs. Among population-based interventions, taxing sugar-sweetened beverages was cost-saving from boththe health care system and governmental perspectives. Evaluations of otherpopulation-based interventionsdincluding fruit and vegetable subsidies, commu-nity-based education programs, and modifications to the built environmentdshowed inconsistent results.

CONCLUSIONS

Most of the T2D prevention interventions included in our review were found to beeither cost-effective or cost-saving. Our findings may help decision makers setpriorities and allocate resources for T2D prevention in real-world settings.

1Division of Diabetes Translation, Centers forDisease Control and Prevention, Atlanta, GA2College of Nursing and Disability, Aging andTechnology Cluster, University of Central Florida,Orlando, FL3Oak Ridge Institute for Science and Education,Oak Ridge, TN

Corresponding author: Ping Zhang, paz2@cdc.gov

Received 23 March 2020 and accepted 3 April2020

The findings and conclusions are those of theauthors and do not necessarily represent theofficial position of the Centers for Disease Controland Prevention.

© 2020 by the American Diabetes Association.Readersmayuse this article as longas thework isproperly cited, the use is educational and not forprofit, and the work is not altered. More infor-mation is availableathttps://www.diabetesjournals.org/content/license.

See accompanying article, p. 1557.

Xilin Zhou,1 Karen R. Siegel,1

Boon Peng Ng,1,2 Shawn Jawanda,3

Krista K. Proia,1 Xuanping Zhang,1

Ann L. Albright,1 and Ping Zhang1

Diabetes Care Volume 43, July 2020 1593

SCIEN

TIFICREV

IEW

Diabetes is amajor global health issue. In2019, there were an estimated 463 mil-lion adults aged 20–79 years with di-abetes globally (;9.3%of the populationin this age-group), a figure that is pro-jected to increase to 700 million by2045 (1). Health care expenditures at-tributable to diabetes were estimatedat $1.3 trillion in 2015 (2). Fortunately,type 2diabetes (T2D),which accounts for90–95% of the disease burden (3), can beprevented or delayed through nutritionand lifestyle changes as well as throughpharmacologic interventions (4).Approaches to prevent T2D fall under

two categories: targeting individuals athigh risk for developing T2D (high-riskapproaches) and targeting the wholepopulation regardless of the level of risk(population-based approaches). In gen-eral, high-risk individuals are those whohave prediabetes (a health conditionwith a blood glucose level that is higherthan normal but does not reach the levelofdiagnosedT2D)orwhohave risk factorsfordevelopingT2D,suchashavingafamilyhistoryofT2D, beingoverweightorobese,being physically inactive, being 45 yearsold or older, or being a woman with ahistory of gestational diabetes mellitus(5). Interventions targeting high-risk in-dividuals include screening for T2D inclinics and communities and providinglifestyle or pharmacologic interventions.On the other hand, population-based ap-proaches aim to impact public healththrough policy implementation, cam-paigns, and other environmental changestrategies. For example, imposing taxeson sugar-sweetenedbeverages (SSBs) hasbeen proposed as a population-basedapproach to combat T2D and cardiovas-cular disease by the World Health Orga-nization (6). Epidemiological evidence onthe association between added sugarsand T2D incidence and implementationexperiences from Mexico and selectedcities in the U.S. (Berkeley, for example)have led decision makers to explore thefeasibility and effectiveness of scaling upsuch policies (7,8). Some experts suggestthat the goal of reducing the number ofnew cases of T2D in the U.S. and world-wide is likely best achieved through ap-proaches that combine both high-risk andpopulation-based approaches (9,10).T2D prevention approaches, whether

high-risk or population-based, vary interms of intervention effectiveness andcost. However, their cost-effectiveness

(CE) has not been evaluated comprehen-sively or systematically. Most literaturereviews to date have assessed the effi-cacy of T2D prevention approaches onlywithout considering their CE or withfocus on a single strategy (11–15). Forexample, one review and meta-analysisfocused on nutrition education and ex-amined the cost and CE of using dietmodification as a T2D preventive inter-vention (16). Another systematic reviewmeasured the CE of T2D high-risk pre-vention approaches but focused on life-style interventions only (17). A recentstudy reviewed the CE of both lifestyleandmetformin for T2D prevention amonghigh-risk individuals but did not includepopulation-based approaches (18). An-other review evaluated both high-riskand population-based approaches (19);however, it did not examine key featuresof lifestyle interventionsdsuch as inter-vention delivery mode and formatdthat might affect the CE outcome, and itonly included fiscal policies among thepopulation-based approaches. In addition,many new studies on the CE of T2Dprevention interventions that have beenpublished in recent years need to beevaluated in a review.

Here, we systematically review the CEof both high-risk and population-basedapproaches for T2D prevention. The goalis twofold: 1) to update evidence onhigh-risk approaches implemented inreal-world settings, including whetherto screen, whom to screen, and whichformats are best for delivering lifestyleinterventions (in-person vs. virtual, one-on-one vs. group, etc.) and 2) to synthesizeevidence on population-based preventionstrategies.

RESEARCH DESIGN AND METHODS

Literature SearchWe searched the Cumulative Index toNursing and Allied Health Literature(CINAHL), Cochrane databases, ExcerptaMedica (EMBASE), Medical LiteratureAnalysis and Retrieval System Online(MedlinePlus), PsycINFO, Scopus, andSociological Abstracts (Soc Abs) to iden-tify original economic evaluations ofapproaches to prevent T2D publishedin English from January 2008 to July2017. Search keywords included 1) di-abetes, impaired glucose tolerance, andinsulin resistance; 2) expenditure, healthcare cost, and cost of illness; 3) quality-

adjusted life year (QALY), disability-adjusted life year (DALY), and incidence ofdiabetes; and4) cost-effectiveness analysis(CEA), cost-utility analysis, cost-benefitanalysis, and economic evaluation (20).In addition to searching the seven data-bases above, we manually screened thereference lists of all included studies aswell as the table of contents of majordiabetes journals (Diabetes Care, TheLancet Diabetes & Endocrinology, Diabe-tologia, and Diabetes Research and Clin-ical Practice) during the search period.

Study Design for ReviewingInterventions Targeting High-riskIndividualsFollowing the Cochrane Collaboration’sprotocol for systematic reviews (21), twopeople independently reviewed eachstudy for inclusion/exclusion in our re-view, quality assessment, and data ab-straction. We focused on three types ofeconomic evaluations of high-risk ap-proaches to T2D prevention: CE, cost-utility, and cost-benefit analyses. Weincluded studies that reported quanti-tative measures for the CE outcomes.The outcome was the incremental cost-effectiveness ratio (ICER), which is in theform of cost-per-additional QALY gained orcost-per-additional DALY averted.

Quality Assessment of the IncludedStudiesTo assess the quality of included studies,weuseda tool basedonTheBMJauthors’guide for economic studies (22), whichwas used previously (20). In brief, thetool assesses each study based on 13 at-tributes: sources of cost data, sourcesof benefit data, categories of cost data,categoriesof benefit data, analytical timehorizons, study perspectives, model de-scriptions, structure diagrams, currencyand year of the costs, discounting factorfor costs, discounting factor for benefits,ICERs, and sensitivity analyses. Each at-tribute was given one pointdan equalweightdif the study clearly stated it.Weincluded studies with a quality score ofseven and above (20).

Data Abstraction and Cost AdjustmentWe abstracted the following informationfrom each study: publication informa-tion, study objective, prevention ap-proach, comparison, target population,delivery method, provider, analyticaltime horizon, study method, perspective

1594 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

of the evaluation, and results. We ad-justed ICERs and costs to 2017 U.S. dol-lars using the Consumer Price Index (23).For studies conducted in countries otherthan the U.S., we used the annual ex-change rate from the Federal ReserveBank to convert the foreign currenciesinto U.S. dollars before adjusting themfor inflation (24). In rare cases where thestudy did not report the specific year ofcurrency used to calculate costs, weassumed the costs were calculated1 year before the publication date.Studies were considered cost-effectiveif the ICER was below the $50,000/QALYthreshold (25).

GroupingHigh-riskApproaches toT2DPreventionWe grouped high-risk approaches intofour categories based on their studyobjectives: 1) articles focused on decid-ing whether to screen for prediabetes, 2)articles determining the target popula-tion for screening that would generatethe optimal CE outcomes, 3) articlesevaluating the CE of specific T2D pre-vention interventions, and 4) articlesevaluating the CE of managing gesta-tional diabetes mellitus.To better understand what features

contribute to the CE outcomes of pre-vention interventions, we examined in-terventions from the third categoryabove (those evaluating theCEof specificT2D prevention interventions) and sum-marized the median and range of ICERsfor interventions sharing similar featuresin terms of how the intervention is de-livered (i.e., whether delivered one-on-oneor in a group andwhether conductedin-person or via virtual media, such asinternet or mobile applications) and bywhom (i.e., whether taught by healthcareprovidersor layhealthworkers, suchas trained community health workers ordiabetes educators). The high-risk ap-proaches included lifestyle interventions(translational Diabetes Prevention Pro-gram [DPP] and translational non-DPP)and pharmacologic interventions (met-formin). Translational DPPs refer to nu-trition and physical activity interventionsthat follow the DPP curriculum thattranslated to the real world, such asthose provided in the community orprimary care setting. In contrast, trans-lational non-DPPs are lifestyle interven-tions that do not strictly follow the DPPcurriculum.

Study Design for Population-BasedInterventionsWe modified our study protocol to ac-commodate the methods and resultsreported in studies on population-basedapproaches because many of them didnot use the standard framework for as-sessing CE due to a lack of data. For studyscreening, we included population-basedinterventions if they reported ICERs orif they compared costs given a certainlevel of benefits if benefits were mea-sured as T2D cases prevented or QALYdue to reduction in diabetes. Conse-quently, the result of cost-saving (CS)for population-based interventions shouldbe interpreted with caution, as it couldrefer to a reduction in health costs onlyrather than savings as measured by ICER,which is a negative incremental cost.

Quality assessment for population-based approaches was less restrictiveand reduced to nine scoring attributes(the other four pertained to formalCEA and did not apply in these cases):sources of cost data, sources of bene-fit data, categories of cost data, cate-gories of benefit data, analytical timehorizons, study perspectives, model de-scriptions, currency and year of the costs,and results. Again, we included stud-ies with a quality score of seven andabove.

For selected studies, we abstracteddata on publication information, objec-tive, prevention strategy, comparison,target population, analytic time horizon,study method, the perspective of theevaluation, and results.We thengroupedpopulation-based approaches into fourcategories and summarized CE of eachone: 1) implementing fiscal policy, 2)implementing a regulation, 3) promot-ing health by education and informa-tion, and 4) changing the built or foodenvironment.

RESULTS

Figure 1 shows the 39 studies that metour inclusion criteria: 28 articles on high-risk approaches and 11 articles on pop-ulation-based approaches.

High-risk ApproachesTable 1A shows studies arranged chro-nologically and then alphabetically bythe last name of the first author withineach category (26–53). Among thesestudies, the analytic time horizon rangedfrom 1 year to a lifetime. Studies were

evaluated from either a societal perspec-tive or a health care perspective. Moststudies discounted costs and benefitsat 3%. While most of the studies werebased on simulation modeling, eightstudies assessed prevention strategiesusing randomized controlled trials. Re-sults indicate that screening for pre-diabetes and providing interventions,either lifestyle or pharmacologic inter-ventions, is either cost-effective orCS among individuals with a high riskof T2D. The conclusion held for boththe societal and health care perspec-tives and for shorter or longer timehorizons.

Seventeen studies (or study arms)evaluated the CE of specific interven-tions compared with no intervention(status quo or placebo) from a healthcare system perspective (Table 2) (35–37,39,40,42–44,46,49–51). Results indicatethat all interventions were cost-effective,but the magnitude of the ICERs differedby intervention features. Lifestyle in-terventions were more cost-effectivethan metformin interventions, regard-less of analytical time horizon, deliverymethod, media, mode, and personneltype. Among lifestyle interventions,translational DPPwasmore cost-effectivethan translational non-DPP preventionapproaches. The median ICER for trans-lationalnon-DPPwas twiceashighas thatfor translational DPP. Analytical timehorizon also affects CE outcomes; studiesevaluated over a longer time horizonhave a lower ICER. Among lifestyle in-terventions, in-person interventions hadslightly better CE outcomes than virtualinterventions. The median ICERs for in-terventions delivered in groups and forinterventions provided by a combinationof health professionals and trained layhealth workers were less than half ofthose for the one-on-one interventionsor interventions provided by health pro-fessionals alone.

Population-Based ApproachesTable 1B describes the 11 studies thatevaluated 28 population-based approachesto preventing T2D (54–64). Some stud-ies appear in more than one categorybecause they evaluated multiple inter-ventions that were applied to differentcategories. All studieswere evaluated at10 years or longer. More than half ofthese studies (or study arms) assessed theCE of two fiscal policiesdSSB taxation

care.diabetesjournals.org Zhou and Associates 1595

and fruit and vegetable subsidies. Amongthe nine studies (or study arms) thatevaluated the CE of SSB taxation, themost common taxation rate was 20% ofthe total amount paid. All nine studiesused computer-simulation models andused effectiveness outcomes from pub-lished articles. Two studies used a gov-ernmental perspective while the otherseven used a health care perspective. Allnine studies found the SSB tax to be CS.The included studies also evaluated asugar tax, a fruit and vegetable subsidy,and a combination of taxing unhealthyfoods and subsidizing healthy foods andfound large variations in CE outcomes.For nonfiscal policy interventions, suchas a walking group in the community,opening supermarkets to increase foodaccess, and increasing healthy food op-tions in the workplace, most of theinterventions were cost-effective or CSfrom the health care system perspective.However, the CE results were inconsis-tent from the societal perspective. Inaddition, many of these interventionswere only evaluated by one study,such that we were unable to make adefinite conclusion on the CE of theseinterventions.Table 3 summarizes the CE of population-

based approaches. The SSB tax was found

to beCS from thehealth care systemandgovernmental perspectives. The fourstudies (or study arms) that evaluatedthe CE of subsidies for fruits and veg-etables found mixed results, from morecostly with no net health outcomesbenefits to CS. Similarly, the five studiesthat evaluated community-wide inter-ventions also found them to have var-ious CE outcomes from the health caresystem and societal perspective. Inter-ventions of incentive programs and en-vironmental change were cost-effectivefrom the health care system perspective.

CONCLUSIONS

Our systematic review assessed the CE ofapproaches for preventing T2D from39 studies. Three key findings emerged.First, the ICERs of most of the high-riskapproaches were well below the rangethat is generally considered to be cost-effective. Importantly, differences be-tween delivery methods were small,and the group-delivered translationalDPP provided by a combination of healthprofessionals and trained lay healthworkers seemed most cost-effective.Our findings reinforced the fact that in-terventions to prevent T2D among high-risk individuals are highly cost-effectiveand practical in any given setting. Second,

implementing a population-wide SSBtax was CS and has the potential tobenefit a large population. SSB taxa-tion can be considered as an importantpopulation-based policy approach toprevent T2D globally. Third, althoughthere weremany proposed population-based interventions (including subsi-dies for fruits and vegetables, healthpromotion approaches, and environ-mental changes), the CE of these in-terventions needs further investigationwith real-world data in order to draw aconclusion.

Our findings for high-risk approachesare consistent with previous literature inthat lifestyle programsutilizing the trans-lational DPP curriculum are somewhatmore cost-effective than lifestyle inter-ventions that do not follow the DPPcurriculum (17). The translational DPPlifestyle program is widely used in theCenters for Disease Control and Preven-tion (CDC)-led National Diabetes Preven-tion Program (National DPP)da U.S.translational program providing a frame-work and infrastructure for targetinghigh-risk individuals, and this programis covered by several commercial andpublic insurers (65). For example, theCenters for Medicare & Medicaid Serv-ices began covering the CDC-recognizedDPP lifestyle changeprograms in2018 forMedicare beneficiaries (66).

A noteworthy change in the high-riskapproach category is the adoption ofvirtual media for intervention delivery.In recent years, virtual media interven-tions have become available via onlinecounseling calls, emails, and text mes-sages (29,30,39,49). One benefit of vir-tual media is that it reaches individualswho have barriers to in-person interven-tions, such as the elderly and peoplewholive in rural areas. People may takeadvantage of virtual media interventionsto save time and travel expenses (67).Virtual media interventions also allowparticipants to access the program anytime and with a greater frequency (68).Our review found that few studies eval-uated the CE of interventions deliveredvirtually. The results from this limitedevidence show that virtually deliveredprograms were cost-effective but not ascost-effective as the in-person lifestyleprogram as measured by cost per QALY.Additionally, more rigorous studies areneeded to assess the CE of virtuallydelivered programs.

Figure 1—Summary of evidence search and selection for T2D prevention approaches.

1596 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

Table

1—Des

criptionoftheCEstudiesforhigh-riskandpopulation-b

ase

dT2D

preve

ntionappro

ach

es

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Whether

toscreen

forprediabetes

Colagiuriand

Walker,

2008

/Australia

(27)

Screen

ingfor

prediabetes

and

providelifestyle

interven

tionfor

those

withIGTorIFG

Individualsaged

55–74

yearsandindividuals

aged

45–54

years

withtherisk

ofT2D

10years/10

years

Nointerven

tion

In-person

Simulation

model

3%/0

Red

ucedT2D

inciden

ceby

15%

Healthcare

$56,484/DALY

averted

Gillieset

al.,

2008

/U.K.

(28)

Screen

ingforIGTand

providelifestyle

interven

tionfor

those

screen

edpositive

Individualsat

risk

for

T2D(atleastone:

family

history

of

diabetes,

hypertension,

dyslipidem

ia,CVD,

orBMI.25

)

1year/50

years

Nointerven

tion

In-person

Simulation

model

3.5%

/3.5%

Increased0.17

yearsspen

tdiabetes-free

per

person

Societal

$16,269

Gillieset

al.,

2008

/U.K.

(28)

Screen

ingforIGTand

providemetform

inforthose

screen

edpositive

Individualsat

risk

for

T2D(atleastone:

family

history

of

diabetes,

hypertension,

dyslipidem

ia,CVD,

orBMI.25

)

1year/50

years

Nointerven

tion

In-person

Simulation

model

3.5%

/3.5%

Increased0.11

yearsspen

tdiabetes-free

per

person

Societal

$18,304

Chatterjee

etal.,

2010

/U.S.

(26)

Screen

ingfor

prediabetes,provide

lifestyle

interven

tion

usingDPP

curriculum

forthose

withIGTor

IFG

Individualswithou

tdiabetes:average

age48

years,

averageBMI30

3years/3

years

Nointerven

tion

In-person

Trial

NR

NR

Healthcare

andsocietal

CSfrom

ahealthcare

perspective,cost-

neu

tral

from

asocietal

perspective

Schaufler

and

Wolff,20

10/

Germany(31)

Screen

ingfor

prediabetes,provide

lifestyle

interven

tion

usingDPP

curriculum

forthose

withIGTor

IFG

Individualsaged

35–75

years

3years/

lifetim

eNointerven

tion

In-person

Simulation

model

5%/0

Lived0.8years

longerafter

diagnosis

Healthcare

$998

Schaufler

and

Wolff,20

10/

Germany(31)

Screen

ingfor

prediabetes,provide

metform

inforthose

withIGTorIFG

Individualsaged

35–75

years

3years/

lifetim

eNointerven

tion

In-person

Simulation

model

5%/0

NR

Healthcare

$578

Con

tinu

edon

p.15

98

care.diabetesjournals.org Zhou and Associates 1597

Table

1—Continued

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Neu

mannet

al.,

2011

/Germany(30)

Screen

ingforhigh-risk

peo

ple

withaself-

administered

questionnaire

and

providelifestyle

interven

tion

High-riskindividuals

iden

tified

with

ascreen

ingtoolsuch

astheFINDRISC

5years/

lifetim

eNointerven

tion

In-person

andvirtual

Simulation

model

3%/3%

NR

Societal

Men

aged

30years:

CS;

women

aged

30:CS;

Men

aged

50:CS;

women

aged

50:CS;

Men

aged

70:$5

1,140;

women

aged

70:

$36,078

Liuet

al.,20

13/

China(29)

Screen

ingIGT,

provide

dietinterven

tion

Individualsaged

25–74

years

6years/40

years

Nointerven

tion

In-person

andvirtual

Simulation

model

3%/3%

DeferredT2Dby

0.49–2.51

years

Societal

Initiationageof

25years:$2

,767;

ageof40

:$2

,073;

ageof60

:$4

,877

Liuet

al.,20

13/

China(29)

Screen

ingIGT,

provide

physical

activity

interven

tion

Individualsaged

25–74

years

6years/40

years

Nointerven

tion

In-person

andvirtual

Simulation

model

3%/3%

DeferredT2Dby

0.57–2.94

years

Societal

Initiationageof

25years:$2

,793;

ageof40

:$2

,085;

ageof60

:$5

,027

Liuet

al.,20

13/

China(29)

Screen

ingIGT,

provide

dietandphysical

activity

interven

tion

Individualsaged

25–74

years

6years/40

years

Nointerven

tion

In-person

andvirtual

Simulation

model

3%/3%

DeferredT2Dby

0.55–2.88

years

Societal

Initiationageof

25years:$2

,790;

ageof40

:$1

,603;

ageof60

:$5

,010

Liuet

al.,20

13/

China(29)

Only

screen

ingforIGT

andnofollow-up

interven

tion

Individualsaged

25–74

years

6years/40

years

Nointerven

tion

In-person

andvirtual

Simulation

model

3%/3%

DeferredT2D

by,0.04

years

Societal

Initiationageof

25years:$6

37;

ageof40

:$4

48;

ageof60

:$1

,616

Con

tinu

edon

p.15

99

1598 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

Table

1—Continued

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Determiningthetarget

populationforscreen

ingan

dinterven

tion

Zhuoet

al.,

2012

/U.S.

(33)

Screen

ingfor

prediabetes

with

differentHbA1c

cutoffsrangingfrom

6.4%

to5.5%

,and

give

either

lifestyle

interven

tionas

inDPP

orlifestyle

interven

tionas

inPlan4W

ard

Individualsaged

18yearsandolder

3years/

lifetim

eSameinterven

tion

butprediabetes

isiden

tified

by

adifferentcutoff

In-person

Simulation

model

3%/3%

NR

Healthcare

Ifprediabetes

receiveDPP

interven

tion,and

ifcutoffwas

6.0%

compared

with

6.1%

,$2

6,576;

ifcutoffwas

5.7%

compared

with

5.8%

,$5

6,948;

ifcutoffwas

5.5%

compared

with

5.6%

,$1

21,490

.If

prediabetes

receivePlan4w

ard

interven

tion,and

ifcutoffwas

6.0%

compared

with

6.1%

,$2

2,779;

ifcutoffwas

5.7%

compared

with

5.8%

,$4

3,027;

ifcutoffwas

5.5%

compared

with

5.6%

,$8

8,587

Zhuoet

al.,

2013

/U.S.

(34)

High-riskpeo

ple

iden

tified

with

certaincutoffofFPG

areassumed

toreceivelifestyle

interven

tionas

inDPP

Individualsaged

$45

yearswithou

tdiabetes

Untilonseto

fdiabetes/

lifetim

e

High-riskpeo

ple

iden

tified

with

ahigher

threshold

ofFPGare

assumed

toreceive

lifestyle

interven

tionas

inDPP

In-person

Simulation

model

3%/3%

NR

Healthcare

Cutoffof11

5mg/dL

compared

with

120mg/dL,

$34,483;110mg/dL

comparedwith

115mg/dL,

$37,691;105mg/dL

comparedwith

110mg/dL,

$48,460;100mg/dL

comparedwith

105mg/dL,

$69,539;

95mg/dL

comparedwith

100mg/dL,

$93,712;

90mg/dL

comparedwith

95mg/dL,$132,663

Con

tinu

edon

p.16

00

care.diabetesjournals.org Zhou and Associates 1599

Table

1—Continued

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Breezeet

al.,

2017

/U.K.

(32)

Lifestyleinterven

tion

amongadultsaged

40–65

years,data

from

literature

Individualsaged

40–65

years

1year/

lifetim

eNointerven

tion

In-person

Simulation

model

1.5%

/1.5%

Red

ucedT2Dby

19–38

per

1million

individuals

Healthcare

Interven

tionwith

low

intensity,

$3,680;med

ium

intensity,$6

,544;

highintensity,

$6,192

Breezeet

al.,

2017

/U.K.

(32)

Lifestyleinterven

tion

amonglow

socioeconomic

statuspeo

ple,data

from

literature

Individualsin

the

lowestquantile

of

dep

rivation

1year/

lifetim

eNointerven

tion

In-person

Simulation

model

1.5%

/1.5%

Red

ucedT2Dby

17–51

per

1million

individuals

Healthcare

Interven

tionwith

low

intensity,

$7,869;med

ium

intensity,$9

,704;

highintensity,

$9,365

Breezeet

al.,

2017

/U.K.

(32)

Lifestyleinterven

tion

amongpeo

ple

HbA1c.42

mmol/

mol(6%),datafrom

literature

Individualswith

HbA1c.42

mmol/

mol(6%)

1year/

lifetim

eNointerven

tion

In-person

Simulation

model

1.5%

/1.5%

Red

ucedT2Dby

83–23

5per

1million

individuals

Healthcare

Interven

tionwith

low

intensity,CS;

med

ium

intensity,

CS;

highintensity,

CS

Breezeet

al.,

2017

/U.K.

(32)

Lifestyleinterven

tion

amongpeo

ple

with

FINDRISCprobability

score

.0.1,

data

from

literature

Individualswith

FINDRISCprobability

score

.0.1

1year/

lifetim

eNointerven

tion

In-person

Simulation

model

1.5%

/1.5%

Red

ucedT2Dby

63–17

6per

1million

individuals

Healthcare

Interven

tionwith

low

intensity,CS;

med

ium

intensity,

CS;

highintensity,

CS

Breezeet

al.

2017

/U.K.

(32)

Lifestyleinterven

tion

amongpeo

ple

with

BMI.35

,datafrom

literature

Individualswith

aBMI.35

1year/

lifetim

eNointerven

tion

In-person

Simulation

model

1.5%

/1.5%

Red

ucedT2Dby

20–71

per

1million

individuals

Healthcare

Interven

tionwith

low

intensity,CS;

med

ium

intensity,

CS;

highintensity,

$539

Breezeet

al.

2017

/U.K.

(32)

Lifestyleinterven

tion

amongSouth

Asians,

datafrom

literature

South

Asians

1year/

lifetim

eNointerven

tion

In-person

Simulation

model

1.5%

/1.5%

Red

ucedT2Dby

1–4per

1million

individuals

Healthcare

Interven

tionwith

low

intensity,

$14,680;

med

ium

intensity,$13

,630;

highintensity,

$13,954

EvaluatingtheCEofT2Dpreventionap

proaches

Smithet

al.

2010

/U.S.

(46)

Modified

DPP

interven

tion

adaptedto

the

group-based

setting

Individualswith

BMI$25

and

metabolic

syndrome

12–14weeks/

3years

Nointerven

tion

In-person

Simulation

model

3%/3%

Red

uce

diabetes

inciden

ceby

19.8%

Healthcare

$6,235

Con

tinu

edon

p.16

01

1600 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

Table

1—Continued

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

DPP

Research

Group,20

12/

U.S.(35)

DPP

/DPP

OS:

lifestyle

for16

-sessioncore

curriculum

and

subsequen

tindividual

andgroup

sessions

Individualsaged

$25

yearswithIGTand

fasting

hyperglycem

ia,

BMI$24

(BMI$22

inAsian

Americans)

10years/10

years

Placeb

oIn-person

Trial

3%/3%

NR

Healthcare

andsocietal

Healthcare

perspective,

$15,759;

societal

perspective,

$24,244

DPP

Research

Group,20

12/

U.S.(35)

Metform

inIndividualsaged

$25

yearswithIGTand

fasting

hyperglycem

ia,

BMI$24

(BMI$22

inAsian

Americans)

10years/10

years

Placeb

oIn-person

Trial

3%/3%

NR

Healthcare

andsocietal

CSfrom

both

perspectives

DPP

Research

Group,20

12/

U.S.(35)

DPP

/DPP

OS:

lifestyle

for16

-sessioncore

curriculum

and

subsequen

tindividual

andgroup

sessions

Individualsaged

$25

yearswithIGTand

fasting

hyperglycem

ia,

BMI$24

(BMI$22

inAsian

Americans)

10years/10

years

Metform

inIn-person

Trial

3%/3%

NR

Healthcare

andsocietal

Healthcare

perspective,

$18,216;

societal

perspective,

$56,129

Palm

erand

Tucker,201

2/Australia

(42)

Metform

inIndividualsmeanage

50.6

years,67.8%

female,

meanBMI

34,andIGTpresent

10years/

lifetim

eNointerven

tion

In-person

Simulation

model

5%/5%

Red

uce

diabetes

inciden

ceby

6.6%

Healthcare

$10,174

Palm

erand

Tucker,201

2/Australia

(42)

Intensive

lifestyle

changesas

inDPP

Individualsmeanage

50.6

years,67.8%

female,

meanBMI

34,andIGTpresent

10years/

lifetim

eNointerven

tion

In-person

Simulation

model

5%/5%

Red

uce

diabetes

inciden

ceby

18.2%

Healthcare

CS

Zhuoet

al.,

2012

/U.S.

(50)

DPP

lifestyle

interven

tion

adaptedto

acommunitysetting

Individualsaged

18–84

yearswith

prediabetes

Untilthe

onsetof

diabetes/

25years

Nointerven

tion

In-person

Simulation

model

3%/3%

Preven

tordelay

diabetes

among

interven

tion

groupby7%

Healthcare

CS Con

tinu

edon

p.16

02

care.diabetesjournals.org Zhou and Associates 1601

Table

1—Continued

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Feldman

etal.,

2013

/Sw

eden

(51)

Prim

arycare–based

lifestyle

counseling

People

withdiagnosed

metabolic

syndrome

(33%

havediabetes

already):meanage

53years,meanBMI

32.5

formen

and

32.3

forwomen

1year/

lifetim

eNointerven

tion

In-person

Simulation

model

3%/3%

NR

Healthcare

andsocietal

Societal

perspective:

$10,719formen

withlow

risk

and

CSformen

with

med

ium

andhigh

risk;$1

0,808for

women

withlow

risk,$5

,315

for

women

with

med

ium

risk,and

$26,798for

women

withhigh

risk.Healthcare

perspective:

$16,519formen

withlow

risk,

$7,443

formen

withmed

ium

risk,

and$4

,869

for

men

withhighrisk;

$15,756for

women

withlow

risk,$1

0,871for

women

with

med

ium

risk,and

$27,605for

women

withhigh

risk

Herman

etal.,

2013

/U.S.

(36)

DPP

/DPP

OS:

lifestyle

for16

-sessioncore

curriculum

and

subsequen

tindividual

andgroup

sessions

Individualsaged

$25

years,withIGTand

fasting

hyperglycem

ia,

BMI$24

(Asians

BMI$22

)

10years/10

years

Placeb

oIn-person

Trial

3%/3%

Red

uced

diabetes

inciden

ceby

49.4%

Healthcare

andsocietal

$24,460from

ahealthcare

perspective

and

$3,959

from

asocietal

perspective

Herman

etal.,

2013

/U.S.

(36)

DPP

/DPP

OS:

lifestyle

for16

-sessioncore

curriculum

and

subsequen

tindividual

andgroup

sessions

Individualsaged

$25

years,withIGTand

fasting

hyperglycem

ia,

BMI$24

(Asians

BMI$22

)

10years/10

years

Metform

inIn-person

Trial

3%/3%

Red

uced

diabetes

inciden

ceby

36%

Healthcare

andsocietal

$24,061from

ahealthcare

perspective

and

$31,382from

asocietal

perspective

Con

tinu

edon

p.16

03

1602 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

Table

1—Continued

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Herman

etal.,

2013

/U.S.

(36)

Metform

inIndividualsaged

$25

years,withIGTand

fasting

hyperglycem

ia,

BMI$24

(Asians

BMI$22

)

10years/10

years

Placeb

oIn-person

Trial

3%/3%

Red

uced

diabetes

inciden

ceby

20.8%

Healthcare

andsocietal

$24,699from

ahealthcare

perspective

and

CSfrom

asocietal

perspective

Sahaet

al.,

2013

/Sw

eden

(45)

Lifestyle:

physiotherapist-

supervisedphysical

exercise

anddiet

counselingforthe

first3months,

followed

byaregular

groupmeeting

Individualsaverageage

55years,average

BMI30

,and20

%alreadyhave

diabetes

3years/

lifetim

eReceive

verbal

and

written

inform

ationabout

lifestyle

recommen

dations

inonesingle

meeting

In-person

Simulation

model

3%/3%

NR

Healthcare

andsocietal

CSfrom

both

perspectives

vanWieret

al.,

2013

/the

Netherlands

(47)

Lifestyleinterven

tion

withface-to-face

counselingsessions

andfollow-up

sessionsbyphone

Individualsaged

30–50

yearsat

risk

for

diabetes

and/orCVD

9months/9

years

Nointerven

tion

In-person

andvirtual

Trial

0/0

NR

Societal

CS

Peelset

al.,

2014

/the

Netherlands

(43)

Printedtailored

physical

activity

advice

dep

ended

on

participants’

personal

and

psychosocial

characteristics,

physical

activity

beh

avior,andthe

extentto

whichthey

wereplanningto

change

their

beh

avior(both

diet

andphysicalactivity)

Individualsaged

$50

years

4months/5

years,

10years,

and

lifetim

e

Nointerven

tion

Virtual

Simulation

model

4%/1.5%

Red

uce

diabetes

inciden

ceby

3.1%

in5years,

2.8%

in10

years,and

2%lifetim

e

Healthcare

For5years,$45,530;

for10

years,

$12,557;

for

lifetim

e,$1

2,40

8

Con

tinu

edon

p.16

04

care.diabetesjournals.org Zhou and Associates 1603

Table

1—Continued

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Peelset

al.,

2014

/the

Netherlands

(43)

Web

-based

tailored

physical

activity

advice

dep

ended

on

participants’

personal

and

psychosocial

characteristics,

physical

activity

beh

avior,andthe

extentto

whichthey

wereplanningto

change

their

beh

avior(both

diet

andphysicalactivity)

Individualsaged

$50

years

4months/5

years,

10years,

and

lifetim

e

Nointerven

tion

Virtual

Simulation

model

4%/1.5%

Red

uce

diabetes

inciden

ceby

1.3%

in5years,

1%in10

years,

0.6%

lifetim

e

Healthcare

For5years,$34,346;

for10

years,

$13,997;

for

lifetim

e,$1

6,71

0

Peelset

al.,

2014

/the

Netherlands

(43)

Printedtailored

physical

activity

advice

dep

ended

on

participants’

personal

and

psychosocial

characteristics,

physical

activity

beh

avior,andthe

extentto

whichthey

wereplanningto

change

their

beh

avior(both

diet

andphysicalactivity)

Individualsaged

$50

years

4months/5

years,

10years,

and

lifetim

e

Theweb

-based

interven

tionofthe

samecontent

insteadofprinted

Virtual

Simulation

model

4%/1.5%

NR

Healthcare

For5years,$53,421;

for10

years,

$11,648;

for

lifetim

e,$1

1,30

0

Con

tinu

edon

p.16

05

1604 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

Table

1—Continued

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Peelset

al.,

2014

/the

Netherlands

(43)

Printedtailored

physical

activity

advice

dep

ended

on

participants’

personal

and

psychosocial

characteristics,

physical

activity

beh

avior,andthe

extentto

whichthey

wereplanningto

change

their

beh

avior,pluslocal

environmen

tal

attributes,such

asneighborhood

walkingandcycling

routes(both

dietand

physical

activity)

Individualsaged

$50

years

4months/5

years,

10years,

and

lifetim

e

Basicinterven

tion

withou

ten

vironmen

tal

attributes

Virtual

Simulation

model

4%/1.5%

Red

uce

diabetes

inciden

ceby

1.2%

in5years,

1.1%

in10

years,0.8%

lifetim

e

Healthcare

More

cost,less

effectiveforall

timehorizons

PngandYoong,

2014

/Singapore

(44)

Lifestyleas

inDPP

,datafrom

DPP

Nondiabetic

population

3years/3

years

Nointerven

tion

In-person

Simulation

model

3%/3%

NR

Healthcare

andsocietal

Healthsystem

perspective,

$19,686;

societal

perspective,

$42,001/QALY

PngandYoong,

2014

/Singapore

(44)

Metform

inNondiabetic

population

3years/

3years

Nointerven

tion

In-person

Simulation

model

3%/3%

NR

Healthcare

andsocietal

Healthsystem

perspective,

$24,133;

societal

perspective,

$7,294/Q

ALY

Hoergeret

al.,

2015

/U.S.

(37)

Lifestyle,

usingDPP

data

Med

icareben

eficiaries

withobesity,

no

diabetes

6–12

months/

10years

Nointerven

tion

In-person

Simulation

model

3%/3%

NR

Healthcare

CS Con

tinu

edon

p.16

06

care.diabetesjournals.org Zhou and Associates 1605

Table

1—Continued

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Wilsonet

al.,

2015

/U.S.

(48)

Community-based

lifestyle

interven

tion

andweightcontrol

Lower

socioeconomic

statuscommunity

withlargelyfemale,

middle-aged,and

Mexico-born;32%

overw

eightand

more

than

half

obese

12weeks/5

years,

10years,

20years

Nointerven

tion

In-person

Simulation

model

3%/3%

34%

sample

had

a2%

weight

loss,14

%sample

had

a5%

weight

loss

Societal

2%weightloss

goal:

ICER

was

$68,203,

$207

,369

,and

$578

,494

for20

,10

,and5-year

timehorizon,

respectively;5%

weightloss

goal:

ICER

was

$73,504,

$222

,603

,and

$668

,751

for20

,10

,and5-year

timehorizon,

respectively

Hollenbeak

etal.,20

16/

U.S.(38)

Telephoneadaptations

oftheDPP

lifestyle

interven

tion,with

conference

calls

Individualswith

diagnosedmetabolic

syndrome:

largely

female,

middle-

aged

,andHispanic

1year/1

year

Telephone

adaptationsofthe

DPP

lifestyle

interven

tion,with

individual

call

In-person

Trial

NR

Red

uce

waist

circumference

by0.68

cm(10%

),reduce

weightby

1.11

kg(18%

),reduce

BMIby

0.28

(14%

)

Societal

$10,342

Wonget

al.,

2016

/China-

HongKo

ng

(49)

Short

text

message

on

lifestyle

interven

tion

Individualswith

prediabetes

2years/

lifetim

eNointerven

tion

Virtual

Simulation

model

3%/3%

Red

ucedT2D

inciden

ceby

5%

Healthcare

CS

Neu

mannet

al.,

2017

/Sw

eden

(41)

Lifestyleinterven

tion

comparable

tothe

Finnish

Diabetes

Preven

tionStudy

Individualsat

risk

for

diabetes

5years/

lifetim

eNointerven

tion

In-person

Simulation

model

3%/3%

NR

Societal

Male:

initiationage

30years,$7

,626;

initiationage50

,$1

1,303;

initiation

age70

,$1

7,108

Female:

initiation

age30

years,

$7,116;initiation

age50

,$1

0,501;

initiationage70

,$1

6,204

Con

tinu

edon

p.16

07

1606 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

Table

1—Continued

A:Interven

tionstargetinghigh-riskindividuals(high-riskap

proaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Lealetal.,20

17/

U.K.(39)

Lifestyleinterven

tion:

receiveabooklet,

structured

education,nursing

support

phonecalls,

group-based

maintenance

sessions

Individualswith

prediabetes

3years/3

years

Nointerven

tion

In-person

andvirtual

Trial

3.5%

/3.5%

NR

Healthcare

$6,355

Linet

al.,20

17/

U.S.(40)

Lifestylecounseling,

databased

onthe

USPSTFreview

Individualsaged

$18

years,overw

eightor

obeseandwithat

leastoneCVDrisk

factorincluding

metabolic

syndrome

orelevated

blood

pressure,lipids,or

glucose

level,butno

history

ofCVD

1year/25

years

Nointerven

tion

In-person

Simulation

model

3%/3%

NR

Healthcare

$15,179

Man

agingGDM

Oostdam

etal.,

2012

/the

Netherlands

(53)

Lifestyleinterven

tion,

group-based

exercise

program

Pregnantwomen

with

arisk

ofdeveloping

GDM

During

pregnancy/

lifetim

e

Nointerven

tion

In-person

Trial

NR

Nosignificant

effect

on

maternal

fastingblood

glucose

or

birth

weight

Societal

More

cost,less

effective

Kolu

etal.,

2016

/Finland

(52)

Maternallifestyle

counseling

Pregnantwomen

with

arisk

ofdeveloping

GDM

During

pregnancy/

7years

Nointerven

tion

In-person

Trial

NR

NR

Societal

CS

B:Interven

tionstargetingthewhole

population(population-based

approaches)

Study

Interven

tion

Target

population

Timehorizon

N/A

N/A

N/A

Discount

rate:cost/

ben

efit

Form

alCEA

Perspective

ICER

,$/QALY

(in

2017

US$)

Fiscal

policy–SSBtax

Wanget

al.,

2012

/U.S.

(54)

Apen

ny-per-ounce

tax

onSSB

Individualsaged

25–64

years

10years

N/A

N/A

N/A

3%/N

RNo

Healthcare

CS Con

tinu

edon

p.16

08

care.diabetesjournals.org Zhou and Associates 1607

Table

1—Continued

B:Interven

tionstargetingthewholepopulation

(population-based

approaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Basuet

al.,

2013

/U.S.

(55)

Apen

ny-per-ounce

tax

onSSBforSN

AP

dollars

SNAPparticipantsaged

25–64

years

10years

N/A

N/A

N/A

3%/3%

Yes

Governmen

tal

CS

Mekonnen

etal.,20

13/

U.S.(56)

Apen

ny-per-ounce

tax

onSSB

Residen

tsin

California

10years

N/A

N/A

N/A

3%/N

RNo

Healthcare

CS

Manyemaet

al.,

2015

/Sou

thAfrica(57)

A20%

taxonSSB

Nationwide

20years

N/A

N/A

N/A

0/0

No

Healthcare

CS

Sanchez-

Romeroetal.,

2016

/Mexico

(58)

A10%

taxonSSB

Individualsaged

35–94

years

10years

N/A

N/A

N/A

NR

No

Healthcare

CS

Sanchez-

Romeroetal.,

2016

/Mexico

(58)

Anassumed

taxrate

on

SSBto

reduce

the

consumptionby20%

Individualsaged

35–94

years

10years

N/A

N/A

N/A

NR

No

Healthcare

CS

Veerm

anet

al.,

2016

/Australia

(59)

A20%

taxonSSB

Individualsaged

$20

years

Lifetime

N/A

N/A

N/A

0/0

No

Governmen

tal

CS

Breezeet

al.,

2017

/U.K.

(60)

A20%

taxonSSB

Individualsaged

$16

yearswithou

tdiabetes

Lifetime

N/A

N/A

N/A

1.5%

/1.5%

Yes

Healthcare

CS

Cobiac

etal.,

2017

/Australia

(61)

Ataxof$0

.52/liter

on

SSB

Nationwide

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Healthcare

CS

Fiscal

policy–sugartax

Cobiac

etal.,

2017

/Australia

(61)

Sugartax:

ataxonice

cream

for$1

.05/

100mLandonsugar

contentin

other

productsfor$0.95/

100g

Nationwide

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Healthcare

CS Con

tinu

edon

p.16

09

1608 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

Table

1—Continued

B:Interven

tionstargetingthewholepopulation

(population-based

approaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Fiscal

policy–fruitsan

dvegetable

subsidy

Basuet

al.,

2013

/U.S.

(55)

Arewardof30

cents

added

toSN

AP

purchasecardsfor

every$1

offruitsand

vegetables

purchased

using

SNAPben

efits

SNAPparticipantsaged

25–64

years

10years

N/A

N/A

N/A

3%/3%

Yes

Governmen

tal

More

costnochange

inben

efit

Basuet

al.,

2013

/U.S.

(55)

Asubsidyof3

0centsof

every$1

offruitsand

vegetables

purchased

using

SNAPben

efits

SNAPparticipantsaged

25–64

years

10years

N/A

N/A

N/A

3%/3%

Yes

Governmen

tal

$1,000,359

Choi

etal.,

2017

/U.S.

(62)

Asubsidyof3

0centsof

every$1

offruitsand

vegetables

purchased

using

SNAPben

efits

SNAPparticipantsaged

0–85

years

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Societal

CS

Cobiac

etal.,

2017

/Australia

(61)

Asubsidyof$0.15/

100goffruits

and

vegetables

purchased

Nationwide

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Healthcare

More

cost

andless

ben

efit

Fiscal

policy–combined

taxan

dsubsidy

Cobiac

etal.

2017

/Australia

(61)

Acombinationoftaxes

onsaturatedfat,salt,

SSB,andsugarasw

ell

assubsidiesonfruits

andvegetables

Nationwide

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Healthcare

CS

Regulation

Basuet

al.,

2013

/U.S.

(55)

Theban

onusingSN

AP

dollars

forSSB

purchases

SNAPparticipantsaged

25–64

years

10years

N/A

N/A

N/A

3%/3%

Yes

Governmen

tal

CS Con

tinu

edon

p.16

10

care.diabetesjournals.org Zhou and Associates 1609

Table

1—Continued

B:Interven

tionstargetingthewholepopulation

(population-based

approaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Healthed

ucationan

dpromotion

Rouxet

al.,

2008

/U.S.

(63)

Stanford

five-city

project:community-

widehealth

education

interven

tionto

improve

physical

activity,including

printedmaterials,

radio,TV

,seminars,

communitywalking

even

ts,and

worksite-andschoo

l-based

program

s

Individualsaged

25–64

yearswithou

tCHD,

ischem

icstroke,

T2D,breastcancer,

orcolorectal

cancer

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Societal

$92,481

Rouxet

al.,

2008

/U.S.

(63)

WheelingWalks:an

8-weekcommunity-

wideinterven

tion

that

promotes

walkingam

ong

seden

tary

individualsaged

50–

65yearsusingpaid

med

ia(TV,radio,

new

spapers,

web

sites,billboards),

public

relations,and

public

health

activities

atworksites,churches,

andlocal

organizations

Individualsaged

50–65

yearswithou

tCHD,

ischem

icstroke,

T2D,breastcancer,

orcolorectal

cancer

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Societal

$19,271

Rouxet

al.,

2008

/U.S.

(63)

Promote

physical

activity

with

organized

walking

groups,social

gatherings,phone

calls,cards,home

visits,and

anew

sletterto

enhance

exercise

compliance

Individualsaged

25–64

yearswithou

tCHD,

ischem

icstroke,

T2D,breastcancer,

orcolorectal

cancer

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Societal

$53,541

Con

tinu

edon

p.16

11

1610 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

Table

1—Continued

B:Interven

tionstargetingthewholepopulation

(population-based

approaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Rouxet

al.,

2008

/U.S.

(63)

Promote

physical

activity

with

awalkingprogram

withan

initial

trainingsession

involvingwalking

mapsandhandouts

andfollow-upphone

calls

Individualsaged

25–64

yearswithou

tCHD,

ischem

icstroke,

T2D,breastcancer,

orcolorectal

cancer

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Societal

$36,925

Cobiac

etal.

2009

/Australia

(64)

Massmed

ia–based

campaign:a6-week

campaign

combines

physical

activity

promotionviamass

med

ia,distribution

ofpromotional

materials,and

communityeven

tsandactivities

Individualsaged

25–60

years

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Healthcare

CS

Cobiac

etal.,

2009

/Australia

(64)

Travelsm

art:an

active

transport

program

targetshousehold

withtailored

inform

ation(m

aps

oflocalwalking

paths,etc.)and

merchandise(w

ater

bottles,keyrings)as

anincentive

and

rewardforreducing

theuse

ofcars

for

transport

Urban

individuals

aged

$15

years

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Healthcare

$18,717

Cobiac

etal.,

2009

/Australia

(64)

Pedometers:

acommunity

program

encourages

theuse

of

ped

ometersas

amotivational

tool

that

increases

physical

activity

Individualsaged

$15

years

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Healthcare

CS Con

tinu

edon

p.16

12

care.diabetesjournals.org Zhou and Associates 1611

Table

1—Continued

B:Interven

tionstargetingthewholepopulation

(population-based

approaches)

Study

Interven

tion

Target

population

Duration/

analytical

timehorizon

Comparison

Interven

tion

med

iaStudy

method

Discount

rate:cost/

ben

efit

Effectiven

ess

outcomes

Perspective

ICER

,$/QALY

(in20

17US$)

Cobiac

etal.,

2009

/Australia

(64)

Internet:participants

arerecruited

via

massmed

iato

access

physical

activity

inform

ationand

advice

across

the

internet

viaaweb

site

ande-mail

Internet

users

aged

$15

years

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Healthcare

$2,080

Breezeet

al.,

2017

/U.K.

(60)

Inthemost

dep

rived

communities,men

wereoffered

diet

educationand

women

wereoffered

cookingclasses

Individualsaged

$16

yearswithou

tdiabetes

Lifetime

N/A

N/A

N/A

1.5%

/1.5%

Yes

Healthcare

More

ben

efitandno

change

incost

Environmen

talchan

ges

Rouxet

al.,

2008

/U.S.

(63)

Improve

access

toan

active

lifestyle

(bike

paths,extended

fitnessfacilityhours,

theopen

ingofa

new

fitnesscenter,

cyclingclub

s,marked

runningcourses,

organized

athletic

even

ts)

Individualsaged

25–64

yearswithou

tCHD,

ischem

icstroke,

T2D,breastcancer,

orcolorectal

cancer

Lifetime

N/A

N/A

N/A

3%/3%

Yes

Societal

$38,510

Breezeet

al.,

2017

/U.K.

(60)

Improve

thefood

environmen

tby

open

inganew

supermarketin

adep

rivedurban

area

Individualsaged

$16

yearswithou

tdiabetes

Lifetime

N/A

N/A

N/A

1.5%

/1.5%

Yes

Healthcare

CS

Breezeet

al.

2017

/U.K.

(60)

Increase

healthyfood

optionsinworkplace

cafeterias

Individualsaged

$16

yearswithou

tdiabetes

Lifetime

N/A

N/A

N/A

1.5%

/1.5%

Yes

Healthcare

CS

CHD,congenitalheartdisease;C

VD,cardiovasculardisease;D

PPOS,Diabetes

Preven

tionProgram

Outcom

esStudy;FINDRISC,Finnish

Diabetes

RiskScore;FPG

,fastingplasm

aglucose;G

DM,gestationaldiabetes

mellitus;IFG,impairedfastingglucose;IGT,im

pairedglucose

tolerance;N

R,notreported

;N/A,notapplicable;Plan4w

ard,PromotingaLifestyleofActivityandNutritionforWorkingto

Alter

theRiskofDiabetes;

USPSTF,

U.S.Preven

tive

Services

Task

Force.

1612 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

The results of our review also dem-onstrate great potential for population-based interventions to prevent T2D (69).Among fiscal policies, taxing SSBs maybe a better approach than subsidies forhealthy foods for two main reasons: 1)tax policies generated better CE out-comes and 2) evidence supporting taxpolicies was stronger as multiple studiescollectively reached a consistent conclu-sion. From a health care system perspec-tive, SSB taxes would be CS. The SSB taxwould reduceSSBconsumptionat zeroorlittle health intervention costs andwouldalso reduce health care spending. Thenine studies in our review showed howmuch health care costs would be savedfrom SSB taxation. In addition, thesestudies showed that such an interventionwould be CS or cost-effective from thegovernmental perspective. On the otherhand, the ICERs of interventions to pro-mote the consumption of fruits and veg-etables ranged widely. These studiesdiffered in features thatwould change theresults, such as the targeted population(general population vs. participants in the

Supplemental Nutrition Assistance Pro-gram [SNAP]), analytical time horizon(10 years vs. lifetime), and study per-spective (governmental, health care sys-tem, or societal). Although evidenceindicates that an SSB tax could be a CSintervention to prevent T2D, there arepolitical and other considerations thatimpact its implementation in the realworld (70). The uptake of that strategy isdependent on state and local decision-making (70–72).

Our study is one of the first to includearticles evaluating the CE of population-based approaches to prevent T2D ina systematic review. The adoption ofpopulation-based approaches could havegreat potential for improving populationhealth. A recent analysis found that only3.1% of U.S. adults without T2D (regard-less of prediabetes status) met T2D riskreduction lifestyle goals in 2007–2012(73), suggesting the need for broaderpublic health efforts to reach the major-ity of the U.S. population for reducingtheir risk of T2D. Individuals at high riskfor T2D could benefit from population-

based prevention efforts in conjunctionwith targeted, high-risk approaches. Forthose who have not been screened forT2D, population-based interventions mayalso slow their progression to T2D andprovide other health benefits from bet-ter nutrition and more physical activity(9).

Our findings on the CE of both high-riskapproaches and population-based ap-proaches indicate that investing in T2Dprevention is an efficient use of limitedhealth care and societal resources. Sincethe development of T2D is a result of acombination of multiple risk factors in-cluding genetics, environment, and be-haviors, a combined strategy of both high-risk and population-based approachesmay be the best one to achieve optimaloutcomes of T2D prevention (9,10). In-terventions targeting high-risk individualsare effective and cost-effective amongindividuals at risk for T2D. However, thelow uptake and resource-intensive natureof high-risk approaches limit their applica-tion. In contrast, while population-basedapproaches use “upstream” approachesthat reach a broader population, theirimpact at the individual level is weaker,and the evidence of their effectiveness ismore limited.

Based on our review, we suggest twoavenues for the future economic evalu-ation of T2D prevention approaches.The first is to conduct rigorous CEAsusing real-world data on population-based interventions. The studies inthis review generated considerable var-iation in CE, indicating uncertainty aboutthe CE of these interventions. Manystudies are based on simulation model-ing. Although high-quality simulationmodels can generate reliable results,they rely on strong assumptions thatmay or may not be reflected in reality.In contrast, data from empirical studiesdnatural experiments, for exampledaredirectly observed and reflect the “true”behavioral change of the population tointerventions. Although such studies usu-ally last for a couple of years, they areoften the foundation for modeling stud-ies. Additional research that evaluatesthe impact of taxes, subsidies, food label-ing, and other approaches that are al-ready implemented (“natural experiments”)are needed to obtain stronger data. Sec-ond, effectiveandcost-effectivepopulation-based approaches are needed for bothdeveloping and developed countries.

Table 2—Summary of the CE of interventions targeting high-risk individuals forT2D prevention*

GroupStudyarm, n

Median ICER(range), $/QALY,

health care systemperspective†

Prevention strategyLifestyle 13 $12,510 (CS–$24,368)Metformin 4 $17,089 (CS–$24,606)

Type of lifestyle interventionTranslational DPP‡ 7 $6,212 (CS–$24,368)Translational non-DPP 6 $13,228 (CS–$16,177)

Time horizon of lifestyle intervention,10 years 5 $19,612 ($6,212–$45,358)$10 years 10 $13,779 (CS–$24,368)

Intervention media of lifestyle interventionIn-person 8 $10,956 (CS–$24,368)Virtual 3 $12,510 (CS–$13,944)Combination of both 2 $6,331, $15,122

The delivery setting of in-person lifestyle interventionOne-on-one 5 $15,700 (CS–$24,368)Group 2 CS, $6,212Combination of both 1 $16,177

Provider of in-person lifestyle interventionHealth professionals 5 $15,700 (CS–$24,368)Health professionals and trained lay health workers 3 $6,212 (CS–$16,177)

*Studies included in this table satisfy three conditions: 1) the main objective of a study wasevaluating theCEof an intervention,2) theeffect of the interventionwas comparedwith theeffectof a “status quo” or a placebo scenario, and 3) the evaluation was from a health care systemperspective. †The range of ICER is reported if there are three or more data points. Costs are in2017 U.S. dollars. ‡Translational DPPs refer to diet and physical activity interventions that followthe DPP curriculum that translated to real-world settings, such as provided in the community orprimary care. In contrast, translational non-DPPs are lifestyle interventions that do not strictlyfollow the DPP curriculum.

care.diabetesjournals.org Zhou and Associates 1613

Although we found a disproportionateimbalance in the number of studiespublished involving high-income coun-tries, population-based approaches arestrategies to reach a large scale of thepopulation to address the dramatic in-crease in diabetes prevalence worldwide.Conclusions from this review need to

be interpretedwith caution. First,most ofthe evaluations, especially population-based approaches, utilized simulationmodeling,whichcanbeheavily influencedby assumptions. Unlike data from clinicaltrials, which are directly observed, modeldata are usually from published articles.Even thoughmanymodels useddata fromclinical trials for the initial years of inter-ventions, theymustmakeassumptionsonthe persistence of costs and effectivenessbeyondthe trial studyperiod tosimulate alonger time horizon. Because of thesecontraints, in our review, we tried torely on evidence if it was consistentacross multiple modeling studies. Sec-ond, in order to include as many studieson population-based interventions aspossible, we used somewhat “looser”quality criteria for these studies. Manyof the population-based approaches did

not conduct formal CEA. As a result, theCS results fromthese studiesneeds tobebetter understood, as they were a sim-ple comparison of costs given a certainlevel of health benefit. Also,many of theCE results were estimated from govern-mental or health care system perspec-tives rather than a societal perspective.Third, the societal perspective de-fined in population-based approacheswas not as inclusive as it was for high-risk approaches. Some cost categorieswere not included in the societal per-spective, such as productivity loss ortime cost. Fourth, we compared theCE of interventions based on the me-dian ICERs without explicitly consid-ering other study information, suchas the evaluation method and rigorous-ness of data. This comparison followsprevious literature (17) but may notreflect a real difference in CE. Fifth,our results provide information for de-cision makers to choose among inter-ventions based on CE criteria only.Manyother issues such as health equality,acceptability, and feasibility shouldalso be considered in real-world decision-making.

Evidence from our review indicatesthat investing in T2D prevention, usingeither high-risk approaches or population-based approaches, is an efficient use ofhealth care and societal resources. Giventhe enormous cost associatedwith T2D, ifhealth care resources are limited, thenprevention is a highly efficient use ofsuch resources. Interventions targetinghigh-risk individuals with group-deliv-ered translational DPP lifestyle interven-tion, provided by a combination of healthprofessionals and trained lay health work-ers, was more cost-effective comparedwith one-on-one interventions providedby health professionals solely; however,all interventions targeting high-risk in-dividuals were cost-effective. Amongpopulation-based approaches, the SSBtaxation saves costs and resourcesof thehealth care system and government.Therefore, expansion of insurance-cov-ered, professional, and lay-deliveredgroup DPPs with a simultaneous insti-tution of SSB taxation can be consideredas a priority to stem the rising tide ofT2D. A combined approach that targetsboth high-risk individuals and the wholepopulation could be a policy choice for

Table 3—Summary of the CE of population-based T2D prevention approaches

InterventionStudyarm, n Perspective CE outcome*

Penny-per-ounce, 10–20%, or $0.5/liter tax on SSB 9 Health care andgovernmental

CS

Tax sugar for $0.99/100 mL of ice cream and $0.9/100 gof all other products 1 Health care CS

30% subsidy for the consumption of fruits and vegetables among SNAP beneficiaries 4 Health care,governmental,and societal

CS to worse healthand more cost

A bundled policy of taxing $1.45/100 g of saturated fat, $0.32/1 g of sodium, $0.5/liter of SSB,$0.99/100 mL of ice cream, $0.9/100 g of sugar of all other products, and subsidizing $0.15/100 g of fruits and vegetables 1 Health care CS

Ban on using SNAP dollars for SSB purchases 1 Governmental CS

Community-wide programs for health education (newspaper column, booklet, television news,talks, seminars, workshops, and diet and cooking classes) and physical activity promotion(organized walking events, worksite exercise programs, financial incentives, home visits, andphone calls)

5 Health careand societal

CS to notcost-effective

Themassmediacampaign, including televisionadvertising, advertisements inprintmedia,a toll-free telephone line for community-level support, and marketing of campaign merchandise 1 Health care CS

Targeted incentive program, including distributing tailoredmaps of local walking paths and busschedules, using merchandise as incentive or reward for reducing the use of cars, andencouraging use of pedometers

2 Health care CS tocost-effective

Internet intervention, includinggivingaccess tophysical activity informationandadvice throughwebsite and e-mail 1 Health care Cost-effective

Environmental change, including building bicycle paths, extending hours at recreation facilities,opening fitness centers, increasing the convenient supply of healthy foods, nutritioninformation pamphlets placed on dining tables, color-coded labeling for foods, opening newsupermarkets, and increasing healthy food options in workplace cafeterias

3 Health careand societal

CS tocost-effective

*For studies that did not conduct formal CEA, CS indicates that the intervention reduces cost.

1614 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020

preventing T2D in the U.S. and probablyin other high-income countries.

Acknowledgments. Thiswork is a collaborationbetween the Centers for Disease Control andPrevention and the American Diabetes Associ-ation. The authors thank the external and in-ternal reviewers for their valuable commentsduring the reviewprocess. The authors thank RuiLi (CDC) for generously sharing materials fromher previous review and providing guidance,William Thomas (CDC) for his timely help withthe literature search, and Clarice G. Conley (CDC)for her editorial assistance.Duality of Interest. No potential conflicts ofinterest relevant to this article were reported.Author Contributions. X.Zho. and P.Z. de-signed the research. X.Zho. analyzed data, in-terpreted results, and drafted the manuscript.K.R.S. made a critical revision of the manuscript.X.Zho., K.R.S., B.P.N., S.J., and K.K.P. screenedstudies and abstracted data. B.P.N., X.Zha., A.L.A.,and P.Z. provided important intellectual contentto the manuscript.

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1616 Systematic Review of CE Analysis of T2D Prevention Diabetes Care Volume 43, July 2020