Economic evaluation of type 2 diabetes prevention programmes: Markov model of low- and high-intensity lifestyle programmes and metformin in participants with different categories of intermediate hyperglycaemia
Open accessAbstract
BACKGROUND: National guidance on preventing type 2 diabetes mellitus (T2DM) in the UK recommends low-intensity lifestyle interventions for individuals with intermediate categories of hyperglycaemia defined in terms of impaired fasting glucose (IFG) or 'at-risk' levels of HbA1c. In a recent systematic review of economic evaluations of such interventions, most studies had evaluated intensive trial-based lifestyle programmes in participants with impaired glucose tolerance (IGT). This study examines the costs and effects of different intensity lifestyle programmes and metformin in participants with different categories of intermediate hyperglycaemia. METHODS: We developed a decision tree and Markov model (50-year horizon) to compare four approaches, namely (1) a low-intensity lifestyle programme based on current NICE guidance, (2) a high-intensity lifestyle programme based on the US Diabetes Prevention Program, (3) metformin, and (4) no intervention, modelled for three different types of intermediate hyperglycaemia (IFG, IGT and HbA1c). A health system perspective was adopted and incremental analysis undertaken at an individual and population-wide level, taking England as a case study. RESULTS: Low-intensity lifestyle programmes were the most cost-effective (£44/QALY, £195/QALY and £186/QALY compared to no intervention in IGT, IFG and HbA1c, respectively). Intensive lifestyle interventions were also cost-effective compared to no intervention (£2775/QALY, £6820/QALY and £7376/QALY, respectively, in IGT, IFG and HbA1c). Metformin was cost-effective relative to no intervention (£5224/QALY, £6842/QALY and £372/QALY in IGT, IFG and HbA1c, respectively), but was only cost-effective relative to other treatments in participants identified with HbA1c. At a willingness-to-pay threshold of £20,000/QALY, low- and high-intensity lifestyle programmes were cost-effective 98%, 99% and 98% and 81%, 81% and 71% of the time in IGT, IFG and HbA1c, respectively. An England-wide programme for 50-59 year olds could reduce T2DM incidence by < 3.5% over 50 years and would cost 0.2-5.2% of the current diabetes budget for 2-9 years. DISCUSSION: This analysis suggests that current English national policy of low-intensity lifestyle programmes in participants with IFG or HbA1c will be cost-effective and have the most favourable budget impact, but will prevent only a fraction of cases of T2DM. Additional approaches to prevention need to be investigated urgently.
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A four-state model structure was adopted because it has been clinically validated and used in several studies in the UK context.
“We adopted a four-state model structure: normal state (NGT), prediabetes state (PreD)/type 2 diabetes (T2D), and death (D) as it has been clinically validated and used in several studies in the UK context [14,15,21,30].”
From Economic evaluation of wearable fitness trackers versus metformin for preventing type 2 diabetes in the UK population (2025) · cites this paper as [21]
The Methods and Validation sections (pages not provided) describe a four-state model, verification with a clinical team in East London, and expert testing of the model structure’s face validity. The Discussion says previous economic evaluations commonly used Markov models, but it does not establish that several UK studies used this particular four-state structure. (LLM, conf=0.87)
Experimental — accuracy not yet measuredIncremental effects from Herman et al. (2005) were used because they have been used in the most recent studies in the UK context.
“Table 6 presents the incremental effects from Herman et al. (2005) as they have been used in the most recent studies in the U.K. context [14,21].”
From Economic evaluation of wearable fitness trackers versus metformin for preventing type 2 diabetes in the UK population (2025) · cites this paper as [21]
In Methods > Model parameters (page unavailable), Table 2 shows incremental utility effects used in this England-based model. It attributes those utilities to NICE guidance [32], not directly to Herman et al. (2005), and does not establish that Herman’s effects were used across recent UK studies. (LLM, conf=0.78)
Experimental — accuracy not yet measuredThe economic value of fitness trackers relative to established pharmacological treatments such as metformin is still underexplored.
“First, the economic value of fitness trackers relative to established pharmacological treatments such as metformin [19,20] is still underexplored [21].”
From Economic evaluation of wearable fitness trackers versus metformin for preventing type 2 diabetes in the UK population (2025) · cites this paper as [21]
A cycle length of one year was chosen, in line with similar studies in the UK context.
“We chose a cycle length of one year, in line with similar studies in the UK context [14,21].”
From Economic evaluation of wearable fitness trackers versus metformin for preventing type 2 diabetes in the UK population (2025) · cites this paper as [21]
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Lifestyle Interventions for the Prevention of Type 2 Diabetes Mellitus
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- Authors
- Roberts, S., Craig, D., Adler, A., McPherson, K., & Greenhalgh, T.
- Affiliations
- University of Oxford (GB)
- Newcastle University (GB)
- Addenbrooke's Hospital (GB)
- Corresponding author
- Roberts, Samantha
- Venue
- BMC Medicine
- Published
- 2018-01-30
- Volume
- 16
- Issue
- 1
- Pages
- 16-16
- ISSN
- 1741-7015 (ISSN-L)
- PMC
- PMC5798197
- OpenAlex
- W2785435636
- Cited by
- 48
- References
- 34
- Citations by year
- 2026: 4 · 2025: 5 · 2024: 8 · 2023: 5 · 2022: 4 · 2021: 5 · 2020: 4 · 2019: 11 · 2018: 2
- FWCI
- 8.36
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- BMC Medicine (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Newcastle University ePrints (Newcastle Univesity) (cc-by)
- Funders
- National Institute for Health Research (Oxford Biomedical Research Centre)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Keywords
- type 2 diabetes prevention, prediabetes, impaired fasting glucose, impaired glucose tolerance, HbA1c, lifestyle intervention, metformin, cost-effectiveness, Markov model, Diabetes Prevention Program, NICE guidelines, health system costs, quality-adjusted life years, willingness-to-pay threshold
- MeSH terms
- Cost-Benefit Analysis, Diabetes Mellitus, Type 2, Female, Humans, Hyperglycemia, Male, Metformin
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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