A National Health Service (NHS) England-style diabetes prevention program (DPP) would be cost-effective and likely cost saving for adults with prediabetes in Ontario and Quebec, according to a new modeling study. The findings support the potential value of investing in DPP in Canada and highlight an opportunity to reduce the burden of type 2 diabetes, according to the researchers.

In the late 1990s and early 2000s, clinical trials conducted in China, Finland, the US, Japan, India, and the UK showed that structured dietary and physical activity counseling can prevent type 2 diabetes among patients with prediabetes. Counseling reduced the incidence of diabetes by 30%-70% over 3-5 years compared with minimal information-based approaches.

In Canada, no province has implemented a publicly funded DPP, although estimates suggest that as many as one quarter of Canadian adults have prediabetes. Some jurisdictions have introduced time-limited projects. For example, an Alberta pilot delivered a virtual DPP to adults with prediabetes through a smartphone app with personalized health coaching. The NHS DPP represents a compelling model for Canada, given its demonstrated cost-effectiveness and the structural similarities between the English and Canadian healthcare systems, according to the researchers.

“We chose to model Ontario and Quebec because they’re Canada’s largest provinces and because we’ve been in dialogue with Quebec Public Health and Ontario Health, both of which are interested in considering this type of program. We’re making a conservative assumption that just 1 year in the program reduces participants’ probability of transitioning to type 2 diabetes by 20%,” study author Kaberi Dasgupta, MD, PhD, physician scientist at the McGill University Health Centre in Montreal, told Medscape News Canada. “That, in turn, reduces hospitalization, diabetes-related care, and associated healthcare costs,” she explained.

The data were published on September 28 in CMAJ.

Benefits for Doctors and Patients

The study evaluated the long-term cost-effectiveness of implementing a program like that of England compared with usual care, which was defined as prediabetes counseling and follow-up consistent with Diabetes Canada’s recommendations. These recommendations emphasize engaging in at least 150 minutes of moderate-intensity physical activity per week and adopting evidence-based healthy dietary patterns. Monitoring of A1c or fasting plasma glucose levels is recommended at 3-6 months and at least annually thereafter.

The mean total costs of the DPP strategy were $101,833 per participant in Quebec and $101,835 in Ontario compared with $102,077 for usual care. This result yielded an incremental cost savings of $244 per participant in Quebec and $242 in Ontario. The DPP was less costly and more effective than usual care in 74.8% of simulations in Quebec and 74.7% of simulations in Ontario.

Without the program, patients with prediabetes would incur even higher healthcare costs. The study provides powerful evidence, and policies and programs based on evidence are needed, said Dasgupta. “We’ve now had years of clinical trials and research settings showing that diabetes prevention is possible. It’s time for us to invest in this to save money, save lives, and reduce the risks associated with type 2 diabetes, including blindness and kidney and heart disease,” she added. The prevalence of diabetes was 3% in the 1970s but is now closer to 15%.

A preventive diabetes program would be beneficial for clinicians, patients, and the public because it would give clinicians a place to refer their patients, according to Dasgupta. She noted that if prediabetes is identified, there needs to be a direct, streamlined path to prevention and treatment. Such a path would help reduce the overall burden of the disease, including demand for care, hospital emergency stays, and complications. “It would have major impact in preventing or delaying a diagnosis of type 2 diabetes, which translates to less damage to the blood vessels, liver, heart, and other organs. This would result in less personal suffering and less disability in the longer term,” said Dasgupta.

Lack of Access to Care

The average patient with prediabetes doesn’t necessarily have the money to find a dietitian and an exercise trainer and work on lifestyle modification, Dasgupta commented. A publicly funded program could make this benefit accessible to a broad number of people. “With diabetes, as with most chronic and acute diseases, there is a higher risk with lower income. There is a clear economic gradient to diabetes. It’s not sufficient to say to a patient, ‘Go find a way to manage it on your own.’ A program can provide support, guidance, and the structure that can make a difference.”

“This cost-effective implementation modeling didn’t completely mirror the intense processes that took place in the trials that were originally published many decades ago,” Minna Woo, MD, PhD, endocrinologist at the University Health Network in Toronto, told Medscape News Canada. “However, any measures to prevent progression from prediabetes to diabetes would be beneficial in reducing the incidence of the related comorbidities like heart attacks and strokes.” Woo did not participate in the research.

“As endocrinologists, we’re well aware of the impact of the diabetes prevention program. While in this modeling study, it was extremely resource-intensive in terms of the care that subjects received, it’s an important proof of principle. In diabetes prevention or treatment, drugs are not first-line therapy. If you look at any guidelines such as those of the American Diabetes Association and Canadian Diabetes Association/Diabetes Canada, they always emphasize lifestyle first. We know that that’s where the power lies. And we all acknowledge that lifestyle modification is very, very difficult,” she concluded.

The Fonds de recherche du Québec — Santé Post-diplôme professionnel and the Canadian Institutes of Health Research supported this study. Dasgupta and Woo reported no relevant financial relationships.

Evra Taylor is a widely published freelance medical writer and reporter with 20 years of experience covering a broad range of therapeutic sectors, including family health, cardiology, psychiatry, ophthalmology, and dermatology.