Within-Trial Cost-Effectiveness of a Structured Lifestyle Intervention in Adults With Overweight/Obesity and Type 2 Diabetes: Results From the Action for Health in Diabetes (Look AHEAD) Study

The dual challenge of diabesity: pathophysiology, management, and future directions

Diabesity, the concurrent occurrence of obesity and type-2 diabetes mellitus (T2DM), represents a pressing global health challenge characterized by intricate pathophysiological mechanisms and a wide range of associated comorbidities. Central to its development are insulin resistance, metabolic syndrome, and chronic low-grade inflammation mediated by dysregulated adipokine secretion and systemic metabolic dysfunction. These mechanisms underpin the progression of diabesity and its complications, including cardiovascular disease and hypertension. Management strategies encompass lifestyle interventions focusing on tailored dietary modifications and structured physical activity, pharmacological treatments targeting both glycemic control and weight loss, and surgical interventions such as bariatric surgery, which have demonstrated efficacy in achieving durable outcomes. Clinical trials and meta-analyses underscore the comparative advantages of different treatment modalities in terms of efficacy, safety, and sustainability. Moreover, long-term follow-up studies emphasize the critical need for sustained multidisciplinary interventions to prevent relapse and enhance patient outcomes. Future advancements in management include exploring precision medicine approaches that integrate individual metabolic profiles, lifestyle factors, and emerging therapeutic innovations. A multidisciplinary approach combining advanced therapeutic strategies and patient-centered care remains pivotal for optimizing management and improving prognoses for individuals with diabesity. This review highlights the complex interplay between obesity and T2DM, offering comprehensive insights into their pathophysiology, clinical presentation, and management paradigms.

A perspective on the use of patient-reported experience and patient-reported outcome measures in ambulatory healthcare

INTRODUCTION

Patient-reported experience measures (PREMs) are patient reports about their healthcare, whereas patient-reported outcome measures (PROMs) are reports about their functioning and well-being regarding physical, mental, and social health. We provide a perspective on using PREMs and PROMs in ambulatory healthcare.

AREAS COVERED

We conducted a narrative review of the literature about using PREMs and PROMs in research and clinical practice, identified challenges and possibilities for addressing them, and provided suggestions for future research and clinical practice.

EXPERT OPINION

Substantial progress in using PREMs and PROMs has occurred during the last half-century. Collecting and reporting PREMs to clinicians in ambulatory care settings has improved communication with patients, diagnosis, and treatment, which may improve patients' health. Optimal use requires appropriate data analysis, minimizing implementation barriers, and facilitating interpretation of PREMs and PROMs in clinical practice. Also, formal structures and processes that include patient and family input into care improvement are needed (e.g. patient and family advisory councils as partners in co-design and coproduction of quality improvement). PREMs and PROMs have been used primarily in more affluent countries (e.g. the United States, Australia, United Kingdom, Netherlands, Japan, and Portugal), but this is expected to increase in many countries.

Lifetime Health Effects and Cost-Effectiveness of Tirzepatide and Semaglutide in US Adults

Importance

Newer antiobesity medications lead to greater weight loss and lower cardiometabolic risks. However, the high costs of these medications have raised policy questions about their value and coverage decisions.

Objective

To compare the cost-effectiveness of 4 antiobesity medications with lifestyle modification vs lifestyle modification alone in the US.

Design, Setting, and Participants

A lifetime cost-effectiveness analysis was conducted in 2024 using the validated Diabetes, Obesity, Cardiovascular Disease Microsimulation model for US adults. Data were included from the 2017-2020 National Health and Nutrition Examination Survey of 4823 individuals (representing 126 million eligible US adults) aged 20 to 79 years who would meet clinical trial inclusion criteria for antiobesity medications. Individual-level simulations projected long-term cardiometabolic outcomes, quality-adjusted life-years (QALYs), and health care expenditures. Probabilistic sensitivity analyses, subgroup analyses (across body mass index [BMI] categories [≥30 or ≥27 and at least 1 weight-related comorbidity], presence of comorbidities), and multiple scenario analyses (varying treatment discontinuation rates, value-based pricing benchmarks) were conducted. Future costs and QALYs were discounted at 3% annually.

Interventions

Lifestyle modification with naltrexone-bupropion, phentermine-topiramate, semaglutide, or tirzepatide vs lifestyle modification alone.

Main Outcomes and Measures

Obesity, diabetes, and cardiovascular disease cases averted, life-years and QALYs gained, costs incurred (2023 US dollars), and incremental cost-effectiveness ratios.

Results

Among the 126 million eligible US adults, the mean age was 48 (SE, 0.5) years; 51% were female; and the initial mean BMI was 34.7 (SE, 0.2); and 85% had at least 1 weight-related comorbidity. Over a lifetime, tirzepatide would avert 45 609 obesity cases (95% uncertainty interval [UI], 45 092-46 126) per 100 000 individuals and semaglutide would avert 32 087 cases (95% UI, 31 292-32 882) per 100 000 individuals. Tirzepatide would reduce 20 854 incident cases of diabetes (95% UI, 19 432-22 276) per 100 000 individuals and semaglutide would reduce 19 211 cases (95% UI, 17 878-20 544) per 100 000 individuals. Tirzepatide would reduce 10 655 cardiovascular disease cases (95% UI, 10 124-11 186) per 100 000 individuals and semaglutide would reduce 8263 cases (95% UI, 7738-8788) per 100 000 individuals. Despite the largest incremental QALY gains of 0.35 for tirzepatide and 0.25 for semaglutide among all antiobesity medications, the incremental cost-effectiveness ratios were $197 023/QALY and 467 676/QALY, respectively. To reach the $100 000/QALY threshold, their prices would require additional discounts by 30.5% for tirzepatide and 81.9% for semaglutide from their current net prices. Naltrexone-bupropion was cost saving due to its lower cost and had an 89.1% probability of being cost-effective at $100 000/QALY, whereas phentermine-topiramate had a 23.5% probability of being cost-effective at $100 000/QALY. Tirzepatide and semaglutide both had a 0% probability across all QALY threshold ranges examined ($100 000-$200 000/QALY).

Conclusions and Relevance

This economic evaluation found that although tirzepatide and semaglutide offered substantial long-term health benefits, they were not cost-effective at current net prices. Efforts to reduce the net prices of new antiobesity medications are essential to ensure equitable access to highly effective antiobesity medications.

Optimizing diabetes management interventions for Black and Hispanic adults using the multiphase optimization strategy: Protocol for a randomized mixed methods factorial trial

BACKGROUND

Black and Hispanic adults with diabetes are more likely to experience diabetes complications and die from diabetes compared to non-Hispanic whites. This disparity may be due to medication adherence being negatively affected by social determinants of health (SDOH) and negative beliefs about diabetes and diabetes medicines. Pharmacist delivered medication therapy management (MTM) improves clinical outcomes. However, pharmacists have limited capacity and expertise to address SDOH barriers and health misperceptions. Supplementing MTM with Community Health Workers (CHWs) to address these factors may be more effective with potential for implementation.

AIM

To investigate what combination of two possible components, pharmacist delivered MTM and CHWs addressing SDOH barriers and health misperceptions, represents the optimized intervention for Black and Hispanic adults with uncontrolled diabetes.

METHODS/DESIGN

We will use a 2 × 2 factorial design (MTM, CHW: ON vs. OFF) where participants will be randomized to one of four treatment conditions in a 6-month intervention delivered mostly by phone. We will recruit 376 Black or Hispanic adults with type 2 diabetes and hemoglobin A1C of ≥8 %, a clinical indicator of uncontrolled type 2 diabetes. The primary outcome is A1C measured at 6 months, and at 12 months for sustained change. The secondary outcome is medication adherence. Several psychosocial factors will be examined as potential mediators. An embedded experimental mixed methods approach will be used to obtain participant perspectives through qualitative interviews and integrated to assess intervention acceptability.

DISCUSSION

Our findings will identify the optimized intervention, e.g., comprising MTM or CHW or both intervention components, that effectively and efficiently improves diabetes outcomes among Black and Hispanic adults with uncontrolled diabetes, informing dissemination.

Parent-Derived Health State Utilities for Developmental Dysplasia of the Hip

BACKGROUND

Developmental hip dysplasia (DDH) is a common condition associated with pain, disability and early hip osteoarthritis when untreated. Health utility scores have not previously been defined for a comprehensive set of DDH health states. The purpose of this study was to establish utility scores associated with DDH health states.

METHODS

Patients treated for DDH using either Pavlik harness or abduction bracing and closed/open hip reduction between February 2016 and March 2023 were identified. Thirteen vignettes describing health states in the DDH life cycle were developed. Parents of patients were asked to score each state from 0 to 100 using the feeling thermometer. A score of "0" represents the worst state imaginable/death and a score of "100" represents perfect health. Utility scores were calculated and compared between parents of patients treated operatively and nonoperatively.

RESULTS

Ninety parents of children with DDH (45 operative, 45 nonoperative) were enrolled. There were 82 (91.1%) female children (median age of 4.9 years at enrollment). Median utility scores ranged from 77.5 [interquartile range (IQR): 70.0 to 90.0] for Pavlik harness and 80.0 (IQR: 60.0 to 86.3) for abduction bracing to 40.0 (IQR: 20.0 to 60.0) for reduction/spica cast and 40.0 (IQR: 20.0 to 50.0) for end-stage hip arthritis. Utility scores were lower in the operative group for Pavlik harness (median 70.0 vs. 80.0, P <0.01), end-stage arthritis (30.0 vs. 40.0, P =0.04), and 1 year after total hip arthroplasty (85.0 vs. 90.0, P =0.03) health states compared with the nonoperative group. There were no differences in other scores.

CONCLUSIONS

Thirteen health states related to the life cycle of DDH were collected. Nonoperative interventions for DDH were viewed by parents slightly more favorably than operative treatments or long-term sequelae of untreated DDH. Future studies can assess other potential treatment experiences for patients with DDH or use these scores to perform cost-effectiveness analysis of different screening techniques for DDH.

LEVEL OF EVIDENCE

Level III.

Cost-effectiveness of goal-directed and outcome-based financial incentives for weight loss in low-income populations: the FIReWoRk randomized clinical trial

BACKGROUND

The Financial Incentives for Weight Reduction (FIReWoRk) clinical trial showed that financial incentive weight-loss strategies designed using behavioral economics were more effective than provision of weight-management resources only. We now evaluate cost-effectiveness.

METHODS

Cost-effectiveness analysis of a multisite randomized trial enrolling 668 participants with obesity living in low-income neighborhoods. Participants were randomized to (1) goal-directed incentives (targeting behavioral goals), (2) outcome-based incentives (targeting weight-loss), and (3) resources only, which were provided to all participants and included a 1-year commercial weight-loss program membership, wearable activity monitor, food journal, and digital scale. We assessed program costs, time costs, quality of life, weight, and incremental cost-effectiveness in dollars-per-kilogram lost.

RESULTS

Mean program costs at 12 months, based on weight loss program attendance, physical activity participation, food diary use, self-monitoring of weight, and incentive payments was $1271 in the goal-directed group, $1194 in the outcome-based group, and $834 in the resources-only group (difference, $437 [95% CI, 398 to 462] and $360 [95% CI, 341-363] for goal-directed or outcome-based vs resources-only, respectively; difference, $77 [95% CI, 58-130] for goal-directed vs outcome-based group). Quality of life did not differ significantly between the groups, but weight loss was substantially greater in the incentive groups (difference, 2.34 kg [95% CI, 0.53-4.14] and 1.79 kg [95% CI, -0.14 to 3.72] for goal-directed or outcome-based vs resources only, respectively; difference, 0.54 kg [95% CI, -1.29 to 2.38] for goal-directed vs outcome-based). Cost-effectiveness of incentive strategies based on program costs was $189/kg lost in the goal-directed group (95% CI, $124/kg to $383/kg) and $186/kg lost in the outcome-based group (95% CI, $113/kg to $530/kg).

CONCLUSIONS

Goal-directed and outcome-based financial incentives were cost-effective strategies for helping low-income individuals with obesity lose weight. Their incremental cost per kilogram lost were comparable to other weight loss interventions.

Association of Intensive Lifestyle Intervention for Type 2 Diabetes With Labor Market Outcomes

Importance

An intensive lifestyle intervention (ILI) has been shown to improve diabetes management and physical function. These benefits could lead to better labor market outcomes, but this has not been previously studied.

Objective

To estimate the association of an ILI for weight loss in type 2 diabetes with employment, earnings, and disability benefit receipt during and after the intervention.

Design, Setting, and Participants

This cohort study included participants with type 2 diabetes and overweight or obesity and compared an ILI with a control condition of diabetes support and education. Data for the original trial were accrued from August 22, 2001, to September 14, 2012. Trial data were linked with Social Security Administration records to investigate whether, relative to the control group, the ILI was associated with improvements in labor market outcomes during and after the intervention period. Difference-in-differences models estimating relative changes in employment, earnings, and disability benefit receipt between the ILI and control groups were used, accounting for prerandomization differences in outcomes for linked participants. Outcome data were analyzed from July 13, 2020, to May 17, 2023.

Exposure

The ILI consisted of sessions with lifestyle counselors, dieticians, exercise specialists, and behavioral therapists on a weekly basis in the first 6 months, decreasing to a monthly basis by the fourth year, designed to achieve and maintain at least 7% weight loss. The control group received group-based diabetes education sessions 3 times annually during the first 4 years, with 1 annual session thereafter.

Main Outcomes and Measures

Employment and receipt of federal disability benefits (Supplemental Security Income and Social Security Disability Insurance), earnings, and disability benefit payments from 1994 through 2018.

Results

A total of 3091 trial participants were linked with Social Security Administration data (60.1% of 5145 participants initially randomized and 97.0% of 3188 of participants consenting to linkage). Among the 3091 with fully linked data, 1836 (59.4%) were women, and mean (SD) age was 58.4 (6.5) years. Baseline clinical and demographic characteristics were similar between linked participants in the ILI and control groups. Employment increased by 2.9 (95% CI, 0.3-5.5) percentage points for the ILI group relative to controls (P = .03) with no significant relative change in disability benefit receipt (-0.9 [95% CI, -2.1 to 0.3] percentage points; P = .13).

Conclusions and Relevance

The findings of this cohort study suggest that an ILI to prevent the progression and complications of type 2 diabetes was associated with higher levels of employment. Labor market productivity should be considered when evaluating interventions to manage chronic diseases.

A Systematic Review of the Evidence for Non-surgical Weight Management for Adults with Severe Obesity: What is Cost Effective and What are the Implications for the Design of Health Services?

PURPOSE OF REVIEW

Severe obesity (BMI ≥ 35 kg/m2) increases premature mortality and reduces quality-of-life. Obesity-related disease (ORD) places substantial burden on health systems. This review summarises the cost-effectiveness evidence for non-surgical weight management programmes (WMPs) for adults with severe obesity.

RECENT FINDINGS

Whilst evidence shows bariatric surgery is often cost-effective, there is no clear consensus on the cost-effectiveness of non-surgical WMPs. Thirty-two studies were included. Most were short-term evaluations that did not capture the long-term costs and consequences of ORD. Decision models often included only a subset of relevant ORDs, and made varying assumptions about the rate of weight regain over time. A lack of sensitivity analyses limited interpretation of results. Heterogeneity in the definition of WMPs and usual care prevents formal evidence synthesis. We were unable to establish the most cost-effective WMPs. Addressing these limitations may help future studies provide more robust cost-effectiveness evidence for decision makers.

Overcoming the Limitations of Stem Cell-Derived Beta Cells

Great advances in type 1 diabetes (T1D) and type 2 diabetes (T2D) treatment have been made to this day. However, modern diabetes therapy based on insulin injections and cadaveric islets transplantation has many disadvantages. That is why researchers are developing new methods to regenerate the pancreatic hormone-producing cells in vitro. The most promising approach is the generation of stem cell-derived beta cells that could provide an unlimited source of insulin-secreting cells. Recent studies provide methods to produce beta-like cell clusters that display glucose-stimulated insulin secretion—one of the key characteristics of the beta cell. However, in comparison with native beta cells, stem cell-derived beta cells do not undergo full functional maturation. In this paper we review the development and current state of various protocols, consider advantages, and propose ways to improve them. We examine molecular pathways, epigenetic modifications, intracellular components, and the microenvironment as a possible leverage to promote beta cell functional maturation. A possibility to create islet organoids from stem cell-derived components, as well as their encapsulation and further transplantation, is also examined. We try to combine modern research on beta cells and their crosstalk to create a holistic overview of developing insulin-secreting systems.

Health-Related Quality of Life Measurement in Public Health

Patient-reported outcomes are recognized as essential for the evaluation of medical and public health interventions. Over the last 50 years, health-related quality of life (HRQoL) research has grown exponentially from 0 to more than 17,000 papers published annually. We provide an overview of generic HRQoL measures used widely in epidemiological studies, health services research, population studies, and randomized clinical trials [e.g., Medical Outcomes Study SF-36 and the Patient-Reported Outcomes Measurement Information System (PROMIS^®)-29]. In addition, we review methods used for economic analysis and calculation of the quality-adjusted life year (QALY). These include the EQ-5D, the Health Utilities Index (HUI), the self-administered Quality of Well-being Scale (QWB-SA), and the Health and Activities Limitation Index (HALex). Furthermore, we consider hybrid measures such as the SF-6D and the PROMIS-Preference (PROPr). The plethora of HRQoL measures has impeded cumulative science because incomparable measures have been used in different studies. Linking among different measures and consensus on standard HRQoL measurement should now be prioritized. In addition, enabling widespread access to common measures is necessary to accelerate future progress. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Pointers and Pitfalls in Interpreting Nutrition and Dietetics Research: The Importance of Statistical and Clinical Significance

This monograph focuses on understanding statistical and clinical significance and is one of a research and statistics series published by the statistical team of the Journal of the Academy of Nutrition and Dietetics. The content covers the research questions, the definition of clinical significance, hypothesis testing, p-values, effect sizes, sample sizes, confidence intervals, power analyses, minimal clinically important differences, and validity. This monograph concludes with a summary of the importance of clinical and statistical results, for nutrition professionals to consider when assessing statistical and clinical significance. The assessment will help readers make subjective clinical judgements in the application of research findings based on their experience.

Cost-effectiveness of bariatric surgery and non-surgical weight management programmes for adults with severe obesity: a decision analysis model

OBJECTIVES

To determine the most cost-effective weight management programmes (WMPs) for adults, in England with severe obesity (BMI ≥ 35 kg/m2), who are more at risk of obesity related diseases.

METHODS

An economic evaluation of five different WMPs: 1) low intensity (WMP1); 2) very low calorie diets (VLCD) added to WMP1; 3) moderate intensity (WMP2); 4) high intensity (Look AHEAD); and 5) Roux-en-Y gastric bypass (RYGB) surgery, all compared to a baseline scenario representing no WMP. We also compare a VLCD added to WMP1 vs. WMP1 alone. A microsimulation decision analysis model was used to extrapolate the impact of changes in BMI, obtained from a systematic review and meta-analysis of randomised controlled trials (RCTs) of WMPs and bariatric surgery, on long-term risks of obesity related disease, costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) measured as incremental cost per QALY gained over a 30-year time horizon from a UK National Health Service (NHS) perspective. Sensitivity analyses explored the impact of long-term weight regain assumptions on results.

RESULTS

RYGB was the most costly intervention but also generated the lowest incidence of obesity related disease and hence the highest QALY gains. Base case ICERs for WMP1, a VLCD added to WMP1, WMP2, Look AHEAD, and RYGB compared to no WMP were £557, £6628, £1540, £23,725 and £10,126 per QALY gained respectively. Adding a VLCD to WMP1 generated an ICER of over £121,000 per QALY compared to WMP1 alone. Sensitivity analysis found that all ICERs were sensitive to the modelled base case, five year post intervention cessation, weight regain assumption.

CONCLUSIONS

RYGB surgery was the most effective and cost-effective use of scarce NHS funding resources. However, where fixed healthcare budgets or patient preferences exclude surgery as an option, a standard 12 week behavioural WMP (WMP1) was the next most cost-effective intervention.

Does Lifestyle Intervention Improve Health of Adults with Overweight/Obesity and Type 2 Diabetes? Findings from the Look AHEAD Randomized Trial

This paper reviews the main findings from the Action for Health in Diabetes (Look AHEAD) Trial, a randomized trial testing the long-term health effects of intensive lifestyle interventions (ILIs) in 5,145 persons with overweight/obesity and type 2 diabetes. Although the primary outcome originally focused on cardiovascular morbidity and mortality, secondary outcomes included a broad range of health parameters related to diabetes and obesity. As the cohort aged, study outcomes were expanded to include health problems affecting geriatric populations, such as cognitive impairment and disability.This review summarizes the history of this trial and presents findings related to a wide range of health outcomes. Studies are reviewed that showed positive impact of ILI on diabetes control and complications, depression, physical health-related quality of life, sleep apnea, incontinence, brain structure, and health care use and costs. Several composite indices were also positively impacted by ILI, including multimorbidity, geriatric syndromes, and disability-free life years. However, there are also some important outcomes that did not show significant differences between the intervention and control, including cardiovascular morbidity and mortality, cancer, cognitive function, and cognitive impairment; for several of these nonsignificant effects, post hoc analyses suggested that there may be differences among subgroups, raising the possibility that ILI may be beneficial to some but potentially harmful to others. The only adverse effects of ILI relative to diabetes support and education were on frailty fractures and the related negative effects on body composition and bone density. Through this review, the manuscript seeks to determine whether weight loss should be encouraged in this population; given the large number of beneficial effects, relative to the small number of adverse effects, the answer appears to be yes.