Type 2 diabetes continues to adversely impact life expectancy, quality of life, and medical costs. Compounding the problem is that obesity among patients with diabetes is also increasing, further impacting the potential for future improvements in life expectancy and quality of life for these patients. It has been well established that the excess morbidity and mortality experienced by people with diabetes is primarily due to increased cardiovascular disease (CVD) risk, specifically the triad of hyperglycemia, hypertension, and hyperlipidemia. People with type 2 diabetes die about 8 years earlier than those without the disease, primarily due to their increased risk of CVD. Interventions to reduce the adverse health outcomes of diabetes are primarily directed at cardiovascular risk factors, but despite these efforts most patients do not appear to be achieving optimal care goals for CVD risk reduction.
Clinical studies have demonstrated that effective programs for people with diabetes that achieve long-term weight loss and increase physical activity are promising for improving cardiovascular risk while minimizing use of pharmacologic agents. More research continues to explore the role of lifestyle interventions in these patients. The Look AHEAD (Action for Health in Diabetes) study is an ongoing NIH trial, which is examining the effect of an intensive lifestyle intervention (ILI) on CVD morbidity and mortality in people with diabetes. The ILI includes group and individual meetings to achieve and maintain weight loss by decreasing caloric intake and increasing physical activity; the comparator is a traditional diabetes support and education intervention (DSE). In the June 2010 issue of Diabetes Care, my colleagues and I examined the effect of the Look AHEAD intervention on medication requirements. We also estimated medication costs to treat CVD risk factors at the start of the Look AHEAD study and after the initial year of the ILI and DSE interventions.
Assessing Early Results
At 1 year, patients randomized to the Look AHEAD ILI group had significantly improved CVD risk factors—specifically diabetes, blood pressure, and lipid parameters—and reduced prescription medication use and cost when compared with those assigned to the DSE group. The average number of medications prescribed to treat CVD risk factors was lower for the ILI group than the DSE group, and the estimated total monthly medication costs were $143 and $173, respectively. At 1 year, ILI participants were also less likely to be using insulin. Patients randomized to DSE who met optimal care goals at 1 year were taking more medications and accrued higher costs per month than ILI recipients who achieved optimal care. The Look AHEAD intervention more than doubled the percentage of participants achieving optimal care goals.
It should be noted that improvements in diabetes, blood pressure, and lipid parameters—as were seen in the Look AHEAD study—might prompt personal physicians to reduce medication doses for their patients rather than discontinue medications altogether. Therefore, our estimates likely underestimate the cost differences between the ILI and DSE groups.
More to Come
Although we must await completion of the Look AHEAD trial (which is expected by 2014) before more thorough comparisons and interpretations can be made, it appears that the ILI used in the study is feasible and has the potential to reduce at least one component of healthcare costs while also reducing cardiovascular risk. More research is needed, but the ILI used in Look AHEAD may substantially benefit public health if these changes can be sustained for the long term. Continued intervention and follow-up will likely determine whether intensive lifestyle changes are maintained and reduce cardiovascular risk.
Redmon JB, Bertoni AG, Connelly S, et al, for the Look AHEAD Research Group. Effect of the Look AHEAD study intervention on medication use and related cost to treat cardiovascular disease risk factors in individuals with type 2 diabetes. Diabetes Care. 2010;33:1153-1158. Available at: http://care.diabetesjournals.org/content/33/6/1153.abstract.
Pi-Sunyer X, Blackburn G, Brancati FL, et al. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the Look AHEAD trial. Diabetes Care. 2007;30:1374-1383.
Franco OH, Steyerberg EW, Hu FB, Mackenbach J, Nusselder W. Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Arch Intern Med. 2007;167:1145-1151.
Davidson MB. Triple therapy: definitions, application, and treating to target. Diabetes Care. 2004;27:1834-1835.
Holman RR, Thorne KI, Farmer AJ, et al. Addition of biphasic, prandial, or basal insulin to oral therapy in type 2 diabetes. N Engl J Med. 2007;357:1716-1730.