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Risk equations for the development of worsened glucose status and type 2 diabetes mellitus in a Swedish intervention program
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Cancer Epidemiology, University Cancer Center, University Hospital, Technische Universität Dresden, Germany.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. (Arcum)ORCID iD: 0000-0003-2475-7131
Cancer Epidemiology, University Cancer Center, University Hospital, Technische Universität Dresden, Germany.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-2021-0028-7401
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2013 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13, 1014Article in journal (Refereed) Published
Abstract [en]

Background: Several studies investigated transitions and risk factors from impaired glucose tolerance (IGT) to type 2 diabetes mellitus (T2D). However, there is a lack of information on the probabilities to transit from normal glucose tolerance (NGT) to different pre-diabetic states and from these states to T2D. The objective of our study is to estimate these risk equations and to quantify the influence of single or combined risk factors on these transition probabilities. Methods: Individuals who participated in the VIP program twice, having the first examination at ages 30, 40 or 50 years of age between 1990 and 1999 and the second examination 10 years later were included in the analysis. Participants were grouped into five groups: NGT, impaired fasting glucose (IFG), IGT, IFG&IGT or T2D. Fourteen potential risk factors for the development of a worse glucose state (pre-diabetes or T2D) were investigated: sex, age, education, perceived health, triglyceride, blood pressure, BMI, smoking, physical activity, snus, alcohol, nutrition and family history. Analysis was conducted in two steps. Firstly, factor analysis was used to find candidate variables; and secondly, logistic regression was employed to quantify the influence of the candidate variables. Bootstrap estimations validated the models. Results: In total, 29 937 individuals were included in the analysis. Alcohol and perceived health were excluded due to the results of the factor analysis and the logistic regression respectively. Six risk equations indicating different impacts of different risk factors on the transition to a worse glucose state were estimated and validated. The impact of each risk factor depended on the starting or ending pre-diabetes state. High levels of triglyceride, hypertension and high BMI were the strongest risk factors to transit to a worsened glucose state. Conclusions: The equations could be used to identify individuals with increased risk to develop any of the three pre-diabetic states or T2D and to adapt prevention strategies.

Place, publisher, year, edition, pages
BioMed Central, 2013. Vol. 13, 1014
Keyword [en]
Diabetes mellitus, type 2, Pre-diabetic state, Prevention & control, Risk factors, Glucose, Sweden, Logistic models, Factor analysis, statistical, Early intervention, Life style
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-85814DOI: 10.1186/1471-2458-13-1014ISI: 000329290200002OAI: oai:DiVA.org:umu-85814DiVA: diva2:695865
Available from: 2014-02-12 Created: 2014-02-10 Last updated: 2017-12-06Bibliographically approved
In thesis
1. Prevention of type 2 diabetes: modeling the cost-effectiveness of diabetes prevention
Open this publication in new window or tab >>Prevention of type 2 diabetes: modeling the cost-effectiveness of diabetes prevention
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Diabetes is a common and costly disease that is expected to continue even to grow in prevalence and health expenditures over the coming decades. Type 2 diabetes is the most common diabetes type and is characterized by insulin resistance and relative insulin deficiency. Type 2 diabetes develops over a long period and is often undetected over years. During this time, people almost always first develop any of the pre-diabetic states, i.e. impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or a combination of both (IFG&IGT). This thesis focuses on type 2 diabetes only. In the following, the term diabetes is used to refer to type 2 diabetes only. Diabetes is associated with a sedentary lifestyle and obesity. While those are not the only factors contributing to the development and maintenance of diabetes, several studies have shown that prevention of diabetes among individuals at high risk through lifestyle change is possible, effective and cost-effective, especially targeting diet and exercise to reduce weight. No previous study had, however, estimated the cost-effectiveness of diabetes prevention strategies from a population-based perspective including healthy individuals and also considered IFG and IGT as two distinct pre-diabetic states.

Objective: The overall objective of this thesis was to establish, describe and evaluate a model that can assess the cost-effectiveness of lifestyle intervention programs to prevent diabetes.

Methods: First, a Markov Model was established using data from the literature. The cost of a German diabetes prevention program was estimated. Second, risk equations for change to worsened glucose states were estimated using factor analysis and logistic regression based on consecutive data from the Västerbotten Intervention Program (VIP). The risk equations described transition probabilities in the final model and were based on several risk factors such as age, sex, physical activity and smoking status. Third, information on the Short-Form 36 questionnaire from the VIP population was transformed into Short-Form 6D. Health utility weights (HUW) by glucose group and four risk factors were estimated using beta regression. Fourth, an updated Markov model was established using an updated model structure compared to the one in Paper I, program costs of Paper I, risk equations of Paper II, health utility weights of Paper III and updated cost and mortality estimates.

Results: The first model in Paper I showed that lifestyle intervention programs have the potential to be cost-effective with a high degree of uncertainty. The risk equations in Paper II indicated that the impact of each risk factor depended on the starting and ending pre-diabetes state, where high levels of triglyceride, hypertension, and high body mass index were the strongest risk factors to transit to a worsened glucose state. The overall mean HUW in Paper III was 0.764 with healthy individuals having the highest HUW, those with diabetes the lowest and those in pre-diabetic states ranging in between. The intervention described in Paper IV was cost-effective for all sex and age scenarios ranging from 3,833 EUR/QALY gained (women, 30 years) to 9,215 EUR/QALY gained (men, 70 years). The probability that the intervention is cost-effective was high (85.0-91.1%).

Conclusion: We established a model that can estimate the cost-effectiveness of different scenarios of initiatives to prevent diabetes. The prevention or the delay of the onset of diabetes is feasible and cost-effective. A small investment in a healthy lifestyle with the change in physical activity and diet together with weight loss can have a decent, cost-effective result. The full range of possibilities this model offers has not been evaluated so far. We have, however, shown that implementing a lifestyle intervention program like the Västerbotten Intervention Programme would be cost-effective.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2016. 69 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1821
Keyword
type 2 diabetes mellitus, prevention, health economics, Markov modeling, risk equations, health-related quality of life, lifestyle modification, pre-diabetic states, cost-effectiveness, Västerbotten Intervention Programme
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-123553 (URN)978-91-7601-517-9 (ISBN)
Public defence
2016-09-02, sal 135, Allmänmedicin, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2016-08-15 Created: 2016-07-05 Last updated: 2016-08-18Bibliographically approved

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Neumann, AnneNorberg, MargaretaNorström, FredrikJohansson, IngegerdLindholm, Lars

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