Type 2 diabetes prevention from research to practice

the SLIMMER lifestyle intervention

G. Duijzer

Research output: Thesisinternal PhD, WU

Abstract

INTRODUCTION

Diabetes is a worldwide epidemic, causing a high disease and economic burden. Type 2 diabetes, the most common form of diabetes, is associated with overweight and obesity and an unfavourable lifestyle, including unhealthy diet and physical inactivity. Over the last two decades, many large-scale experimental trials have shown that type 2 diabetes can be delayed or prevented by lifestyle modification in high-risk subjects. This evidence has been translated and implemented in interventions in real-world settings, however, no (cost)effective diabetes prevention programme in Dutch primary health care was available at the start of the current project in 2008. Therefore the SLIMMER study (SLIM iMplementation Experience Region Noord- en Oost-Gelderland) was started in which the SLIM intervention, revealing a 47% diabetes risk reduction, was translated to Dutch primary health care. The aim of this thesis was to implement the SLIMMER intervention in Dutch primary health care and to evaluate its (cost)effectiveness and implementation.

METHODS

In 2010-2011, the SLIMMER intervention was tested for its feasibility and desired impact in a one-year pilot study (n = 31) with process evaluation, including quantitative and qualitative methods. From 2011 to 2014, the SLIMMER intervention was implemented on a larger scale in Dutch public health and primary health care. A randomised controlled trial was conducted (n = 316), including subjects aged 40 to 70 years with impaired fasting glucose or high risk of diabetes. The 10-month SLIMMER intervention involved a dietary and physical activity programme, including case management and a maintenance programme. The control group received usual health care. A logic model of change was composed to link intervention activities with intervention outcomes in a logical order. Primary outcome was fasting insulin. Measurements were performed at baseline and after 12 and 18 months and covered quality of life, clinical and metabolic risk factors (e.g. glucose tolerance, serum lipids, body fatness, and blood pressure), and eating and physical activity behaviour. Furthermore, a process evaluation including quantitative and qualitative methods was conducted. Data on process indicators (recruitment, reach, dose received, acceptability, implementation integrity, and applicability) were collected in semi-structured interviews with health care professional (n = 45) and intervention participant questionnaires (n = 155). Moreover, cost-effectiveness analyses were performed from both a societal and a health care perspective. Participants completed questionnaires to assess health care utilisation, participant out-of-pocket costs, and productivity losses.

RESULTS

The pilot study showed that participants lost on average 3.5 kg (p = 0.005) of their body weight. Both participants and health care professionals were satisfied with the intervention, which was implemented as planned and appeared to be suitable for application in practice. Refinements were identified and made prior to further implementation. The randomised controlled trial showed that after 12 and 18 months, the intervention group significantly improved weight (β=-2.7 kg (95% CI: -3.7;-1.7) and β=-2.5 kg (95% CI: -3.6;-1.4), respectively), and fasting insulin (β=-12.1 pmol/l (95% CI: -19.6;-4.6) and β=-8.0 pmol/l (95% CI: -14.7;-0.53), respectively) compared with the control group. Intervention subjects improved weight and glucose tolerance, independent of manner of recruitment (laboratory glucose test or Diabetes Risk Test). Furthermore, intake of total and saturated fat decreased and fibre intake increased in the intervention group compared with the control group, both at 12 and 18 months (p < 0.05). The DHD-index score – indicating adherence to the Dutch dietary guidelines – was significantly higher in the intervention group than in the control group, both at 12 and at 18 months (p < 0.05). Vigorous activities and physical fitness improved both at 12 and at 18 months. Finally, beneficial changes in several domains of quality of life were found both at 12 and at 18 months, although not all domains reached statistical significance. From the process evaluation it was revealed that it was possible to recruit the intended high-risk population, and the SLIMMER intervention was very well received by both participants and health care professionals. The intervention programme was to a large extent implemented as planned and was applicable in Dutch primary health care. Higher dose received and participant acceptability were related to improved health outcomes and dietary behaviour, but not to physical activity behaviour. The cost-effectiveness analysis showed that, from a societal perspective, the incremental costs of the SLIMMER lifestyle intervention were €547 and that the incremental effect was 0.02 QALY, resulting in an incremental cost-effectiveness ratio (ICER) of 28,094/QALY. When cost-effectiveness was calculated from a health care perspective, the ICER decreased to 13,605/QALY, with a moderate probability of being cost-effective (56% at a willingness to pay (WTP) of €20,000/QALY and 81% at a WTP of €80,000/QALY.

CONCLUSION

In conclusion, this study showed that a thorough preparation of translation and implementation has led to a cost-effective intervention to prevent type 2 diabetes which is feasible to implement in Dutch primary health care. In fact, our clinical effects were larger than those in most other real-world intervention programmes, and most effects sustained at 18 months. Furthermore, we showed that a higher intervention dose and participant acceptability were associated with improved health outcomes and dietary behaviour. Further research is needed on effects and costs over longer follow-up, effective intervention components, and consequences of suggested adaptations of the programme on intervention effectiveness. The results of this study provide valuable insights that can contribute to structural embedding and funding of effective diabetes prevention programmes in Dutch primary health care.

Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • Wageningen University
Supervisors/Advisors
  • Feskens, Edith, Promotor
  • Hiddink, Gerrit Jan, Promotor
  • Haveman-Nies, Annemien, Co-promotor
Award date19 Feb 2016
Place of PublicationWageningen
Publisher
Print ISBNs9789462576391
Publication statusPublished - 2016

Fingerprint

Type 2 Diabetes Mellitus
Life Style
Quality-Adjusted Life Years
Primary Health Care
Cost-Benefit Analysis
Delivery of Health Care
Research
Costs and Cost Analysis
Glucose
Fasting
Control Groups
Randomized Controlled Trials
Patient Acceptance of Health Care
Quality of Life
Insulin
Weights and Measures
Nutrition Policy
Cost of Illness
Physical Fitness
Health

Keywords

  • type 2 diabetes
  • disease prevention
  • disease control
  • health care
  • health care costs
  • pilot projects
  • evaluation
  • netherlands

Cite this

Duijzer, G.. / Type 2 diabetes prevention from research to practice : the SLIMMER lifestyle intervention. Wageningen : Wageningen University, 2016. 216 p.
@phdthesis{dee7ecd8218d4844ac7905429632ac54,
title = "Type 2 diabetes prevention from research to practice: the SLIMMER lifestyle intervention",
abstract = "INTRODUCTION Diabetes is a worldwide epidemic, causing a high disease and economic burden. Type 2 diabetes, the most common form of diabetes, is associated with overweight and obesity and an unfavourable lifestyle, including unhealthy diet and physical inactivity. Over the last two decades, many large-scale experimental trials have shown that type 2 diabetes can be delayed or prevented by lifestyle modification in high-risk subjects. This evidence has been translated and implemented in interventions in real-world settings, however, no (cost)effective diabetes prevention programme in Dutch primary health care was available at the start of the current project in 2008. Therefore the SLIMMER study (SLIM iMplementation Experience Region Noord- en Oost-Gelderland) was started in which the SLIM intervention, revealing a 47{\%} diabetes risk reduction, was translated to Dutch primary health care. The aim of this thesis was to implement the SLIMMER intervention in Dutch primary health care and to evaluate its (cost)effectiveness and implementation. METHODS In 2010-2011, the SLIMMER intervention was tested for its feasibility and desired impact in a one-year pilot study (n = 31) with process evaluation, including quantitative and qualitative methods. From 2011 to 2014, the SLIMMER intervention was implemented on a larger scale in Dutch public health and primary health care. A randomised controlled trial was conducted (n = 316), including subjects aged 40 to 70 years with impaired fasting glucose or high risk of diabetes. The 10-month SLIMMER intervention involved a dietary and physical activity programme, including case management and a maintenance programme. The control group received usual health care. A logic model of change was composed to link intervention activities with intervention outcomes in a logical order. Primary outcome was fasting insulin. Measurements were performed at baseline and after 12 and 18 months and covered quality of life, clinical and metabolic risk factors (e.g. glucose tolerance, serum lipids, body fatness, and blood pressure), and eating and physical activity behaviour. Furthermore, a process evaluation including quantitative and qualitative methods was conducted. Data on process indicators (recruitment, reach, dose received, acceptability, implementation integrity, and applicability) were collected in semi-structured interviews with health care professional (n = 45) and intervention participant questionnaires (n = 155). Moreover, cost-effectiveness analyses were performed from both a societal and a health care perspective. Participants completed questionnaires to assess health care utilisation, participant out-of-pocket costs, and productivity losses. RESULTS The pilot study showed that participants lost on average 3.5 kg (p = 0.005) of their body weight. Both participants and health care professionals were satisfied with the intervention, which was implemented as planned and appeared to be suitable for application in practice. Refinements were identified and made prior to further implementation. The randomised controlled trial showed that after 12 and 18 months, the intervention group significantly improved weight (β=-2.7 kg (95{\%} CI: -3.7;-1.7) and β=-2.5 kg (95{\%} CI: -3.6;-1.4), respectively), and fasting insulin (β=-12.1 pmol/l (95{\%} CI: -19.6;-4.6) and β=-8.0 pmol/l (95{\%} CI: -14.7;-0.53), respectively) compared with the control group. Intervention subjects improved weight and glucose tolerance, independent of manner of recruitment (laboratory glucose test or Diabetes Risk Test). Furthermore, intake of total and saturated fat decreased and fibre intake increased in the intervention group compared with the control group, both at 12 and 18 months (p < 0.05). The DHD-index score – indicating adherence to the Dutch dietary guidelines – was significantly higher in the intervention group than in the control group, both at 12 and at 18 months (p < 0.05). Vigorous activities and physical fitness improved both at 12 and at 18 months. Finally, beneficial changes in several domains of quality of life were found both at 12 and at 18 months, although not all domains reached statistical significance. From the process evaluation it was revealed that it was possible to recruit the intended high-risk population, and the SLIMMER intervention was very well received by both participants and health care professionals. The intervention programme was to a large extent implemented as planned and was applicable in Dutch primary health care. Higher dose received and participant acceptability were related to improved health outcomes and dietary behaviour, but not to physical activity behaviour. The cost-effectiveness analysis showed that, from a societal perspective, the incremental costs of the SLIMMER lifestyle intervention were €547 and that the incremental effect was 0.02 QALY, resulting in an incremental cost-effectiveness ratio (ICER) of 28,094/QALY. When cost-effectiveness was calculated from a health care perspective, the ICER decreased to 13,605/QALY, with a moderate probability of being cost-effective (56{\%} at a willingness to pay (WTP) of €20,000/QALY and 81{\%} at a WTP of €80,000/QALY. CONCLUSION In conclusion, this study showed that a thorough preparation of translation and implementation has led to a cost-effective intervention to prevent type 2 diabetes which is feasible to implement in Dutch primary health care. In fact, our clinical effects were larger than those in most other real-world intervention programmes, and most effects sustained at 18 months. Furthermore, we showed that a higher intervention dose and participant acceptability were associated with improved health outcomes and dietary behaviour. Further research is needed on effects and costs over longer follow-up, effective intervention components, and consequences of suggested adaptations of the programme on intervention effectiveness. The results of this study provide valuable insights that can contribute to structural embedding and funding of effective diabetes prevention programmes in Dutch primary health care.",
keywords = "type 2 diabetes, disease prevention, disease control, health care, health care costs, pilot projects, evaluation, netherlands, diabetes type 2, ziektepreventie, ziektebestrijding, gezondheidszorg, kosten van de gezondheidszorg, proefprojecten, evaluatie, nederland",
author = "G. Duijzer",
note = "WU thesis 6288",
year = "2016",
language = "English",
isbn = "9789462576391",
publisher = "Wageningen University",
school = "Wageningen University",

}

Duijzer, G 2016, 'Type 2 diabetes prevention from research to practice: the SLIMMER lifestyle intervention', Doctor of Philosophy, Wageningen University, Wageningen.

Type 2 diabetes prevention from research to practice : the SLIMMER lifestyle intervention. / Duijzer, G.

Wageningen : Wageningen University, 2016. 216 p.

Research output: Thesisinternal PhD, WU

TY - THES

T1 - Type 2 diabetes prevention from research to practice

T2 - the SLIMMER lifestyle intervention

AU - Duijzer, G.

N1 - WU thesis 6288

PY - 2016

Y1 - 2016

N2 - INTRODUCTION Diabetes is a worldwide epidemic, causing a high disease and economic burden. Type 2 diabetes, the most common form of diabetes, is associated with overweight and obesity and an unfavourable lifestyle, including unhealthy diet and physical inactivity. Over the last two decades, many large-scale experimental trials have shown that type 2 diabetes can be delayed or prevented by lifestyle modification in high-risk subjects. This evidence has been translated and implemented in interventions in real-world settings, however, no (cost)effective diabetes prevention programme in Dutch primary health care was available at the start of the current project in 2008. Therefore the SLIMMER study (SLIM iMplementation Experience Region Noord- en Oost-Gelderland) was started in which the SLIM intervention, revealing a 47% diabetes risk reduction, was translated to Dutch primary health care. The aim of this thesis was to implement the SLIMMER intervention in Dutch primary health care and to evaluate its (cost)effectiveness and implementation. METHODS In 2010-2011, the SLIMMER intervention was tested for its feasibility and desired impact in a one-year pilot study (n = 31) with process evaluation, including quantitative and qualitative methods. From 2011 to 2014, the SLIMMER intervention was implemented on a larger scale in Dutch public health and primary health care. A randomised controlled trial was conducted (n = 316), including subjects aged 40 to 70 years with impaired fasting glucose or high risk of diabetes. The 10-month SLIMMER intervention involved a dietary and physical activity programme, including case management and a maintenance programme. The control group received usual health care. A logic model of change was composed to link intervention activities with intervention outcomes in a logical order. Primary outcome was fasting insulin. Measurements were performed at baseline and after 12 and 18 months and covered quality of life, clinical and metabolic risk factors (e.g. glucose tolerance, serum lipids, body fatness, and blood pressure), and eating and physical activity behaviour. Furthermore, a process evaluation including quantitative and qualitative methods was conducted. Data on process indicators (recruitment, reach, dose received, acceptability, implementation integrity, and applicability) were collected in semi-structured interviews with health care professional (n = 45) and intervention participant questionnaires (n = 155). Moreover, cost-effectiveness analyses were performed from both a societal and a health care perspective. Participants completed questionnaires to assess health care utilisation, participant out-of-pocket costs, and productivity losses. RESULTS The pilot study showed that participants lost on average 3.5 kg (p = 0.005) of their body weight. Both participants and health care professionals were satisfied with the intervention, which was implemented as planned and appeared to be suitable for application in practice. Refinements were identified and made prior to further implementation. The randomised controlled trial showed that after 12 and 18 months, the intervention group significantly improved weight (β=-2.7 kg (95% CI: -3.7;-1.7) and β=-2.5 kg (95% CI: -3.6;-1.4), respectively), and fasting insulin (β=-12.1 pmol/l (95% CI: -19.6;-4.6) and β=-8.0 pmol/l (95% CI: -14.7;-0.53), respectively) compared with the control group. Intervention subjects improved weight and glucose tolerance, independent of manner of recruitment (laboratory glucose test or Diabetes Risk Test). Furthermore, intake of total and saturated fat decreased and fibre intake increased in the intervention group compared with the control group, both at 12 and 18 months (p < 0.05). The DHD-index score – indicating adherence to the Dutch dietary guidelines – was significantly higher in the intervention group than in the control group, both at 12 and at 18 months (p < 0.05). Vigorous activities and physical fitness improved both at 12 and at 18 months. Finally, beneficial changes in several domains of quality of life were found both at 12 and at 18 months, although not all domains reached statistical significance. From the process evaluation it was revealed that it was possible to recruit the intended high-risk population, and the SLIMMER intervention was very well received by both participants and health care professionals. The intervention programme was to a large extent implemented as planned and was applicable in Dutch primary health care. Higher dose received and participant acceptability were related to improved health outcomes and dietary behaviour, but not to physical activity behaviour. The cost-effectiveness analysis showed that, from a societal perspective, the incremental costs of the SLIMMER lifestyle intervention were €547 and that the incremental effect was 0.02 QALY, resulting in an incremental cost-effectiveness ratio (ICER) of 28,094/QALY. When cost-effectiveness was calculated from a health care perspective, the ICER decreased to 13,605/QALY, with a moderate probability of being cost-effective (56% at a willingness to pay (WTP) of €20,000/QALY and 81% at a WTP of €80,000/QALY. CONCLUSION In conclusion, this study showed that a thorough preparation of translation and implementation has led to a cost-effective intervention to prevent type 2 diabetes which is feasible to implement in Dutch primary health care. In fact, our clinical effects were larger than those in most other real-world intervention programmes, and most effects sustained at 18 months. Furthermore, we showed that a higher intervention dose and participant acceptability were associated with improved health outcomes and dietary behaviour. Further research is needed on effects and costs over longer follow-up, effective intervention components, and consequences of suggested adaptations of the programme on intervention effectiveness. The results of this study provide valuable insights that can contribute to structural embedding and funding of effective diabetes prevention programmes in Dutch primary health care.

AB - INTRODUCTION Diabetes is a worldwide epidemic, causing a high disease and economic burden. Type 2 diabetes, the most common form of diabetes, is associated with overweight and obesity and an unfavourable lifestyle, including unhealthy diet and physical inactivity. Over the last two decades, many large-scale experimental trials have shown that type 2 diabetes can be delayed or prevented by lifestyle modification in high-risk subjects. This evidence has been translated and implemented in interventions in real-world settings, however, no (cost)effective diabetes prevention programme in Dutch primary health care was available at the start of the current project in 2008. Therefore the SLIMMER study (SLIM iMplementation Experience Region Noord- en Oost-Gelderland) was started in which the SLIM intervention, revealing a 47% diabetes risk reduction, was translated to Dutch primary health care. The aim of this thesis was to implement the SLIMMER intervention in Dutch primary health care and to evaluate its (cost)effectiveness and implementation. METHODS In 2010-2011, the SLIMMER intervention was tested for its feasibility and desired impact in a one-year pilot study (n = 31) with process evaluation, including quantitative and qualitative methods. From 2011 to 2014, the SLIMMER intervention was implemented on a larger scale in Dutch public health and primary health care. A randomised controlled trial was conducted (n = 316), including subjects aged 40 to 70 years with impaired fasting glucose or high risk of diabetes. The 10-month SLIMMER intervention involved a dietary and physical activity programme, including case management and a maintenance programme. The control group received usual health care. A logic model of change was composed to link intervention activities with intervention outcomes in a logical order. Primary outcome was fasting insulin. Measurements were performed at baseline and after 12 and 18 months and covered quality of life, clinical and metabolic risk factors (e.g. glucose tolerance, serum lipids, body fatness, and blood pressure), and eating and physical activity behaviour. Furthermore, a process evaluation including quantitative and qualitative methods was conducted. Data on process indicators (recruitment, reach, dose received, acceptability, implementation integrity, and applicability) were collected in semi-structured interviews with health care professional (n = 45) and intervention participant questionnaires (n = 155). Moreover, cost-effectiveness analyses were performed from both a societal and a health care perspective. Participants completed questionnaires to assess health care utilisation, participant out-of-pocket costs, and productivity losses. RESULTS The pilot study showed that participants lost on average 3.5 kg (p = 0.005) of their body weight. Both participants and health care professionals were satisfied with the intervention, which was implemented as planned and appeared to be suitable for application in practice. Refinements were identified and made prior to further implementation. The randomised controlled trial showed that after 12 and 18 months, the intervention group significantly improved weight (β=-2.7 kg (95% CI: -3.7;-1.7) and β=-2.5 kg (95% CI: -3.6;-1.4), respectively), and fasting insulin (β=-12.1 pmol/l (95% CI: -19.6;-4.6) and β=-8.0 pmol/l (95% CI: -14.7;-0.53), respectively) compared with the control group. Intervention subjects improved weight and glucose tolerance, independent of manner of recruitment (laboratory glucose test or Diabetes Risk Test). Furthermore, intake of total and saturated fat decreased and fibre intake increased in the intervention group compared with the control group, both at 12 and 18 months (p < 0.05). The DHD-index score – indicating adherence to the Dutch dietary guidelines – was significantly higher in the intervention group than in the control group, both at 12 and at 18 months (p < 0.05). Vigorous activities and physical fitness improved both at 12 and at 18 months. Finally, beneficial changes in several domains of quality of life were found both at 12 and at 18 months, although not all domains reached statistical significance. From the process evaluation it was revealed that it was possible to recruit the intended high-risk population, and the SLIMMER intervention was very well received by both participants and health care professionals. The intervention programme was to a large extent implemented as planned and was applicable in Dutch primary health care. Higher dose received and participant acceptability were related to improved health outcomes and dietary behaviour, but not to physical activity behaviour. The cost-effectiveness analysis showed that, from a societal perspective, the incremental costs of the SLIMMER lifestyle intervention were €547 and that the incremental effect was 0.02 QALY, resulting in an incremental cost-effectiveness ratio (ICER) of 28,094/QALY. When cost-effectiveness was calculated from a health care perspective, the ICER decreased to 13,605/QALY, with a moderate probability of being cost-effective (56% at a willingness to pay (WTP) of €20,000/QALY and 81% at a WTP of €80,000/QALY. CONCLUSION In conclusion, this study showed that a thorough preparation of translation and implementation has led to a cost-effective intervention to prevent type 2 diabetes which is feasible to implement in Dutch primary health care. In fact, our clinical effects were larger than those in most other real-world intervention programmes, and most effects sustained at 18 months. Furthermore, we showed that a higher intervention dose and participant acceptability were associated with improved health outcomes and dietary behaviour. Further research is needed on effects and costs over longer follow-up, effective intervention components, and consequences of suggested adaptations of the programme on intervention effectiveness. The results of this study provide valuable insights that can contribute to structural embedding and funding of effective diabetes prevention programmes in Dutch primary health care.

KW - type 2 diabetes

KW - disease prevention

KW - disease control

KW - health care

KW - health care costs

KW - pilot projects

KW - evaluation

KW - netherlands

KW - diabetes type 2

KW - ziektepreventie

KW - ziektebestrijding

KW - gezondheidszorg

KW - kosten van de gezondheidszorg

KW - proefprojecten

KW - evaluatie

KW - nederland

M3 - internal PhD, WU

SN - 9789462576391

PB - Wageningen University

CY - Wageningen

ER -

Duijzer G. Type 2 diabetes prevention from research to practice: the SLIMMER lifestyle intervention. Wageningen: Wageningen University, 2016. 216 p.