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Cost-Effectiveness of Three Doses of a Behavioral Intervention to Prevent or Delay Type 2 Diabetes in Rural Areas

Published:December 30, 2019DOI:



      Rural Americans have higher prevalence of obesity and type 2 diabetes (T2D) than urban populations and more limited access to behavioral programs to promote healthy lifestyle habits. Descriptive evidence from the Rural Lifestyle Intervention Treatment Effectiveness trial delivered through local cooperative extension service offices in rural areas previously identified that behavioral modification with both nutrition education and coaching resulted in a lower program delivery cost per kilogram of weight loss maintained at 2-years compared with an education-only comparator intervention.


      This analysis extended earlier Rural Lifestyle Intervention Treatment Effectiveness trial research regarding weight loss outcomes to assess whether nutrition education with behavioral coaching delivered through cooperative extension service offices is cost-effective relative to nutrition education only in reducing T2D cases in rural areas.


      A cost-utility analysis was conducted.


      Trial participants (n=317) from June 2008 through June 2014 were adults residing in rural Florida counties with a baseline body mass index between 30 and 45, but otherwise identified as healthy.


      Trial participants were randomly assigned to low, moderate, or high doses of behavioral coaching with nutrition education (ie, 16, 32, or 48 sessions over 24 months) or a comparator intervention that included 16 sessions of nutrition education without coaching. Participant glycated hemoglobin level was measured at baseline and the end of the trial to assess T2D status.

      Main outcome measures

      T2D categories by treatment arm were used to estimate participants’ expected annual health care expenditures and expected health-related utility measured as quality adjusted life years (ie, QALYs) over a 5-year time horizon. Discounted incremental costs and QALYs were used to calculate incremental cost-effectiveness ratios for each behavioral coaching intervention dose relative to the education-only comparator.

      Statistical analyses performed

      Using a third-party payer perspective, Markov transition matrices were used to model participant transitions between T2D states. Replications of the individual participant behavior were conducted using Monte Carlo simulation.


      All three doses of the behavioral coaching intervention had lower expected total costs and higher estimated QALYs than the education-only comparator. The moderate dose behavioral coaching intervention was associated with higher estimated QALYs but was costlier than the low dose; the moderate dose was favored over the low dose with willingness to pay thresholds over $107,895/QALY. The low dose behavioral coaching intervention was otherwise favored.


      Because most rural Americans live in counties with cooperative extension service offices, nutrition education with behavioral coaching programs similar to those delivered through this trial may be effective and efficient in preventing or delaying T2D-associated consequences of obesity for rural adults.


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      T. A. Radcliff is a professor, Department of Health Policy and Management, and associate dean, Texas A&M University School of Public Health, College Station, University of Florida, Gainesville.


      M. J. Côté is an associate professor, Department of Health Policy and Management, Texas A&M University School of Public Health, College Station, University of Florida, Gainesville.


      M. D. Whittington is a research assistant professor, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, University of Florida, Gainesville.


      M. J. Daniels is a professor, chair, and Andrew Banks Family Endowed Chair, Department of Statistics, University of Florida, Gainesville.


      D. M. Janicke is a professor and associate department chair, Department of Clinical and Health Psychology, University of Florida, Gainesville.


      M. G. Perri is the Robert G. Frank Endowed Professor of Clinical and Health Psychology, and dean of the College of Public Health and Health Professions, University of Florida, Gainesville.


      L. B. Bobroff is professor emerita, Department of Family, Youth, and Community Sciences, University of Florida, Gainesville.