Effectiveness of an Incentives-Enhanced Stepped Care Intervention Program in Diabetes Prevention in a Multiethnic Asian Prediabetes Cohort: Results From the Pre-DICTED Randomized Controlled Trial.

Objective: Diabetes prevention in real-world settings is affected by the challenge of intervention adherence and difficulty in sustaining behavior change. This study evaluated the effectiveness of a stepped care prevention program, enhanced with financial incentives, in reducing the risk of diabetes conversion in a multiethnic prediabetes cohort in Singapore.

Research design and methods: The Pre-Diabetes Interventions and Continued Tracking to Ease Out Diabetes (Pre-DICTED) trial was a randomized controlled trial involving 751 overweight or obese individuals with impaired glucose tolerance, impaired fasting glucose, or both. Participants were assigned to standard care (control arm) or a stepped care intervention program, starting with lifestyle interventions for 6 months before adding metformin for participants who remained at high risk of diabetes conversion based on study visit assessments. Intervention arm participants also received financial incentives for attending lifestyle sessions and for achieving ≥5% weight loss. The primary end point was the proportion of participants developing diabetes at 3 years in the modified intention-to-treat population.

Results: After 3 years, 34.8% of participants in the intervention arm developed diabetes compared with 47.3% in the control arm (adjusted risk difference -10.93%; 95% CI -18.04 to -3.81; P = 0.003). The adjusted relative risk was 0.74 (95% CI 0.62-0.88; P < 0.001). In the intervention arm, 26.4% of participants received metformin, and 45.1% received cash incentives. Adverse events were more common in the intervention arm, mainly because of metformin-related gastrointestinal symptoms.

Conclusions: A stepped care diabetes prevention program, enhanced with financial incentives, effectively reduced diabetes conversion in a multiethnic Asian prediabetes cohort.