Incentivized stepped-care approach cuts diabetes conversion risk in prediabetics

Findings from the Pre-DICTED* trial show that a stepped-care programme, which integrates lifestyle modifications, adds metformin as needed, and provides financial incentives, effectively reduces the risk of diabetes conversion in patients with prediabetes in Singapore.

“Community diabetes prevention programmes often struggle with participant adherence and sustained behaviour change. Although financial incentives can boost participant engagement and weight loss, their value in large-scale diabetes prevention remains unclear,” said principal investigator Associate Professor Bee Yong Mong from Singapore General Hospital, in a press release.

“Our study has suggested that financial incentives, when integrated with a structured stepped care approach, may actually make a difference in lowering diabetes incidence in high-risk individuals with prediabetes,” Bee said.

A total of 751 overweight or obese adults with prediabetes (mean age 52.5 years, 53.1 percent women, mean weight 77.2 kg, mean BMI 29 kg/m²) were randomized 1:1 to the intervention or control arm and were followed for 3 years. The goals were to achieve ≥5 percent weight loss from baseline and to engage in ≥150 min of moderate-intensity activity per week. [Diabetes Care 2025;48:1951-1959]

Most participants were Chinese (77.4 percent), followed by Asian Indian (10.4 percent) and Malay (8.9 percent). Prediabetes subtypes included impaired glucose tolerance (IGT**; 63.9 percent), impaired fasting glucose (IFG**; 13.3 percent), and IGT plus IFG (22.8 percent).

In the intervention arm, participants received lifestyle interventions (eg, nutrition workshops, exercise sessions). After 6 months, 26.4 percent of participants who remained at high risk of developing diabetes received metformin. Forty-five percent were given cash incentives for attending sessions and achieving the weight-loss target.

At 3 years, fewer participants in the intervention vs control arm developed diabetes, both in the modified intention-to-treat (37 percent vs 47.9 percent; adjusted relative risk [aRR], 0.74; p<0.001) and sensitivity (38.2 percent vs 49.9 percent; aRR, 0.74; p<0.001) analyses.

The cumulative incidence of diabetes was lower in the intervention than the control arm (11.93 vs 16.43 per 100 person-years; hazard ratio, 0.67; p<0.001). The Kaplan-Meier curves split at 6 months and continued to diverge through 36 months.

More participants in the intervention arm met the weight-loss target than the control arm at 36 months (30.1 percent vs 15.7 percent; p<0.001).

Adverse events (AEs) were more common in the intervention than the control arm (n=57 vs 14 events) and were primarily attributable to metformin-related gastrointestinal symptoms. Nineteen severe AEs were reported (including two deaths in the intervention arm), but none were related to the interventions.

War on Diabetes

Pre-DICTED is part of Singapore’s War on Diabetes initiative launched in 2016 and mirrors the D-CLIP*** approach. [Lancet Diabetes Endocrinol 2022;10:391-392; Diabetes Care 2016;39:1760-1767] However, only two D-CLIP participants achieved the target weight with the intervention, and the average weight loss dwindled over time. Pre-DICTED aimed to address these issues by incorporating cash incentives.

“Our findings show that modest financial incentives can be a cost-effective way to encourage participants to lower their blood sugar levels, with benefits reflected in improved quality of life as they achieve better control of their diabetes,” noted co-author Professor Eric Finkelstein from Duke-NUS Medical School, Singapore, in the press release.

“These results suggest that it may be a good value for money for governments or insurers looking to integrate similar approaches into strategies promoting healthy lifestyles, offering novel tools in Singapore’s fight against diabetes,” said Finkelstein.

Furthermore, the stepped-care approach, which prioritizes lifestyle modifications before medicating, aligns with recommendations and forestalls medicalizing a pre-disease state. [Diabetes Care 2025;48:S6-S13]

“This approach offers a pragmatic model for diabetes prevention efforts in real-world settings and provides valuable insights for policymakers seeking to implement cost-effective diabetes prevention programmes,” the investigators concluded.