human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background National and international policy makers have been increasing their focus on developing strategies to enable poor countries achieve the millennium development goals . This requires information on the costs of different types of health interventions and the re sources needed to scale them up , either singly or in combinations . Cost data also guides decisions about the most appropriate mix of interventions in different setting s , in view of the increasing , but still limited , re sources available to improve health . Many cost and cost-effectiveness studies include only the costs incurred at the point of delivery to beneficiaries , omitting those incurred at other levels of the system such as administration , media , training and overall management . The few studies that have measured them directly suggest that they can sometimes account for a substantial proportion of total costs , so that their omission can result in biased estimates of the re sources needed to run a programme or the relative cost-effectiveness of different choices . However , prices of different inputs used in the production of health interventions can vary substantially within a country . Basing cost estimates on a single price observation runs the risk that the results are based on an outlier observation rather than the typical costs of the input . Methods We first explore the determinants of the observed variation in the  prices  of selected  " non-traded " intermediate inputs to health programmes – printed matter and media advertising , and water and electricity – accounting for variation within and across countries . We then use the estimated relationship to impute average prices for countries where limited data are available with uncertainty intervals . Results Prices vary across countries with GDP per capita and a number of determinants of supply and dem and . Media and printing were inelastic with respect to GDP per capita , with a positive correlation , while the utilities had a surprisingly negative relationship . All equations had relatively good fits with the data . Conclusion While the preferred option is to derive costs from a r and om sample of prices in each setting , this option is often not available to analysts . In this case , we suggest that the approach described in this paper could represent a better option than basing policy recommendations on results that are built on the basis of a single , or a few , price observations Aims /hypothesisWe determined the effects of 6 years of lifestyle intervention in persons with impaired glucose tolerance ( IGT ) on the development of retinopathy , nephropathy and neuropathy over a 20 year period . Methods In 1986 , 577 adults with IGT from 33 clinics in Da Qing , China were r and omly assigned by clinic to a control group or one of three lifestyle intervention groups ( diet , exercise , and diet plus exercise ) . Active intervention was carried out from 1986 to 1992 . In 2006 we conducted a 20 year follow-up study of the original participants to compare the incidence of microvascular complications in the combined intervention group vs the control group . Results Follow-up information was obtained on 542 ( 94 % ) of the 577 original participants . The cumulative incidence of severe retinopathy was 9.2 % in the combined intervention group and 16.2 % in the control group ( p = 0.03 , log-rank test ) . After adjusting for clinic and age , the incidence of severe retinopathy was 47 % lower in the intervention group than the control group ( hazard rate ratio 0.53 , 95 % CI 0.29–0.99 , p = 0.048 ) . No significant differences were found in the incidence of severe nephropathy ( hazard rate ratio 1.05 , 95 % CI 0.16–7.05 , intervention vs control , p = 0.96 ) or in the prevalence of neuropathy ( 8.6 % vs 9.1 % , p = 0.89 ) among the 20 year survivors . Conclusions /interpretationLifestyle intervention for 6 years in IGT was associated with a 47 % reduction in the incidence of severe , vision-threatening retinopathy over a 20 year interval , primarily due to the reduced incidence of diabetes in the intervention group . However , similar benefits were not seen for nephropathy or neuropathy Background Cost-effectiveness studies of lifestyle interventions in people at risk for lifestyle-related diseases , addressing ‘ real-world ’ implementation , are needed . This study examines the cost-effectiveness of a primary care intervention from a societal perspective , compared with provision of health brochures , alongside a r and omized controlled trial . Methods Adults aged 30 - 50 years , at risk of type 2 diabetes ( T2DM ) and /or cardiovascular disease ( CVD ) , were recruited from twelve general practice s in The Netherl and s. They were r and omized to the intervention ( n = 314 ) or control group ( n = 308 ) . The intervention consisted of up to six face-to-face counseling sessions with a trained practice nurse , followed by three-monthly sessions by phone . Costs were collected using three-monthly retrospective question naires . Quality of life was measured with the EuroQol-5D-3L , at baseline , 6 , 12 and 24 months . Nine-year risk of developing T2DM and ten-year risk of CVD mortality were estimated using the ARIC and SCORE formulae , respectively , based on measurements at baseline and 24 months while applying a fixed age of 60 years at both time points . Results Small , statistically non-significant differences in effects were found between the intervention and control group with regard to risk scores and Quality Adjusted Life Years ( QALYs ) gained . The mean difference in costs between the intervention and control group was € -866 ( 95 % confidence interval -2372 ; 370 ) . The probability that the intervention was cost-effective varied from 93 % at € 8000/QALY to 88 % at € 80,000/QALY . Conclusion A primary care lifestyle intervention aim ed at adults at increased risk of T2DM and /or CVD  could result in cost savings over a two-year period . However , due to method ological uncertainty no advice can be given regarding the implementation of the intervention in Dutch general practice s . Trial registration Current Controlled Trials IS RCT N59358434 Background The prevalence of gestational diabetes mellitus ( GDM ) is increasing worldwide . GDM and the risks associated with GDM lead to increased health care costs and losses in productivity . The objective of this study is to evaluate whether the FitFor2 exercise program during pregnancy is cost-effective from a societal perspective as compared to st and ard care . Methods A r and omised controlled trial ( RCT ) and simultaneous economic evaluation of the FitFor2 program were conducted . Pregnant women at risk for GDM were r and omised to an exercise program to prevent high maternal blood glucose ( n = 62 ) or to  st and ard care  ( n = 59 ) . The exercise program consisted of two sessions of aerobic and strengthening exercises per week . Clinical outcome measures were maternal fasting blood glucose levels , insulin sensitivity and infant birth weight . Quality of life was measured using the EuroQol 5-D and quality -adjusted life-years ( QALYs ) were calculated . Re source utilization and sick leave data were collected by question naires . Data were analysed according to the intention-to-treat principle . Missing data were imputed using multiple imputations . Bootstrapping techniques estimated the uncertainty surrounding the cost differences and incremental cost-effectiveness ratios . Results There were no statistically significant differences in any outcome measure . During pregnancy , total health care costs and costs of productivity losses were statistically non-significant ( mean difference € 1308 ; 95%CI € -229 - € 3204 ) . The cost-effectiveness analyses showed that the exercise program was not cost-effective in comparison to the control group for blood glucose levels , insulin sensitivity , infant birth weight or QALYs . Conclusion The twice-weekly exercise program for pregnant women at risk for GDM evaluated in the present study was not cost-effective compared to st and ard care . Based on these results , implementation of this exercise program for the prevention of GDM can not be recommended . Trial registration BACKGROUND In the 2.8 years of the Diabetes Prevention Program ( DPP ) r and omised clinical trial ,  diabetes incidence  in high-risk adults was reduced by 58 % with intensive lifestyle intervention and by 31 % with metformin , compared with placebo . We investigated the persistence of these effects in the long term . METHODS All active DPP participants were eligible for continued follow-up . 2766 of 3150 ( 88 % ) enrolled for a median additional follow-up of 5.7 years ( IQR 5.5 - 5.8 ) . 910 participants were from the lifestyle , 924 from the metformin , and 932 were from the original placebo groups .  On the basis of the benefits from the intensive lifestyle intervention in the DPP , all three groups were offered group-implemented lifestyle intervention . Metformin treatment was continued in the original metformin group ( 850 mg twice daily as tolerated ) , with participants unmasked to assignment , and the original lifestyle intervention group was offered additional lifestyle support . The primary outcome was development of diabetes according to American Diabetes Association criteria . Analysis was by intention-to-treat . This study is registered with Clinical Trials.gov , number NCT00038727 . FINDINGS During the 10.0-year ( IQR 9.0 - 10.5 ) follow-up since r and omisation to DPP , the original lifestyle group lost , then partly regained weight . The modest weight loss with metformin was maintained . Diabetes incidence rates during the DPP were 4.8 cases per 100 person-years ( 95 % CI 4.1 - 5.7 ) in the intensive lifestyle intervention group , 7.8 ( 6.8 - 8.8 ) in the metformin group , and 11.0 ( 9.8 - 12.3 ) in the placebo group . Diabetes incidence rates in this follow-up study were similar between treatment groups : 5.9 per 100 person-years ( 5.1 - 6.8 ) for lifestyle , 4.9 ( 4.2 - 5.7 ) for metformin , and 5.6 ( 4.8 - 6.5 ) for placebo . Diabetes incidence in the 10 years since DPP r and omisation was reduced by 34 % ( 24 - 42 ) in the lifestyle group and 18 % ( 7 - 28 ) in the metformin group compared with placebo . INTERPRETATION During follow-up after DPP , incidences in the former placebo and metformin groups fell to equal those in the former lifestyle group , but the cumulative incidence of diabetes remained lowest in the lifestyle group . Prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years . FUNDING National Institute of Diabetes and Digestive and Kidney Diseases ( NIDDK ) BACKGROUND Type 2 diabetes mellitus is increasingly common , primarily because of increases in the prevalence of a sedentary lifestyle and obesity . Whether type 2 diabetes can be prevented by interventions that affect the lifestyles of subjects at high risk for the disease is not known . METHODS We r and omly assigned 522 middle-aged , overweight subjects ( 172 men and 350 women ; mean age , 55 years ; mean body-mass index [ weight in kilograms divided by the square of the height in meters ] , 31 ) with impaired glucose tolerance to either the intervention group or the control group . Each subject in the intervention group received individualized counseling aim ed at reducing weight , total intake of fat , and intake of saturated fat and increasing intake of fiber and physical activity . An oral glucose-tolerance test was performed annually ; the diagnosis of diabetes was confirmed by a second test . The mean duration of follow-up was 3.2 years . RESULTS The mean ( + /-SD ) amount of weight lost between base line and the end of year 1 was 4.2+/-5.1 kg in the intervention group and 0.8+/-3.7 kg in the control group ; the net loss by the end of year 2 was 3.5+/-5.5 kg in the intervention group and 0.8+/-4.4 kg in the control group ( P<0.001 for both comparisons between the groups ) . The cumulative incidence of diabetes after four years was 11 percent ( 95 percent confidence interval , 6 to 15 percent ) in the intervention group and 23 percent ( 95 percent confidence interval , 17 to 29 percent ) in the control group . During the trial , the risk of diabetes was reduced by 58 percent ( P<0.001 ) in the intervention group . The reduction in the incidence of diabetes was directly associated with changes in lifestyle . CONCLUSIONS Type 2 diabetes can be prevented by changes in the lifestyles of high-risk subjects Aims /hypothesisLifestyle modification helps in the primary prevention of diabetes in multiethnic American , Finnish and Chinese population s. In a prospect i ve community-based study , we tested whether the progression to diabetes could be influenced by interventions in native Asian Indians with IGT who were younger , leaner and more insulin resistant than the above population s. Methods We r and omised 531 ( 421 men 110 women ) subjects with IGT ( mean age 45.9±5.7 years , BMI 25.8±3.5 kg/m2 ) into four groups . Group 1 was the control , Group 2 was given advice on lifestyle modification ( LSM ) , Group 3 was treated with metformin ( MET ) and Group 4 was given LSM plus MET . The primary outcome measure was type 2 diabetes as diagnosed using World Health Organization criteria . Results 
    Output:
    
agent
T2D prevention by physical activity or diet or both proved cost-effective according to accepted thresholds , except for five inconclusive studies , three on diabetes prevention and two on obesity control .
This confirms that lifestyle interventions for the primary prevention of diabetes are cost-effective .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background National and international policy makers have been increasing their focus on developing strategies to enable poor countries achieve the millennium development goals . This requires information on the costs of different types of health interventions and the re sources needed to scale them up , either singly or in combinations . Cost data also guides decisions about the most appropriate mix of interventions in different setting s , in view of the increasing , but still limited , re sources available to improve health . Many cost and cost-effectiveness studies include only the costs incurred at the point of delivery to beneficiaries , omitting those incurred at other levels of the system such as administration , media , training and overall management . The few studies that have measured them directly suggest that they can sometimes account for a substantial proportion of total costs , so that their omission can result in biased estimates of the re sources needed to run a programme or the relative cost-effectiveness of different choices . However , prices of different inputs used in the production of health interventions can vary substantially within a country . Basing cost estimates on a single price observation runs the risk that the results are based on an outlier observation rather than the typical costs of the input . Methods We first explore the determinants of the observed variation in the  prices  of selected  " non-traded " intermediate inputs to health programmes – printed matter and media advertising , and water and electricity – accounting for variation within and across countries . We then use the estimated relationship to impute average prices for countries where limited data are available with uncertainty intervals . Results Prices vary across countries with GDP per capita and a number of determinants of supply and dem and . Media and printing were inelastic with respect to GDP per capita , with a positive correlation , while the utilities had a surprisingly negative relationship . All equations had relatively good fits with the data . Conclusion While the preferred option is to derive costs from a r and om sample of prices in each setting , this option is often not available to analysts . In this case , we suggest that the approach described in this paper could represent a better option than basing policy recommendations on results that are built on the basis of a single , or a few , price observations Aims /hypothesisWe determined the effects of 6 years of lifestyle intervention in persons with impaired glucose tolerance ( IGT ) on the development of retinopathy , nephropathy and neuropathy over a 20 year period . Methods In 1986 , 577 adults with IGT from 33 clinics in Da Qing , China were r and omly assigned by clinic to a control group or one of three lifestyle intervention groups ( diet , exercise , and diet plus exercise ) . Active intervention was carried out from 1986 to 1992 . In 2006 we conducted a 20 year follow-up study of the original participants to compare the incidence of microvascular complications in the combined intervention group vs the control group . Results Follow-up information was obtained on 542 ( 94 % ) of the 577 original participants . The cumulative incidence of severe retinopathy was 9.2 % in the combined intervention group and 16.2 % in the control group ( p = 0.03 , log-rank test ) . After adjusting for clinic and age , the incidence of severe retinopathy was 47 % lower in the intervention group than the control group ( hazard rate ratio 0.53 , 95 % CI 0.29–0.99 , p = 0.048 ) . No significant differences were found in the incidence of severe nephropathy ( hazard rate ratio 1.05 , 95 % CI 0.16–7.05 , intervention vs control , p = 0.96 ) or in the prevalence of neuropathy ( 8.6 % vs 9.1 % , p = 0.89 ) among the 20 year survivors . Conclusions /interpretationLifestyle intervention for 6 years in IGT was associated with a 47 % reduction in the incidence of severe , vision-threatening retinopathy over a 20 year interval , primarily due to the reduced incidence of diabetes in the intervention group . However , similar benefits were not seen for nephropathy or neuropathy Background Cost-effectiveness studies of lifestyle interventions in people at risk for lifestyle-related diseases , addressing ‘ real-world ’ implementation , are needed . This study examines the cost-effectiveness of a primary care intervention from a societal perspective , compared with provision of health brochures , alongside a r and omized controlled trial . Methods Adults aged 30 - 50 years , at risk of type 2 diabetes ( T2DM ) and /or cardiovascular disease ( CVD ) , were recruited from twelve general practice s in The Netherl and s. They were r and omized to the intervention ( n = 314 ) or control group ( n = 308 ) . The intervention consisted of up to six face-to-face counseling sessions with a trained practice nurse , followed by three-monthly sessions by phone . Costs were collected using three-monthly retrospective question naires . Quality of life was measured with the EuroQol-5D-3L , at baseline , 6 , 12 and 24 months . Nine-year risk of developing T2DM and ten-year risk of CVD mortality were estimated using the ARIC and SCORE formulae , respectively , based on measurements at baseline and 24 months while applying a fixed age of 60 years at both time points . Results Small , statistically non-significant differences in effects were found between the intervention and control group with regard to risk scores and Quality Adjusted Life Years ( QALYs ) gained . The mean difference in costs between the intervention and control group was € -866 ( 95 % confidence interval -2372 ; 370 ) . The probability that the intervention was cost-effective varied from 93 % at € 8000/QALY to 88 % at € 80,000/QALY . Conclusion A primary care lifestyle intervention aim ed at adults at increased risk of T2DM and /or CVD  could result in cost savings over a two-year period . However , due to method ological uncertainty no advice can be given regarding the implementation of the intervention in Dutch general practice s . Trial registration Current Controlled Trials IS RCT N59358434 Background The prevalence of gestational diabetes mellitus ( GDM ) is increasing worldwide . GDM and the risks associated with GDM lead to increased health care costs and losses in productivity . The objective of this study is to evaluate whether the FitFor2 exercise program during pregnancy is cost-effective from a societal perspective as compared to st and ard care . Methods A r and omised controlled trial ( RCT ) and simultaneous economic evaluation of the FitFor2 program were conducted . Pregnant women at risk for GDM were r and omised to an exercise program to prevent high maternal blood glucose ( n = 62 ) or to  st and ard care  ( n = 59 ) . The exercise program consisted of two sessions of aerobic and strengthening exercises per week . Clinical outcome measures were maternal fasting blood glucose levels , insulin sensitivity and infant birth weight . Quality of life was measured using the EuroQol 5-D and quality -adjusted life-years ( QALYs ) were calculated . Re source utilization and sick leave data were collected by question naires . Data were analysed according to the intention-to-treat principle . Missing data were imputed using multiple imputations . Bootstrapping techniques estimated the uncertainty surrounding the cost differences and incremental cost-effectiveness ratios . Results There were no statistically significant differences in any outcome measure . During pregnancy , total health care costs and costs of productivity losses were statistically non-significant ( mean difference € 1308 ; 95%CI € -229 - € 3204 ) . The cost-effectiveness analyses showed that the exercise program was not cost-effective in comparison to the control group for blood glucose levels , insulin sensitivity , infant birth weight or QALYs . Conclusion The twice-weekly exercise program for pregnant women at risk for GDM evaluated in the present study was not cost-effective compared to st and ard care . Based on these results , implementation of this exercise program for the prevention of GDM can not be recommended . Trial registration BACKGROUND In the 2.8 years of the Diabetes Prevention Program ( DPP ) r and omised clinical trial ,  diabetes incidence  in high-risk adults was reduced by 58 % with intensive lifestyle intervention and by 31 % with metformin , compared with placebo . We investigated the persistence of these effects in the long term . METHODS All active DPP participants were eligible for continued follow-up . 2766 of 3150 ( 88 % ) enrolled for a median additional follow-up of 5.7 years ( IQR 5.5 - 5.8 ) . 910 participants were from the lifestyle , 924 from the metformin , and 932 were from the original placebo groups .  On the basis of the benefits from the intensive lifestyle intervention in the DPP , all three groups were offered group-implemented lifestyle intervention . Metformin treatment was continued in the original metformin group ( 850 mg twice daily as tolerated ) , with participants unmasked to assignment , and the original lifestyle intervention group was offered additional lifestyle support . The primary outcome was development of diabetes according to American Diabetes Association criteria . Analysis was by intention-to-treat . This study is registered with Clinical Trials.gov , number NCT00038727 . FINDINGS During the 10.0-year ( IQR 9.0 - 10.5 ) follow-up since r and omisation to DPP , the original lifestyle group lost , then partly regained weight . The modest weight loss with metformin was maintained . Diabetes incidence rates during the DPP were 4.8 cases per 100 person-years ( 95 % CI 4.1 - 5.7 ) in the intensive lifestyle intervention group , 7.8 ( 6.8 - 8.8 ) in the metformin group , and 11.0 ( 9.8 - 12.3 ) in the placebo group . Diabetes incidence rates in this follow-up study were similar between treatment groups : 5.9 per 100 person-years ( 5.1 - 6.8 ) for lifestyle , 4.9 ( 4.2 - 5.7 ) for metformin , and 5.6 ( 4.8 - 6.5 ) for placebo . Diabetes incidence in the 10 years since DPP r and omisation was reduced by 34 % ( 24 - 42 ) in the lifestyle group and 18 % ( 7 - 28 ) in the metformin group compared with placebo . INTERPRETATION During follow-up after DPP , incidences in the former placebo and metformin groups fell to equal those in the former lifestyle group , but the cumulative incidence of diabetes remained lowest in the lifestyle group . Prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years . FUNDING National Institute of Diabetes and Digestive and Kidney Diseases ( NIDDK ) BACKGROUND Type 2 diabetes mellitus is increasingly common , primarily because of increases in the prevalence of a sedentary lifestyle and obesity . Whether type 2 diabetes can be prevented by interventions that affect the lifestyles of subjects at high risk for the disease is not known . METHODS We r and omly assigned 522 middle-aged , overweight subjects ( 172 men and 350 women ; mean age , 55 years ; mean body-mass index [ weight in kilograms divided by the square of the height in meters ] , 31 ) with impaired glucose tolerance to either the intervention group or the control group . Each subject in the intervention group received individualized counseling aim ed at reducing weight , total intake of fat , and intake of saturated fat and increasing intake of fiber and physical activity . An oral glucose-tolerance test was performed annually ; the diagnosis of diabetes was confirmed by a second test . The mean duration of follow-up was 3.2 years . RESULTS The mean ( + /-SD ) amount of weight lost between base line and the end of year 1 was 4.2+/-5.1 kg in the intervention group and 0.8+/-3.7 kg in the control group ; the net loss by the end of year 2 was 3.5+/-5.5 kg in the intervention group and 0.8+/-4.4 kg in the control group ( P<0.001 for both comparisons between the groups ) . The cumulative incidence of diabetes after four years was 11 percent ( 95 percent confidence interval , 6 to 15 percent ) in the intervention group and 23 percent ( 95 percent confidence interval , 17 to 29 percent ) in the control group . During the trial , the risk of diabetes was reduced by 58 percent ( P<0.001 ) in the intervention group . The reduction in the incidence of diabetes was directly associated with changes in lifestyle . CONCLUSIONS Type 2 diabetes can be prevented by changes in the lifestyles of high-risk subjects Aims /hypothesisLifestyle modification helps in the primary prevention of diabetes in multiethnic American , Finnish and Chinese population s. In a prospect i ve community-based study , we tested whether the progression to diabetes could be influenced by interventions in native Asian Indians with IGT who were younger , leaner and more insulin resistant than the above population s. Methods We r and omised 531 ( 421 men 110 women ) subjects with IGT ( mean age 45.9±5.7 years , BMI 25.8±3.5 kg/m2 ) into four groups . Group 1 was the control , Group 2 was given advice on lifestyle modification ( LSM ) , Group 3 was treated with metformin ( MET ) and Group 4 was given LSM plus MET . The primary outcome measure was type 2 diabetes as diagnosed using World Health Organization criteria . Results 
    Output:
    