Non-pharmacological interventions to reduce the risk of diabetes in people with impaired glucose regulation : a systematic review and economic evaluation

Background The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the UK and worldwide. Before the onset of T2DM, there are two conditions characterised by blood glucose levels that are above normal but below the threshold for diabetes. If screening for T2DM in introduced, many people with impaired glucose tolerance (IGT) will be found and it is necessary to consider how they should be treated. The number would depend on what screening test was used and what cut-offs were chosen. Objective To review the clinical effectiveness and cost-effectiveness of non-pharmacological interventions, including diet and physical activity, for the prevention of T2DM in people with intermediate hyperglycaemia. Data sources Electronic databases, MEDLINE (1996–2011), EMBASE (1980–2011) and all sections of The Cochrane Library, were searched for systematic reviews, randomised controlled trials (RCTs) and other relevant literature on the effectiveness of diet and/or physical activity in preventing, or delaying, progression to T2DM.The databases were also searched for studies on the cost-effectiveness of interventions. Review methods The review of clinical effectiveness was based mainly on RCTs, which were critically appraised. Subjects were people with intermediate hyperglycaemia, mainly with IGT. Interventions could be diet alone, physical activity alone, or the combination. For cost-effectiveness analysis, we updated the Sheffield economic model of T2DM. Modelling based on RCTs may not reflect what happens in routine care so we created a ‘real-life’ modelling scenario wherein people would try lifestyle change but switch to metformin after 1 year if they failed. Results Nine RCTs compared lifestyle interventions (predominantly dietary and physical activity advice, with regular reinforcement and frequent follow-up) with standard care. The primary outcome was progression to diabetes. In most trials, progression was reduced, by over half in some trials. The best effects were seen in participants who adhered best to the lifestyle changes; a scenario of a trial of lifestyle change but a switch to metformin after 1 year in those who did not adhere sufficiently appeared to be the most cost-effective option. Limitations Participants in the RCTs were volunteers and their results may have been better than in general populations. Even among the volunteers, many did not adhere. Some studies were not long enough to show whether the interventions reduced cardiovascular mortality as well as diabetes. The main problem is that we know what people should do to reduce progression, but not how to persuade most to do it. Conclusion In people with IGT, dietary change to ensure weight loss, coupled with physical activity, is clinically effective and cost-effective in reducing progression to diabetes

Executive attention, task selection and attention-based learning in a neurally controlled simulated robot

We describe the design and implementation of an integrated neural architecture, modelled on human executive attention, which is used to control both automatic (reactive) and willed action selection in a simulated robot. The model, based upon Norman and Shallice's supervisory attention system, incorporates important features of human attentional control: selection of an intended task over a more salient automatic task; priming of future tasks that are anticipated; and appropriate levels of persistence of focus of attention. Recognising that attention-based learning, mediated by the limbic system, and the hippocampus in particular, plays an important role in adaptive learning, we extend the Norman and Shallice model, introducing an intrinsic, attention-based learning mechanism that enhances the automaticity of willed actions and reduces future need for attentional effort. These enhanced features support a new level of attentional autonomy in the operation of the simulated robot. Some properties of the model are explored using lesion studies, leading to the identification of a correspondence between the behavioural pathologies of the simulated robot and those seen in human patients suffering dysfunction of executive attention. We discuss briefly the question of how executive attention may have arisen due to selective pressure

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