Diet, Exercise and Empagliflozin Matched on Blood Sugar in Older Diabetics

The findings come from a secondary analysis of the CEV-65 randomised controlled trial, published in BMC Geriatrics in 2026. The trial enrolled 100 older adults with type 2 diabetes. A secondary analysis looks again at data from a completed trial, this time with a new question. Here, the question was about cost and value as well as clinical results. The authors describe their findings as exploratory.

The trial compared three approaches. One was a Mediterranean diet, called VegMedD in the paper. One was empagliflozin, a drug in the SGLT2 inhibitor class. One was circuit resistance training, a form of exercise built around strength work. The researchers tracked HbA1c, a common measure of average blood sugar over recent weeks. They also tracked frailty, a state of increased vulnerability that comes with age and raises the risk of falls, hospital stays and disability.

All three interventions improved glycemic control. Frailty improvements were modest.

The drug did best on one measure. The researchers defined a "responder" as someone who improved on both HbA1c and frailty. Empagliflozin had the highest responder rate. The diet and exercise arms were substantially less costly. On a costeffectiveness analysis built around the responder measure, the lifestyle arms cost less but were less effective.

A second analysis gave a different picture. It used quality-adjusted life years, or QALYs, which combine length of life and quality of life into one number. The team estimated QALYs from SF-12 questionnaire data, using a validated mapping method. On this measure, both the diet and the exercise interventions were "economically dominant". That means they cost less and produced more QALYs than the drug under current pricing. The diet had the highest probability of being cost-effective across conventional willingness-to-pay thresholds.

The authors tested how sturdy these conclusions were. The responder-based results were sensitive to assumptions about drug pricing. The QALY-based results held up comparatively well. The study team used adjusted regression models, propensity score weighting and probabilistic sensitivity analyses.

The limits matter. The follow-up lasted only 10 weeks, and the sample was small. The authors say the results should not be extrapolated to long-term comparative effectiveness. They point in particular to the established long-term heart and kidney benefits of SGLT2 inhibitors, which a 10-week study cannot capture.

The authors conclude that treatments with similar short-term clinical results can differ in economic and population health value. In the short term, they say, lifestyle strategies had more favourable cost–utility profiles. That is a statement about value over 10 weeks. It is not a finding that lifestyle changes are better than medication over the long run.

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Longer trials that follow older adults with diabetes for years, and that track heart, kidney and frailty outcomes alongside costs, would show whether the short-term value seen here lasts.

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