Practice Guidelines

Risk identification and interventions to prevent type 2 diabetes in adults at high risk: summary of NICE guidance

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e4624 (Published 12 July 2012) Cite this as: BMJ 2012;345:e4624
  1. Hilary Chatterton, technical analyst1,
  2. Tricia Younger, associate director2,
  3. Alastair Fischer, technical adviser-health economics2,
  4. Kamlesh Khunti, professor of primary care diabetes and vascular medicine3
  5. on behalf of the Programme Development Group
  1. 1National Institute for Health and Clinical Excellence, Manchester, UK
  2. 2National Institute for Health and Clinical Excellence, London WC1V 6NA, UK
  3. 3Biological Sciences and Psychology Department of Health Sciences, University of Leicester, Leicester, UK
  1. Correspondence to: T Younger tricia.younger{at}nice.org.uk

Almost three million people in the United Kingdom have diabetes and 850 000 people may be undiagnosed. It has been estimated that five million people will have diabetes by 2025. About 90% of them will have type 2 diabetes.1

About 15% (one in seven) of adults have impaired glucose regulation,2 and an estimated 5-12% of these people develop type 2 diabetes each year.1 People with impaired glucose regulation are 5-15 times more likely to develop type 2 diabetes than those with normal glucose values.3 Successful prevention requires population based action for the whole community,4 together with interventions targeted at those at greatest risk.

This article summarises the recommendations from the National Institute for Health and Clinical Excellence (NICE) on the identification and management of type 2 diabetes in people aged 18 or more who are at high risk.5

Recommendations

NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When limited evidence is available, recommendations are based on expert testimony and the Programme Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Risk identification: stage 1

  • Use a risk assessment tool, validated for use in UK populations. This can be a self assessment or opportunistic assessment at general practice surgeries, health centres, community pharmacies, dental surgeries, occupational health departments, optical practices and eye hospitals, prison health services and workplaces, job centres, local authority leisure facilities, shops, libraries, faith centres, residential and care homes, and day centres.

  • General practitioners and other primary healthcare professionals should use a validated computer based risk assessment tool to identify people on their practice register at high risk of type 2 diabetes. Risk factors include increasing age, ethnicity (South Asian, African-Caribbean, Chinese, or black African descent), being overweight or obese, having a first degree relative with type 2 diabetes, having had a low birth weight, and having a sedentary lifestyle. Certain medical conditions can increase the risk of type 2 diabetes, including cardiovascular disease, hypertension, stroke, polycystic ovary syndrome, a history of gestational diabetes, and mental health problems. In addition, people with learning disabilities and those attending emergency departments, emergency medical admission units, vascular and renal surgery units, and ophthalmology departments may be at high risk.

  • The tool should use data that are routinely available from patients’ electronic health records. If a computer based risk assessment tool is not available, the healthcare professional should provide a validated self assessment questionnaire.

  • Pharmacists, opticians, occupational health nurses, and community leaders should either offer a validated self assessment questionnaire or provide information on how to access specific validated online self assessment tools to the following groups of people:

    • -Adults, other than pregnant women, who are aged 40 years or more

    • -People of South Asian and Chinese descent aged 25-39 years, except for pregnant women

    • -Adults with conditions that increase the risk of type 2 diabetes.

  • Advise people with a high risk score to contact their GP or practice nurse for a blood test.

[All the above recommendations are based on moderate quality evidence from cohort and cross sectional studies, in addition to expert testimony]

Risk identification: stage 2

  • Trained healthcare professionals should offer venous blood tests (fasting plasma glucose or glycated haemoglobin (HbA1c)) to adults with high risk scores. Consider a blood test for those aged 25 years or more of South Asian or Chinese descent whose body mass index (BMI) is greater than 23. [Based on moderate quality evidence from cohort and cross sectional studies, expert testimony, and the experience and opinion of the Programme Development Group (PDG)]

  • For people whose fasting plasma glucose is 7.0 mmol/L or above, or whose HbA1c is 48 mmol/mol (6.5%) or above, but who have no symptoms of type 2 diabetes, offer a second blood test to identify possible type 2 diabetes. This test may be a fasting plasma glucose, HbA1c, or an oral glucose tolerance test, according to World Health Organization criteria.6 [Based on economic analysis, expert consensus guidance, and the experience and opinion of the PDG]6 7

Interventions for people at low and moderate risk

The flowchart (figure) outlines the recommendations and indicates interventions for people at various levels of risk.

Figure1

Flowchart outlining the possible interventions for people at low and moderate risk of type 2 diabetes. FPG=fasting plasma glucose; HbA1c=glycated haemoglobin

Intensive lifestyle change programmes for people at high risk

  • Offer a quality assured intensive programme of lifestyle change that is culturally sensitive (figure) and has ongoing tailored support. The programme should be aimed at encouraging people to:

    • -Undertake a minimum of 150 minutes of “moderate intensity” physical activity a week

    • -Gradually lose weight to reach and maintain a BMI within the healthy range

    • -Increase consumption of whole grains, vegetables, and other foods that are high in dietary fibre

    • -Reduce the total amount of fat in their diet

    • -Eat less saturated fat.

  • These programmes may be delivered to groups of 10-15 people who meet at least eight times over 9-18 months. [Based on high quality systematic reviews and evidence from randomised controlled trials and follow-up studies]

  • Participants should have at least 16 hours of contact time within a group, on a one to one basis, or using a mixture of both approaches. [Based on high quality evidence from randomised controlled trials and follow-up studies]

  • Offer follow-up sessions at regular intervals (for example, every three months) for at least two years after the initial intervention period. For those attending group programmes, larger group sizes may be feasible for these maintenance sessions. [Based on high quality systematic reviews and evidence from randomised controlled trials and follow-up studies]

  • Use behavioural change techniques to support lifestyle change. Prompt participants to set achievable and personally relevant short term and long term goals. For example, a realistic initial target, which would help reduce the risk of type 2 diabetes and provide other health benefits, would be for participants to lose 5-10% of their weight in one year. [Based on high quality systematic reviews and analyses of randomised controlled trials]

  • Offer people with a BMI of 30 or more (27.5 or more if South Asian or Chinese) a structured weight loss programme as part of, or a supplement to, the intensive programme of lifestyle change. [Based on high quality systematic reviews, analyses of randomised controlled trials, and the experience and opinion of the PDG]

  • Offer a blood test at least once a year (preferably using the same type of test) and offer to assess weight or BMI for:

    • -People at high risk (a high risk score and fasting plasma glucose of 5.5-6.9 mmol/L or HbA1c of 42-47 mmol/mol (6.0-6.4%))

    • -People without symptoms of type 2 diabetes with a fasting plasma glucose of 7.0 mmol/L or more, or an HbA1c of 48 mmol/mol (6.5%) or greater at their first blood test, but whose second blood test did not confirm a diagnosis of type 2 diabetes. [Based on the experience and opinion of the PDG]

  • Continue to monitor, support, and care for people with a BMI of 30 or more (27.5 or more if South Asian or Chinese) who join slimming clubs or other weight loss programmes. [Based on the experience and opinion of the PDG]

Risk assessment and lifestyle programmes for vulnerable and hard to reach groups

  • These groups may comprise, for example, people with mental health conditions or learning disabilities, people in residential care or prisons.

  • Staff caring for these groups should understand the risk factors for type 2 diabetes and how to increase opportunities for those in their care to be physically active and reduce time spent being sedentary.

  • Educate those involved in buying or preparing food in residential care, day centres, and psychiatric units about what constitutes a healthy diet and how to prepare healthy meals.

  • Provide integrated risk assessment services and intensive programmes of lifestyle change for prisons and residential homes, or arrange for them to be provided in convenient familiar local venues such as day centres, as appropriate.

  • Offer longer appointment times or outreach services to discuss the options after a risk assessment and blood test.

  • Ensure risk assessment services and intensive programmes of lifestyle change are delivered by sensitive, well trained, and dedicated people who are also trained to work with vulnerable groups.

  • Offer to refer travellers and people from other mobile populations to prevention initiatives in the area they are moving to. Alternatively, use electronic communications (such as telephone or text messages) to deliver programmes or provide ongoing support. Ensure confidentiality is maintained.

[All the above recommendations are based on low quality evidence from observational reports and process evaluations, together with the experience and opinion of the PDG]

Metformin

  • Offer standard release metformin to support lifestyle change for adults who are at high risk and:

    • -Whose fasting plasma glucose or HbA1c shows they are still progressing towards type 2 diabetes, despite participation in an intensive programme of lifestyle change, or

    • -Who are unable to participate in such programmes because of a disability or for medical reasons. [Based on high quality evidence from randomised controlled trials]

  • Continue to offer advice on diet and physical activity along with support to achieve their lifestyle and weight loss goals. [Based on high quality evidence from randomised controlled trials]

  • Start with a low dose (such as 500 mg once daily) and then increase gradually as tolerated to 1500-2000 mg daily. If the person is intolerant of standard metformin consider using modified release metformin. [Based on the experience and opinion of the PDG]

  • Prescribe metformin for 6-12 months initially. Monitor fasting plasma glucose or HbA1c at three monthly intervals and stop the drug if no effect is seen. [Based on the experience and opinion of the PDG]

Orlistat

  • Use clinical judgment on whether to offer orlistat to people with a BMI of 28.0 or more as part of an overall plan for managing obesity. Take into account the person’s risk and the level of weight loss and lifestyle change needed to reduce this risk.

  • Advise the person to follow a low fat diet that provides 30% of energy as fat, distributed over three main meals a day. Offer information and regular support from a dietitian or other appropriate healthcare professional.

  • Review the use of orlistat after 12 weeks. If the person has not lost at least 5% of his or her original body weight, use clinical judgment to decide whether to stop the orlistat. However, as with adults who have type 2 diabetes, those at high risk of the condition may lose weight more slowly than average, so less strict goals may be appropriate.

[All the above recommendations are based on high quality evidence from randomised controlled trials and the NICE clinical guideline on obesity CG43] 8

Overcoming barriers

Diabetes risk assessment is already part of the NHS health check programme for eligible adults aged 40-74 years.9 The recommendations for risk assessment tools for other groups are inexpensive, quick, and easy to use. General practices may need to offer some additional appointments to provide blood tests for people who are assessed as high risk but are not eligible for the NHS health check programme. However, testing for HbA1c removes the need for fasting and early morning appointments.

The impact will be greater in some areas. Consequently, the PDG recommends tools that allow staff to prioritise by current risk and to invite people with the highest risk scores for further investigation first.

Clear and timely communication between risk assessment providers and primary care will be essential to coordinate stages 1 and 2 of the risk identification process across different settings.

The guidance presents the opportunity to integrate diabetes risk identification and prevention with existing programmes for other chronic diseases so that the most efficient use is made of scarce resources. There is potential for coordination between the NHS health check programme and community based lifestyle and weight management services.

Further information on the guidance

NICE guidance already exists for the clinical management for type 2 diabetes and its related technologies.10 11 12 The guidance presented here focuses on preventing or delaying the progression from “pre-diabetes” to type 2 diabetes in people at high risk.5 It complements the guidance published in 2011 on community and population level interventions for high risk groups.4

The recommendations provide a coherent route through testing into a range of interventions that depend on the degree of risk (brief advice, brief interventions, and intensive programmes of lifestyle change). It focuses on the risk assessment process and an intensive programme of lifestyle change for people at highest risk. It makes specific recommendations for young people of South Asian and Chinese descent and for vulnerable and hard to reach groups. In the UK, type 2 diabetes is more prevalent in people of South Asian, Chinese, African-Caribbean, and black African descent. People in these groups progress to diabetes at more than twice the rate of white populations.13

The guidance does not cover people younger than 18 years, pregnant women, and people who have already been diagnosed as having type 2 diabetes or other forms of diabetes.

Methods

Development of the guidance followed NICE methodology.14 15 The PDG was composed of specialists in diabetes medicine and endocrinology; GPs; nurses; dietitians; academics who specialise in behaviour change, physical activity, and diabetes prevention; a pharmacist; a health economist; and community members. Three effectiveness and cost effectiveness reviews systematically appraised the evidence on risk identification tools and different assessment strategies, major diabetes prevention programmes, and studies translating the major studies into real world settings. A review of barriers and facilitators to the conduct and uptake of risk assessment and risk management was undertaken. Owing to the limited evidence on vulnerable groups, a report was commissioned that reviewed examples of good practice in risk assessment and management. The PDG considered eight expert papers including presentations on the NHS health check programme, UK approaches to risk reduction, European diabetes prevention programmes, implementation of diabetes prevention in Finland, and community based national programmes in the United States. Health economic modelling was conducted on a range of identification and management strategies for the population as a whole and for people aged 25-39 years of South Asian and Chinese descent.

Fieldwork was carried out to evaluate how relevant and useful these recommendations are for practitioners and how feasible it would be to put them into practice. The PDG revised the guidance in response to comments from stakeholders and feedback from fieldwork.

Future research
  • When identifying and monitoring people at high risk, how effective and cost effective are different combinations of risk assessment tools and blood tests, how effective are they in specific age and ethnic groups, and how often should testing be offered?

  • How effective and cost effective are different components of intensive interventions aimed at lifestyle change and how do they differ between specific age groups and ethnic groups?

  • How effective and cost effective are methods for identifying, assessing, and managing the risk of type 2 diabetes in high risk vulnerable adults, such as frail older adults; homeless people; those with severe mental illness, learning difficulties, or physical disabilities; prisoners; refugees; recent migrants; and travellers?

Notes

Cite this as: BMJ 2012;345:e4624

Footnotes

  • This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

  • The members of the Programme Development Group were Pam Brown, Barry Cassidy, Christine Cottrell, Melanie Davies, Colin Greaves, Jill Hill, Richard Holt, Roger Hughes, Deepa Khatri, Kamlesh Khunti (chair), Sally James, Phil McEwan, Dinesh Nagi, Linda Penn, Claire Phipps, and Thomas Yates.

  • Contributors: All authors contributed to the conception and drafting of this article and revising it critically. They have all approved this version. TY is guarantor.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: KK has NHS Research and Development support for the submitted work; KK receives funding for research and is a member of advisory boards for Novo Nordisk, Eli Lilly, MSD, Bristol Myers, Squibb and Roche; KK’s institution has received funding from the Diabetes Research Network; KK has received sponsorship for attending conferences from Novo Nordisk, Eli Lilly, Sanofi Aventis, Novartis, MSD, BI-Lilly; HC, TY, and AF have no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; none of the authors has other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References