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Preventing type 2 diabetes overview

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Preventing type 2 diabetes HAI

About

What is covered

This pathway covers recommendations on how to prevent type 2 diabetes using interventions aimed at individuals, populations and communities.
Prevention of type 2 diabetes involves adopting a healthy, balanced diet, achieving and maintaining a healthy weight, being physically active and reducing the time spent being sedentary. Successful prevention involves a comprehensive approach which combines population and community-based interventions with interventions targeted at people who are at high risk.
At the population or community level, action is recommended as part of an integrated package of local measures to promote health and prevent a range of non-communicable diseases, including cardiovascular disease and some cancers. National action is also recommended to address the adverse environmental factors driving the increasing prevalence of type 2 diabetes.
The focus is on early intervention among high-risk groups and the general population (adults aged up to 74, in particular, those from black and minority ethnic groups and those from lower socioeconomic groups).
At an individual level, the recommendations focus on how to identify adults who are at high risk and provide them with a quality-assured, evidence-based, intensive lifestyle-change programme. The recommendations for high risk individuals can be used alongside the NHS Health Check programme.
Align actions to prevent type 2 diabetes with strategies to prevent obesity at a community level to ensure a coherent, integrated approach (see the obesity: working with local communities pathway).

Updates

Updates to this pathway

30 October 2014 IFCC units added for HbA1c levels.
8 September 2014 Minor maintenance updates.
3 September 2014 Minor maintenance updates.
11 March 2014 Minor maintenance updates
27 January 2014 Minor maintenance updates
2 January 2014 Minor maintenance
2 July 2013 With the publication of Body mass index and waist circumference thresholds for intervening to prevent ill health among black, Asian and other minority ethnic groups (NICE PH guidance 46), the following changes have been made.
African-Caribbean and black African have been added to the list of populations that are at increased risk of diabetes at lower BMI thresholds than the white population in:
In addition, WHO public health action points have been added to the pathway information.
28 November 2012 Information about obesity prevention added to:
12 July 2012 Guidance 'Preventing type 2 diabetes: risk identification and interventions for individuals at high risk' PH38 added to this pathway
25 October 2011 Minor maintenance updates

Achieving and maintaining a healthy weight

Everyone should aim to maintain or achieve a healthy weight, to improve their health and reduce the risk of diseases associated with overweight and obesity, such as type 2 diabetes. People should follow the strategies listed belowThe first eleven bullet points in this list are adapted from a recommendation in Obesity (2006). NICE clinical guideline 43. The last bullet point is adapted from a recommendation in Physical activity in the workplace (2008). NICE public health guidance 13.. These may make it easier to maintain a healthy weight by balancing 'calories in' (from food and drink) and 'calories out' (from being physically active):
  • base meals on starchy foods such as potatoes, bread, rice and pasta, choosing wholegrain where possible
  • eat fibre-rich foods such as oats, beans, peas, lentils, grains, seeds, fruit, vegetables, wholegrain bread and brown rice and pasta
  • eat at least five portions of a variety of fruit and vegetables each day, in place of foods higher in fat and calories
  • adopt a low-fat diet
  • avoid increasing fat or calorie intake
  • consume as little as possible of fried food; drinks and confectionery high in added sugars (such as cakes, pastries and sugar-sweetened drinks); and other food high in fat and sugar (such as some take-away and fast foods)
  • minimise calorie intake from alcohol
  • watch the portion size of meals and snacks, and how often they are eating throughout the day
  • eat breakfast
  • make activities they enjoy, such as walking, cycling, swimming, aerobics and gardening, a routine part of life and build other activity into their daily routine – for example, by taking the stairs instead of the lift or taking a walk at lunchtime
  • minimise sedentary activities, such as sitting for long periods watching television, at a computer or playing video games
  • use physically active forms of travel such as walking and cycling.

Effective weight-loss programmes

Effective weight-loss programmes shouldThis is adapted from a recommendation in Obesity (2006). NICE clinical guideline 43.:
  • address the reasons why someone might find it difficult to lose weight
  • be tailored to individual needs and choices
  • be sensitive to the person's weight concerns
  • be based on a balanced, healthy diet
  • encourage regular physical activity
  • expect people to lose no more than 0.5–1 kg (1–2 lb) a week
  • identify and address barriers to change.

Overweight and obesity

A healthy weight in relation to height can be defined using the body mass index (BMI). BMI is calculated from the weight in kilograms divided by the height in metres squared. A BMI of between 18.5–24.9 is classified as a healthy weight. A BMI of 25–29.9 is classified as overweight. There are different degrees of obesity: a BMI of 30–34.9 is classified as obesity I, 35–39.9 is obesity II and a BMI of 40 or more is classified as obesity III.
Being overweight or obese is the main contributing factor for type 2 diabetes. In addition, having a large waist circumference increases the risk of developing type 2 diabetes:
  • Men are at high risk if they have a waist circumference of 94–102 cm (37–40 inches). They are at very high risk if it is more than 102 cm.
  • Women are at high risk if they have a waist circumference of 80–88 cm (31.5–35 inches). They are at very high risk if it is more than 88 cm.
The above classification may not apply to some population groups, as noted in NICE's guidance on obesity and body mass index and waist circumference thresholds for intervening to prevent ill health among black, Asian and other minority ethnic groups.
For example, although some South Asian, African-Caribbean and black African adults or older people may have a BMI lower than the overweight classification, they may still be at greater risk of developing conditions and diseases associated with being overweight or obese.

WHO public health action points

BMIs of 23 kg/m2, 27.5 kg/m2, 32.5 kg/m2 and 37.5 kg/m2 are recommended as 'public health action points' by the World Health Organization. These are the triggers for health professionals to intervene to help Asian people manage their weight through, for example, physical activity and healthy eating.
The categories WHO suggests for people from Asian groups are: 18.5–22.9 kg/m2 (increasing but acceptable risk); 23–27.4 kg/m2 (increased risk); and 27.5 kg/m2 or higher (high risk of developing chronic health conditions).

Cultural appropriateness

Culturally appropriate interventions take account of the community's cultural or religious beliefs and language and literacy skillsNetto G, Bhopal R, Lederle N et al. (2010) How can health promotion interventions be adapted for minority ethnic communities? Five principles for guiding the development of behavioural interventions. Health Promotion International 25 (2): 248-57. by:
  • Using community resources to improve awareness of, and increase access to, interventions. For example, they involve community organisations and leaders early on in the development stage, use media, plan events or make use of festivals specific to black and ethnic minority groups.
  • Understanding the target community and the messages that resonate with them.
  • Identifying and addressing barriers to access and participation, for example, by keeping costs low to ensure affordability, and by taking account of different working patterns and education levels.
  • Developing communication strategies which are sensitive to language use and information requirements. For example, they involve staff who can speak the languages used by the community. In addition, they may provide information in different languages and for varying levels of literacy (for example, by using colour-coded visual aids and the spoken rather than the written word).
  • Taking account of cultural or religious values, for example, the need for separate physical activity sessions for men and women, or in relation to body image, or beliefs and practices about hospitality and food. They also take account of religious and cultural practices that may mean certain times of the year, days of the week, settings, or timings are not suitable for community events or interventions. In addition, they provide opportunities to discuss how interventions would work in the context of people's lives.
  • Considering how closely aligned people are to their ethnic group or religion and whether they are exposed to influences from both the mainstream and their community in relation to diet and physical activity.

Identifying people at high risk of developing type 2 diabetes

In January 2011, the World Health Organization (WHO) recommended that glycated haemoglobin (HbA1c) could be used as an alternative to standard glucose measures to diagnose type 2 diabetes among non-pregnant adults.
HbA1c levels of 48 mmol/mol (6.5%) or above indicate that someone has type 2 diabetes. However, WHO did not provide specific guidance on HbA1c criteria for people at increased risk of type 2 diabetesWorld Health Organization (2011) Use of glycated haemoglobin (HbA~1c~) in the diagnosis of diabetes mellitus. .
A report from a UK expert group on the implementation of the WHO guidance recommends using HbA1c values between 42 and 47 mmol/mol (6.0-6.4%) to indicate that a person is at high risk of type 2 diabetes. The group also recognised that there is a continuum of risk across a range of subdiabetic HbA1c levels – and that people with an HbA1c below 42 mmol/mol (6.0%) may also be at riskJohn WG, Hillson R, Alberti G (2011) Use of haemoglobin A~1c~ (HbA~1c~) in the diagnosis of diabetes mellitus. The implementation of World Health Organization (WHO) guidance. .

Supporting behaviour change

Changing people's health-related behaviour involves:
  • Helping them to understand the short, medium and longer-term consequences of health-related behaviour.
  • Helping them to feel positive about the benefits and value of health-enhancing behaviours and changing their behaviours.
  • Building the person's confidence in their ability to make and sustain changes.
  • Recognising how people's social contexts and relationships may affect their behaviour.
  • Helping people plan changes in terms of easy sustainable steps over time.
  • Identifying and planning for situations that might undermine the changes people are trying to make, and planning explicit 'if-then' coping strategies to maintain changes in behaviour.
  • Encouraging people to make a personal commitment to adopt health-enhancing behaviours by setting (and recording) achievable goals in particular contexts, over a specified time
  • Helping people to use self-regulation techniques (such as self-monitoring, progress review, relapse management and goal revision) to encourage learning from experience
  • Encouraging people to engage the support of others to help them to achieve their behaviour-change goals.
This is an edited extract from Behaviour change: the principles for effective interventions (2007). NICE public health guidance 6. It should be read in conjunction with those recommendations.

Type 2 diabetes

The underlying disorder for type 2 diabetes is usually insulin insensitivity combined with a failure of pancreatic insulin secretion to compensate for increased glucose levels. The insulin insensitivity is usually evidenced by excess body weight or obesity, and exacerbated by over-eating and inactivity. It is commonly associated with raised blood pressure and a disturbance of blood lipid levels. The insulin deficiency is progressive over time, leading to a need for lifestyle change often combined with blood glucose lowering therapy.
Type 2 diabetes is diagnosed in adults who are not pregnant by a glycated haemoglobin (HbA1c) level of 6.5% (48 mmol/mol) or aboveWorld Health Organization (2011) Use of glycated haemoglobin - HbA~1c~ - in the diagnosis of diabetes mellitus. . A type 2 diabetes diagnosis can also be made byWorld Health Organization (2006) Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation.:
  • random venous plasma glucose concentration the same or greater than 11.1 mmol/l; or
  • fasting venous plasma glucose concentration the same or greater than 7.0 mmol/l; or
  • 2-hour venous plasma glucose concentration the same or greater than 11.1 mmol/l 2 hours after 75 g anhydrous glucose in an oral glucose tolerance test (OGTT).
In patients without symptoms, the test must be repeated to confirm the diagnosis using World Health Organization criteria, .
A high risk of type 2 diabetes is indicated in adults who are not pregnant by a glycated haemoglobin (HbA1c) level of 6.0-6.4% (42-47mmol/mol)John WG, Hillson R, Alberti SG (2012) Use of haemoglobin in the diagnosis of diabetes mellitus. The implementation of World Health Organization guidance. . Some adults with a glycated haemoglobin (HbA1c) level of less than 6.0% (42mmol/mol) may still be at risk and should be reviewed and treated as 'at risk'.
Factors which influence someone's risk of type 2 diabetes include: weight, waist circumference, age, physical activity and whether or not they have a family history of type 2 diabetes.
Particular conditions can increase the risk of type 2 diabetes. These include: cardiovascular disease, hypertension, obesity, stroke, polycystic ovary syndrome, a history of gestational diabetes and mental health problems. In addition, people with learning disabilities and those attending accident and emergency, emergency medical admissions units, vascular and renal surgery units and ophthalmology departments may be at high risk.
In addition to these individual risk factors, people from certain communities and population groups are particularly at risk. This includes people of South Asian, African-Caribbean, black African and Chinese descent and those from lower socioeconomic groups.

Short Text

Preventing type 2 diabetes: identifying and supporting individuals at high risk, and population and community-level interventions for high-risk groups and the general population

What is covered

This pathway covers recommendations on how to prevent type 2 diabetes using interventions aimed at individuals, populations and communities.
Prevention of type 2 diabetes involves adopting a healthy, balanced diet, achieving and maintaining a healthy weight, being physically active and reducing the time spent being sedentary. Successful prevention involves a comprehensive approach which combines population and community-based interventions with interventions targeted at people who are at high risk.
At the population or community level, action is recommended as part of an integrated package of local measures to promote health and prevent a range of non-communicable diseases, including cardiovascular disease and some cancers. National action is also recommended to address the adverse environmental factors driving the increasing prevalence of type 2 diabetes.
The focus is on early intervention among high-risk groups and the general population (adults aged up to 74, in particular, those from black and minority ethnic groups and those from lower socioeconomic groups).
At an individual level, the recommendations focus on how to identify adults who are at high risk and provide them with a quality-assured, evidence-based, intensive lifestyle-change programme. The recommendations for high risk individuals can be used alongside the NHS Health Check programme.
Align actions to prevent type 2 diabetes with strategies to prevent obesity at a community level to ensure a coherent, integrated approach (see the obesity: working with local communities pathway).

Updates

Updates to this pathway

30 October 2014 IFCC units added for HbA1c levels.
8 September 2014 Minor maintenance updates.
3 September 2014 Minor maintenance updates.
11 March 2014 Minor maintenance updates
27 January 2014 Minor maintenance updates
2 January 2014 Minor maintenance
2 July 2013 With the publication of Body mass index and waist circumference thresholds for intervening to prevent ill health among black, Asian and other minority ethnic groups (NICE PH guidance 46), the following changes have been made.
African-Caribbean and black African have been added to the list of populations that are at increased risk of diabetes at lower BMI thresholds than the white population in:
In addition, WHO public health action points have been added to the pathway information.
28 November 2012 Information about obesity prevention added to:
12 July 2012 Guidance 'Preventing type 2 diabetes: risk identification and interventions for individuals at high risk' PH38 added to this pathway
25 October 2011 Minor maintenance updates

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Pathway information

Achieving and maintaining a healthy weight

Everyone should aim to maintain or achieve a healthy weight, to improve their health and reduce the risk of diseases associated with overweight and obesity, such as type 2 diabetes. People should follow the strategies listed belowThe first eleven bullet points in this list are adapted from a recommendation in Obesity (2006). NICE clinical guideline 43. The last bullet point is adapted from a recommendation in Physical activity in the workplace (2008). NICE public health guidance 13.. These may make it easier to maintain a healthy weight by balancing 'calories in' (from food and drink) and 'calories out' (from being physically active):
  • base meals on starchy foods such as potatoes, bread, rice and pasta, choosing wholegrain where possible
  • eat fibre-rich foods such as oats, beans, peas, lentils, grains, seeds, fruit, vegetables, wholegrain bread and brown rice and pasta
  • eat at least five portions of a variety of fruit and vegetables each day, in place of foods higher in fat and calories
  • adopt a low-fat diet
  • avoid increasing fat or calorie intake
  • consume as little as possible of fried food; drinks and confectionery high in added sugars (such as cakes, pastries and sugar-sweetened drinks); and other food high in fat and sugar (such as some take-away and fast foods)
  • minimise calorie intake from alcohol
  • watch the portion size of meals and snacks, and how often they are eating throughout the day
  • eat breakfast
  • make activities they enjoy, such as walking, cycling, swimming, aerobics and gardening, a routine part of life and build other activity into their daily routine – for example, by taking the stairs instead of the lift or taking a walk at lunchtime
  • minimise sedentary activities, such as sitting for long periods watching television, at a computer or playing video games
  • use physically active forms of travel such as walking and cycling.

Effective weight-loss programmes

Effective weight-loss programmes shouldThis is adapted from a recommendation in Obesity (2006). NICE clinical guideline 43.:
  • address the reasons why someone might find it difficult to lose weight
  • be tailored to individual needs and choices
  • be sensitive to the person's weight concerns
  • be based on a balanced, healthy diet
  • encourage regular physical activity
  • expect people to lose no more than 0.5–1 kg (1–2 lb) a week
  • identify and address barriers to change.

Overweight and obesity

A healthy weight in relation to height can be defined using the body mass index (BMI). BMI is calculated from the weight in kilograms divided by the height in metres squared. A BMI of between 18.5–24.9 is classified as a healthy weight. A BMI of 25–29.9 is classified as overweight. There are different degrees of obesity: a BMI of 30–34.9 is classified as obesity I, 35–39.9 is obesity II and a BMI of 40 or more is classified as obesity III.
Being overweight or obese is the main contributing factor for type 2 diabetes. In addition, having a large waist circumference increases the risk of developing type 2 diabetes:
  • Men are at high risk if they have a waist circumference of 94–102 cm (37–40 inches). They are at very high risk if it is more than 102 cm.
  • Women are at high risk if they have a waist circumference of 80–88 cm (31.5–35 inches). They are at very high risk if it is more than 88 cm.
The above classification may not apply to some population groups, as noted in NICE's guidance on obesity and body mass index and waist circumference thresholds for intervening to prevent ill health among black, Asian and other minority ethnic groups.
For example, although some South Asian, African-Caribbean and black African adults or older people may have a BMI lower than the overweight classification, they may still be at greater risk of developing conditions and diseases associated with being overweight or obese.

WHO public health action points

BMIs of 23 kg/m2, 27.5 kg/m2, 32.5 kg/m2 and 37.5 kg/m2 are recommended as 'public health action points' by the World Health Organization. These are the triggers for health professionals to intervene to help Asian people manage their weight through, for example, physical activity and healthy eating.
The categories WHO suggests for people from Asian groups are: 18.5–22.9 kg/m2 (increasing but acceptable risk); 23–27.4 kg/m2 (increased risk); and 27.5 kg/m2 or higher (high risk of developing chronic health conditions).

Cultural appropriateness

Culturally appropriate interventions take account of the community's cultural or religious beliefs and language and literacy skillsNetto G, Bhopal R, Lederle N et al. (2010) How can health promotion interventions be adapted for minority ethnic communities? Five principles for guiding the development of behavioural interventions. Health Promotion International 25 (2): 248-57. by:
  • Using community resources to improve awareness of, and increase access to, interventions. For example, they involve community organisations and leaders early on in the development stage, use media, plan events or make use of festivals specific to black and ethnic minority groups.
  • Understanding the target community and the messages that resonate with them.
  • Identifying and addressing barriers to access and participation, for example, by keeping costs low to ensure affordability, and by taking account of different working patterns and education levels.
  • Developing communication strategies which are sensitive to language use and information requirements. For example, they involve staff who can speak the languages used by the community. In addition, they may provide information in different languages and for varying levels of literacy (for example, by using colour-coded visual aids and the spoken rather than the written word).
  • Taking account of cultural or religious values, for example, the need for separate physical activity sessions for men and women, or in relation to body image, or beliefs and practices about hospitality and food. They also take account of religious and cultural practices that may mean certain times of the year, days of the week, settings, or timings are not suitable for community events or interventions. In addition, they provide opportunities to discuss how interventions would work in the context of people's lives.
  • Considering how closely aligned people are to their ethnic group or religion and whether they are exposed to influences from both the mainstream and their community in relation to diet and physical activity.

Identifying people at high risk of developing type 2 diabetes

In January 2011, the World Health Organization (WHO) recommended that glycated haemoglobin (HbA1c) could be used as an alternative to standard glucose measures to diagnose type 2 diabetes among non-pregnant adults.
HbA1c levels of 48 mmol/mol (6.5%) or above indicate that someone has type 2 diabetes. However, WHO did not provide specific guidance on HbA1c criteria for people at increased risk of type 2 diabetesWorld Health Organization (2011) Use of glycated haemoglobin (HbA~1c~) in the diagnosis of diabetes mellitus. .
A report from a UK expert group on the implementation of the WHO guidance recommends using HbA1c values between 42 and 47 mmol/mol (6.0-6.4%) to indicate that a person is at high risk of type 2 diabetes. The group also recognised that there is a continuum of risk across a range of subdiabetic HbA1c levels – and that people with an HbA1c below 42 mmol/mol (6.0%) may also be at riskJohn WG, Hillson R, Alberti G (2011) Use of haemoglobin A~1c~ (HbA~1c~) in the diagnosis of diabetes mellitus. The implementation of World Health Organization (WHO) guidance. .

Supporting behaviour change

Changing people's health-related behaviour involves:
  • Helping them to understand the short, medium and longer-term consequences of health-related behaviour.
  • Helping them to feel positive about the benefits and value of health-enhancing behaviours and changing their behaviours.
  • Building the person's confidence in their ability to make and sustain changes.
  • Recognising how people's social contexts and relationships may affect their behaviour.
  • Helping people plan changes in terms of easy sustainable steps over time.
  • Identifying and planning for situations that might undermine the changes people are trying to make, and planning explicit 'if-then' coping strategies to maintain changes in behaviour.
  • Encouraging people to make a personal commitment to adopt health-enhancing behaviours by setting (and recording) achievable goals in particular contexts, over a specified time
  • Helping people to use self-regulation techniques (such as self-monitoring, progress review, relapse management and goal revision) to encourage learning from experience
  • Encouraging people to engage the support of others to help them to achieve their behaviour-change goals.
This is an edited extract from Behaviour change: the principles for effective interventions (2007). NICE public health guidance 6. It should be read in conjunction with those recommendations.

Type 2 diabetes

The underlying disorder for type 2 diabetes is usually insulin insensitivity combined with a failure of pancreatic insulin secretion to compensate for increased glucose levels. The insulin insensitivity is usually evidenced by excess body weight or obesity, and exacerbated by over-eating and inactivity. It is commonly associated with raised blood pressure and a disturbance of blood lipid levels. The insulin deficiency is progressive over time, leading to a need for lifestyle change often combined with blood glucose lowering therapy.
Type 2 diabetes is diagnosed in adults who are not pregnant by a glycated haemoglobin (HbA1c) level of 6.5% (48 mmol/mol) or aboveWorld Health Organization (2011) Use of glycated haemoglobin - HbA~1c~ - in the diagnosis of diabetes mellitus. . A type 2 diabetes diagnosis can also be made byWorld Health Organization (2006) Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation.:
  • random venous plasma glucose concentration the same or greater than 11.1 mmol/l; or
  • fasting venous plasma glucose concentration the same or greater than 7.0 mmol/l; or
  • 2-hour venous plasma glucose concentration the same or greater than 11.1 mmol/l 2 hours after 75 g anhydrous glucose in an oral glucose tolerance test (OGTT).
In patients without symptoms, the test must be repeated to confirm the diagnosis using World Health Organization criteria, .
A high risk of type 2 diabetes is indicated in adults who are not pregnant by a glycated haemoglobin (HbA1c) level of 6.0-6.4% (42-47mmol/mol)John WG, Hillson R, Alberti SG (2012) Use of haemoglobin in the diagnosis of diabetes mellitus. The implementation of World Health Organization guidance. . Some adults with a glycated haemoglobin (HbA1c) level of less than 6.0% (42mmol/mol) may still be at risk and should be reviewed and treated as 'at risk'.
Factors which influence someone's risk of type 2 diabetes include: weight, waist circumference, age, physical activity and whether or not they have a family history of type 2 diabetes.
Particular conditions can increase the risk of type 2 diabetes. These include: cardiovascular disease, hypertension, obesity, stroke, polycystic ovary syndrome, a history of gestational diabetes and mental health problems. In addition, people with learning disabilities and those attending accident and emergency, emergency medical admissions units, vascular and renal surgery units and ophthalmology departments may be at high risk.
In addition to these individual risk factors, people from certain communities and population groups are particularly at risk. This includes people of South Asian, African-Caribbean, black African and Chinese descent and those from lower socioeconomic groups.

Supporting information

The national recommendations on physical activity for everyone are:
  • Aim to be active daily. Over a week, activity should add up to at least 150 minutes of moderate-intensity activity in bouts of 10 minutes or more. This could be achieved by doing a 30-minute session at least 5 days a week. Undertake physical activity to improve muscle strength on at least 2 days a week. Minimise the amount of time spent being sedentary for long periodsDepartment of Health (2011) Start active, stay active. A report on physical activity for health from the four home countries' chief medical officers..
  • To lose weight: most people may need to do 45–60 minutes of moderate-intensity activity a day, particularly if they do not reduce their energy intakeThis is adapted from a recommendation in Obesity (2006). NICE clinical guideline 43..
  • People who have been obese and have lost weight may need to do 60–90 minutes of activity a day to avoid regaining weight.
  • Keep an up-to-date register of people's level of risk. Introduce a recall system to contact and invite people for regular review, using the two-stage strategy (see identifying those at risk and offer a blood test in this pathway).
  • Offer a reassessment based on the level of risk. Use clinical judgement to determine when someone might need to be reassessed more frequently, based on their combination of risk factors (such as their body mass index [BMI], relevant illnesses or conditions, ethnicity and age).
Professional associations, royal colleges, academic centres, research institutes and community and voluntary sector organisations with an interest in type 2 diabetes prevention should set up a national accreditation body to benchmark, audit, accredit and share effective practice. This body should:
  • Conduct research to establish and implement effective practice.
  • Provide a national, quality-assured training programme and a central database of effective curriculum resources for intensive lifestyle-change programmes. The programme and resources should meet criteria developed by the Department of Health and Diabetes UK Patient Education Working Group (PEWG).
  • Evaluate the effectiveness of the national training and accreditation programme. This includes its impact on practice and outcomes for participants.
GPs and other primary healthcare providers should:
  • Keep an up-to-date register of people's level of risk. Introduce a recall system to contact and invite people for regular review, using the two-stage strategy (see identifying those at risk and offer a blood test in this pathway).
  • Offer a reassessment based on the level of risk. Use clinical judgement to determine when someone might need to be reassessed more frequently, based on their combination of risk factors (such as their body mass index [BMI], relevant illnesses or conditions, ethnicity and age).
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%]), offer a blood test at least once a year (preferably using the same type of test). Also offer to assess their weight or BMI. This includes people without symptoms of type 2 diabetes whose:
  • first blood test measured fasting plasma glucose at 7.0 mmol/l or above, or an HbA1c of 48 mmol/mol (6.5%) or greater, but
  • whose second blood test did not confirm a diagnosis of type 2 diabetes.
At least once a year, review the lifestyle changes people at high risk have made. Use the review to help reinforce their dietary and physical activity goals, as well as checking their risk factors. The review could also provide an opportunity to help people 'restart', if lifestyle changes have not been maintained.

Glossary

For the purpose of this pathway, black, Asian and other minority ethnic groups are defined as follows:
  • South Asian people are immigrants and descendants from Bangladesh, Bhutan, India, Indian-Caribbean (immigrants of South Asian family origin), Maldives, Nepal, Pakistan and Sri Lanka .
  • African-Caribbean/black Caribbean people are immigrants and descendants from the Caribbean islands (people of black Caribbean family origin may also be described as African-American).
  • Black African people are immigrants and descendants from African nations. In some cases, they may also be described as sub-Saharan African or African-American.
  • The phrase other minority ethnic groups refers to people of Chinese, Middle-Eastern and mixed family origin, as follows:
  • Chinese people are immigrants and descendants from China, Taiwan, Singapore and Hong Kong.
  • Middle-Eastern people are immigrants and descendants from Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syria, the United Arab Emirates and Yemen.
  • people of mixed family origin have parents of 2 or more different ethnic groups.
Typically, for diabetes prevention, brief advice might consist of a 5–15 minute consultation. The aim is to help someone make an informed choice about whether to make lifestyle changes to reduce their risk of diabetes. The discussion covers what that might involve and why it would be beneficial. Practitioners may provide written information in a range of formats and languages about the benefits and, if the person is interested in making changes, may discuss how these can be achieved and sustained in the long term.
Brief interventions for diabetes prevention can be delivered by GPs, nurses, healthcare assistants and professionals in primary healthcare and the community. They may be delivered in groups or on a one-to-one basis. They aim to improve someone's diet and help them to be more physically active. A patient-centred or 'shared decision-making' communication style is adopted to encourage people to make choices and have a sense of 'ownership' of their lifestyle goals and individual action plans. Providers of brief interventions should be trained in the use of evidence-based behaviour-change techniques for supporting weight loss through lifestyle change.
Body mass index (BMI) is commonly used to measure whether or not adults are a healthy weight or underweight, overweight or obese. It is defined as the weight in kilograms divided by the square of the height in metres (kg/m2).
A group of people who have common characteristics. Communities can be defined by location, race, ethnicity, age, occupation, a shared interest (such as using the same service), a shared belief (such as religion or faith) or other common bonds. A community can also be defined as a group of individuals living within the same geographical location (such as a hostel, a street, a ward, town or region).
Community champions are inspirational figures, community entrepreneurs, mentors or leaders who 'champion' the priorities and needs of their communities and help them build on their existing skills. They drive forward community activities and pass on their expertise to others. They also provide support, for example, through mentoring, helping people to get appropriate training and by helping to manage small projects.
These tools identify a set of risk characteristics in patient health records. They can be used to interrogate GP patient databases and provide a summary score to indicate someone's level of risk. Examples include the Cambridge diabetes risk score and the Leicester practice score.
Diabetes prevention programmes comprise two integrated components: first, risk identification services and second, intensive lifestyle-change programmes. Participants are acknowledged as the decision-makers throughout the process. Also see 'Intensive lifestyle-change programmes'.
Diabetes is a group of disorders with a number of common features characterised by raised blood glucose. In England the four commonest types of diabetes are:
  • type 1 diabetes
  • type 2 diabetes
  • secondary diabetes (from pancreatic damage, hepatic cirrhosis, endocrinological disease/therapy, or anti-viral/anti-psychotic therapy)
  • gestational diabetes (diabetes of pregnancy)This is an edited extract from Type 2 diabetes (2006). NICE clinical guideline 66.
Diabetes is caused when there is too much glucose in the blood and the body cannot use it as 'fuel' because the pancreas does not produce any or sufficient insulin to help it to enter the body's cells. Alternatively, the problems may be caused because the insulin produced may not work properly (insulin resistance).
Glucose comes from digesting carbohydrate and is also produced by the liver. Carbohydrate comes from many different kinds of food and drink, including starchy foods such as bread, potatoes and chapatis; fruit; some dairy products; sugar and other sweet foodsDiabetes UK (2010) Guide to diabetes: what is diabetes?..
Glycated haemoglobin (HbA1c ) forms when red cells are exposed to glucose in the plasma. The HbA1c test reflects average plasma glucose over the previous eight to 12 weeks. Unlike the oral glucose tolerance test, an HbA1c test can be performed at any time of the day and does not require any special preparation such as fasting. HbA1c is a continuous risk factor for type 2 diabetes. This means there is no fixed point when people are or are not at risk. The World Health Organization recommends a level of 48 mmol/mol (6.5%) for HbA1c as the cut-off point for diagnosing type 2 diabetes in non-pregnant adults.
Impaired fasting glucose (IFG) is defined as a fasting plasma glucose between 6.1 and 6.9 mmol/l.
This is a risk factor for future diabetes and/or other adverse outcomes. The term covers blood glucose levels that are above the normal range but are not high enough for the diagnosis of type 2 diabetes. It is used to describe the presence of impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT) as defined by the WHO.
IFG is defined as fasting plasma glucose 6.1 to 6.9 mmol/l IGT is defined as a fasting plasma glucose (FPG) less than 7 mmol/l and 2-hour venous plasma glucose (after ingestion of 75 g oral glucose load) of 7.8 mmol/l or greater and less than 11.1 mmol/l.
Impaired fasting glucose and impaired glucose tolerance can occur as isolated, mutually exclusive conditions or together, that is, fasting plasma glucose between 6.1 and 6.9 mmol/l and 2-hour glucose of 7.8 mmol/l or greater and less than 11.1 mmol/l during the oral glucose tolerance test.
Impaired glucose tolerance is characterised by blood glucose levels higher than normal on a sustained basis, but not high enough to be classified as type 2 diabetes. It occurs in adults with a fasting plasma glucose (FPG) of less than 7.0 mmol/litre and a plasma glucose between 7.8 and 11.0 mmol/litre 2 hours after ingestion of a 75 g oral glucose load (that is, after being given the oral glucose tolerance test). People with IGT may also have impaired fasting glucose.
Insulin is the hormone produced by the pancreas that allows glucose to enter the body's cells, where it is used as fuel for energy. It is vital for lifeDiabetes UK (2010) Guide to diabetes: what is diabetes?..
A structured and coordinated range of interventions provided in different venues for people identified as being at high risk of developing type 2 diabetes (following a risk assessment and a blood test). The aim is to help people become more physically active and to improve their diet. If the person is overweight or obese, the programme should result in weight loss. Programmes may be delivered to individuals or groups (or involve a mix of both) depending on the resources available. They can be provided by primary care teams and public, private or community organisations with expertise in dietary advice, weight management and physical activity.
People recruited from the local community or subgroup of the population to assist in the delivery of an intervention to a group of people who they identify with and are knowledgeable about. They might be peers or from the wider community but they are not professional health or public health workers.
The terms 'high', 'intermediate' and 'low' risk are used to refer to the results from a risk assessment tool. These terms are used instead of specific numerical scores because the tools have different scoring systems. The term 'moderate risk' is used to denote a high risk assessment score where a blood test did not confirm that risk (FPG less than 5.5mmol/l or HbA1c less than 42mmol/mol [6.0%]). A fasting plasma glucose of 5.5–6.9 mmol/l or an HbA1c level of 42–47 mmol/mol [6.0–6.4%] indicates high risk.
Moderate-intensity physical activity requires an amount of effort and noticeably accelerates the heart rate. Examples include brisk walking, housework and domestic chores. On an absolute scale, moderate-intensity is defined as physical activity that is between 3 and 6 metabolic equivalents (METs).
An oral glucose tolerance test involves measuring the blood glucose level after fasting, and then 2 hours after drinking a standard 75 g glucose drink. Fasting is defined as no calorie intake for at least 8 hours. More than one test on separate days is required for diagnosis in the absence of hyperglycaemic symptoms.
This includes:
  • adult social care
  • education
  • environmental health
  • planning
  • public transport.
A body mass index (BMI) of between 18.5–24.9 is classified as a healthy weight. A BMI of 25–29.9 is classified as overweight. A BMI of 30 or above is classified as obese. For further details, refer to NICE's guidance on obesity.
The full range of human movement, from competitive sport and exercise to active hobbies, walking, cycling and the other physical activities involved in daily living.
Pre-diabetes refers to raised (but not in the diabetic range) blood glucose levels (also known as non-diabetic hyperglycaemia, impaired glucose regulation). It indicates the presence of impaired fasting glucose and/or impaired glucose tolerance. People with pre-diabetes are at increased risk of getting type 2 diabetes. They are also at increased risk of a range of other conditions including cardiovascular disease.
This includes primary healthcare teams and specialists who provide advice and support on physical activity, weight management and diet in the NHS and other public, private, voluntary and community organisations.
Particular conditions can increase the risk of type 2 diabetes. These include: cardiovascular disease, hypertension, obesity, stroke, polycystic ovary syndrome, a history of gestational diabetes and mental health problems. In addition, people with learning disabilities and those attending accident and emergency, emergency medical admissions units, vascular and renal surgery units and ophthalmology departments may be at high risk.
A person's socioeconomic group is defined by a combination of their occupation, income level and education level. There is a strong relationship between socioeconomic group and health, with people from lower socioeconomic groups generally experiencing poorer health than those from higher socioeconomic groups.
Type 2 diabetes (previously termed non-insulin dependent diabetes) results from reduced tissue sensitivity to insulin (insulin resistance) and/or reduced insulin production.
Vigorous-intensity physical activity requires a large amount of effort, causes rapid breathing and a substantial increase in heart rate. Examples include running and climbing briskly up a hill. On an absolute scale, vigorous intensity is defined as physical activity that is above 6 metabolic equivalents (METs).
This includes people:
  • with severe mental health problems
  • with learning disabilities
  • with physical or sensory disabilities
  • who live in hostels, nursing and residential homes, residential mental health and psychiatric care units, secure hospitals, prisons and remand centres
  • who are part of a mobile population such as travellers, asylum seekers and refugees
  • who are homeless.
In this pathway, the term weight management includes:
  • assessing and monitoring body weight
  • preventing someone from becoming overweight (body mass index [BMI] of 25–29.9 kg/m2, or 23–27.4 kg/m2 if they are of South Asian or Chinese descent)
  • preventing someone from becoming obese (BMI greater than or equal to 30 kg/m2, or 27.5 kg/m2 or above if they are of South Asian or Chinese descent)
  • helping someone who is overweight or obese to achieve and maintain a 5–10% weight loss and progress to a healthy weight (BMI of 18.5–24.9 kg/m2, or 18.5–22.9 kg/m2 if they are of South Asian or Chinese descent) by adopting a healthy diet and being physically active.

Paths in this pathway

Pathway created: August 2011 Last updated: October 2014

© NICE 2014

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