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Preventing type 2 diabetes overview

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Preventing type 2 diabetes

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

22 July 2015 Obesity: prevention and lifestyle weight management in children and young people (NICE quality standard QS94) added 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

22 July 2015 Obesity: prevention and lifestyle weight management in children and young people (NICE quality standard QS94) added 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

Vending machines

This quality statement is taken from the obesity prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers, using vending machines in local authority and NHS venues can buy healthy food and drink options.

Rationale

The environment in which people live influences their ability to achieve and maintain a healthy weight. Local authorities and NHS organisations can set an example by providing healthy food and drink choices at their venues. They can influence venues in the community (such as leisure centres) and services provided by commercial organisations to have a positive impact on the diet of children and young people using them. Legal requirements govern the provision of food in local authority-maintained schools (see the Department of Education’s Standards for school food in England for further details). Schools are therefore not covered by this quality statement.

Quality measures

Structure
Evidence that local authorities and NHS organisations provide, or make contractual arrangements for the provision of, healthy food and drink options in any vending machines in their venues that are used by children and young people.
Data source: Local data collection.
Process
Proportion of local authority and NHS venues used by children and young people with vending machines that have vending machines that contain healthy food and drink options.
Numerator – the number in the denominator that have vending machines that contain healthy food and drink options.
Denominator – the number of local authority and NHS venues used by children and young people with vending machines.
Data source: Local data collection.

What the quality statement means for local authorities and NHS organisations

Local authorities and NHS organisations ensure that any vending machines in their venues that are used by children and young people offer healthy food and drink options.

What the quality statement means for children and young people and their parents or carers

Children and young people (and their parents or carers) have a choice of healthy food and drink options available from vending machines in local authority and NHS venues (for example hospitals, clinics and leisure centres).

Source guidance

Definitions of terms used in this quality statement

Healthy food and drink
Food and drink that helps people to meet the eatwell plate guidance recommendations, and which does not contain high levels of salt, fat, saturated fat or sugar. Public Health England’s Healthier, more sustainable catering: information for those involved in purchasing food and drink provides definitions for low, medium and high levels of fat, saturates, sugars and salt per portion/serving size for food and drink. The Change4Life website gives suggestions for healthy food and drink alternatives. [Expert consensus]

Nutritional information at the point of choosing food and drink options

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers, see details of nutritional information on menus at local authority and NHS venues.

Rationale

Providing details about the nutritional content of food will allow children and young people (and their parents or carers) to make an informed choice when choosing meals. This information will help people achieve or maintain a healthy weight by enabling them to manage their daily nutritional intake.

Quality measures

Structure
Evidence that local authorities and NHS organisations ensure that information on the nutritional content of meals is included on menus at venues that are used by children and young people.
Data source: Local data collection.

What the quality statement means for local authorities and NHS organisations

Local authorities and NHS organisations ensure that their venues used by children and young people provide details about the nutritional content of menu items.

What the quality statement means for children and young people and their parents or carers

Children and young people (and their parents or carers) selecting meals in catering facilities in local authority and NHS venues have information on the nutritional content of meals to help them choose.

Source guidance

Definitions of terms used in this quality statement

Nutritional information
This includes details on the calorie content of meals as well as information on the fat, saturated fat, salt and sugar content. If the nutritional value of recipes is not known, ingredients should be listed and cooking methods described. [Adapted from expert consensus and NICE guideline PH35, recommendation 8]

Equality and diversity considerations

Information needs to be available in a variety of languages and formats to ensure that it is accessible to people of all ages and meets the needs of the community. Nutritional information should be available in a variety of formats appropriate to the target audience. The format of this information should be suitable for children and young people with sensory impairment.

Prominent placement of healthy options

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers, see healthy food and drink choices displayed prominently in local authority and NHS venues.

Rationale

Local authorities and NHS organisations can set an example by ensuring that healthy food and drink choices are promoted in their venues. Prominent positioning will help to ensure that children and young people (and their parents or carers) will consider healthier options when they are choosing food and drink.

Quality measures

Structure
Evidence that local authority and NHS venues used by children and young people make arrangements to display healthy food and drink options in prominent positions.
Data source: Local data collection.
Outcome
Sales of healthy food and drink options.
Data source: Local data collection.

What the quality statement means for local authorities and NHS organisations

Local authorities and NHS organisations ensure that healthy food and drink choices are displayed in prominent positions in their venues.

What the quality statement means for children and young people and their parents or carers

Children and young people (and their parents or carers) can easily find healthy foods and drinks when using catering facilities in local authority or NHS venues.

Source guidance

Definitions of terms used in this quality statement

Healthy food and drink choices
Food and drink that helps people to meet the eatwell plate guidance recommendations, and which does not contain high levels of salt, fat, saturated fat or sugar. Public Health England’s Healthier, more sustainable catering: information for those involved in purchasing food and drink provides definitions for low, medium and high levels of fat, saturates, sugars and salt per portion/serving size for food and drink. The Change4Life website gives suggestions for healthy food and drink alternatives. [Expert consensus] 

Maintaining details of local lifestyle weight management programmes

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers, have access to a publicly available up to date list of local lifestyle weight management programmes.

Rationale

Effective lifestyle weight management programmes for children and young people can be delivered by a range of organisations, in different locations, covering different age groups. The local authority should maintain an up-to-date list of local lifestyle weight management programmes and make it available to the public. Raising awareness of these locally provided programmes is important to ensure that the public, healthcare professionals and other professionals who work with children and young people are aware of the programmes that exist in their area and how to access them. Increased public awareness may lead to more self referrals to the programmes, either by children and young people themselves or their parents or carers. In addition, raised awareness among healthcare professionals such as GPs, school nurses, health visitors and staff involved in the National Child Measurement Programme and the Healthy Child Programme may lead to more direct referrals.

Quality measures

Structure
Evidence that an up to date list of local lifestyle weight management programmes for children and young people is made publically available by the local authority.
Data source: Local data collection.
Outcome
Number of referrals (including self referrals, by children and young people or their parents or carers) to lifestyle weight management programmes.
Data source: Local data collection.

What the quality statement means for providers of lifestyle weight management programmes, healthcare professionals, other professionals who work with children and young people, and local authorities

Providers of lifestyle weight management programmes ensure that they provide local authorities with up to date lists of local lifestyle weight management programmes for children and young people.
Healthcare professionals (such as GPs, dietitians, pharmacists, health visitors, school nurses and staff involved in the National Child Measurement Programme) and other professionals who work with children and young people (such as youth workers, social workers and pastoral care workers, and those who work in schools, colleges, early years organisations, children’s centres and looked-after children’s teams) ensure that they are aware of the lifestyle weight management programmes for children and young people in their area and how to enrol people on them.
Local authorities ensure that they maintain a publicly available up-to-date list of local lifestyle weight management programmes for children and young people.

What the quality statement means for children and young people and their parents or carers

Children and young people (and their parents or carers) are aware of the lifestyle weight management programmes in their area and how they can enrol on them.

Source guidance

Definitions of terms used in this quality statement

Lifestyle weight management programme
Lifestyle weight management programmes focus on diet, physical activity and behaviour change to help people who are overweight or obese. They are usually based in the community and may be run by the public, private or voluntary sector. [Adapted from NICE guideline PH47]

Raising awareness of lifestyle weight management programmes

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people identified as being overweight or obese, and their parents or carers as appropriate, are given information about local lifestyle weight management programmes.

Rationale

Actively raising the possibility of participation in a local lifestyle weight management programme will help to increase the use of these programmes by children and young people identified as being overweight or obese.

Quality measures

Structure
Evidence of written protocols and local arrangements for healthcare professionals and other professionals to give information about local lifestyle weight management programmes to children and young people identified as being overweight or obese, and their parents or carers (as appropriate).
Data source: Local data collection.
Process
Proportion of children and young people identified as being overweight or obese, and their parents or carers as appropriate, who are given information about local lifestyle weight management programmes.
Numerator – the number in the denominator who are given information about local lifestyle weight management programmes.
Denominator – the number of children and young people identified as being overweight or obese, and their parents or carers as appropriate.
Data source: Local data collection.
Outcome
Number of children and young people enrolling in lifestyle weight management programmes.
Data source: Local data collection.

What the quality statement means for healthcare professionals, other professionals who work with children and young people, and commissioners

Healthcare professionals (such as GPs, dietitians, pharmacists, health visitors, school nurses and staff involved in the National Child Measurement Programme) and other professionals who work with children and young people (such as youth workers, social workers and pastoral care workers, and those who work in schools, colleges, early years organisations, children’s centres and looked after children’s teams) ensure that they provide information about local lifestyle weight management programmes to children and young people identified as being overweight or obese, and their parents or carers (as appropriate).
Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that healthcare professionals, and other professionals who work with children and young people, provide information about local lifestyle weight management programmes to children and young people identified as being overweight or obese, and their parents or carers (as appropriate).

What the quality statement means for children and young people and their parents or carers

Children and young people identified as being overweight or obese (and their parents or carers, as appropriate) are given information about local lifestyle weight management programmes, including an explanation of what the programmes involve and how to take part.

Source guidance

Definitions of terms used in this quality statement

Information about local lifestyle weight management programmes
This information should explain what these programmes involve and how people can take part (including whether or not they can self refer). [Adapted from NICE guideline PH47, recommendation 7]
Lifestyle weight management programme
Lifestyle weight management programmes focus on diet, physical activity and behaviour change to help people who are overweight or obese. They are usually based in the community and may be run by the public, private or voluntary sector. [Adapted from NICE guideline PH47]
Other professionals who work with children and young people
These professionals include youth workers, social workers and pastoral care workers, as well as those who work in schools, colleges, early years organisations, children’s centres and looked after children’s teams. [NICE guideline PH47, recommendation 7] 

Family involvement in lifestyle weight management programmes

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Family members or carers of children and young people are invited to attend lifestyle weight management programmes, regardless of their weight.

Rationale

Family members and carers have an important role and responsibility in influencing the environment in which children and young people live. Therefore, actively involving family members and carers in the programme is important to ensure that children and young people receive positive reinforcement and support away from the programme. Involving the family and carers is also likely to make the programme more successful, change behaviour and lifestyle choices and improve BMI over time in children and young people. It may also benefit family members because they may have the same genetic and/or lifestyle risk factors for weight.

Quality measures

Structure
Evidence that providers of lifestyle weight management programmes for children and young people invite family members or carers to attend, regardless of their weight.
Data source: Local data collection.
Process
Proportion of children and young people who attend a lifestyle weight management programme whose family members or carers have been invited to attend.
Numerator – the number in the denominator whose family members or carers have been invited to attend.
Denominator – the number of children and young people who attend a lifestyle weight management programme.
Data source: Local data collection.

Outcome

Family member attendance and involvement in lifestyle weight management programmes.
Data source: Local data collection.

What the quality statement means for providers of lifestyle weight management programmes, healthcare professionals and public health practitioners, and local authorities

Providers of lifestyle weight management programmes for children and young people ensure that they involve family members and carers in the programme and provide services that include the appropriate core components. Weight management programmes should emphasise the importance, and highlight the benefit, of family member involvement and encouragement.
Healthcare professionals and public health practitioners who deliver lifestyle weight management programmes for children and young people encourage the involvement of family members or carers.
Local authorities ensure that they commission lifestyle weight management programmes for children and young people that encourage family members and carers to be actively involved and contain the core components to involve family members. Local authorities require providers to report on how they have engaged family members and carers in the programme as part of their performance management and contract monitoring.

What the quality statement means for families or carers

Family members or carers of children and young people identified as being overweight or obese are encouraged to be involved in the child’s lifestyle weight management programme, regardless of their own weight. This may include receiving training and resources to support changes in behaviour or, if this is not possible, being provided with information on the aims of the programme. Family members are also encouraged to eat healthily and to be physically active, regardless of their weight.

Source guidance

Definitions of terms used in this quality statement

Lifestyle weight management programme
Lifestyle weight management programmes focus on diet, physical activity and behaviour change to help people who are overweight or obese. They are usually based in the community and may be run by the public, private or voluntary sector. [Adapted from NICE guideline PH47]

Equality and diversity considerations

Particular consideration needs to be given when engaging adult men in the programmes because they are often harder to involve than other family members. Consideration also needs to be given to the language needs of the child or young person accessing the programme, as well as their family members or carers. For some families, the child or young person may be the only English speaker in the family.

Evaluating lifestyle weight management programmes

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

Quality statement

Children and young people, and their parents or carers, can access data on attendance, outcomes and the views of participants and staff from lifestyle weight management programmes.

Rationale

It’s important that providers of lifestyle weight management programmes for children and young people measure outcomes of the programmes and make the results available. This will allow commissioners and the general public to monitor and evaluate particular programmes to assess whether they are meeting their objectives and providing value for money. This ensures that any issues with the programmes are identified as early as possible, so that the programmes can be improved, leading to better outcomes for children and young people using the programmes. It will also help children and young people, and their parents or carers, to select lifestyle weight management programmes.

Quality measures

Structure
a) Evidence that commissioners and providers of lifestyle weight management programmes for children and young people jointly agree the key performance indicators to be collected for monitoring and evaluation.
Data source: Local data collection.
b) Evidence that commissioners and providers of lifestyle weight management programmes for children and young people have used data from monitoring and evaluation to amend and improve programmes.
Data source: Local data collection.
Process
a) Proportion of children and young people recruited to a lifestyle weight management programme that has data on attendance, outcomes and the views of participants and staff collected at recruitment and completion.
Numerator – the number in the denominator that has data on attendance, outcomes and the views of participants and staff collected at recruitment and completion.
Denominator – the number of children and young people recruited to a lifestyle weight management programme.
Data source: Local data collection.
b) Proportion of children and young people who complete a lifestyle weight management programme that has data on outcomes collected at 6 months after completion of the programme.
Numerator – the number in the denominator that has data on outcomes collected at 6 months after completion of the programme.
Denominator – the number of children and young people who complete a lifestyle weight management programme.
Data source: Local data collection.
c) Proportion of children and young people who complete a lifestyle weight management programme that has data on outcomes collected at 1 year after completion of the programme.
Numerator – the number in the denominator that has data on outcomes collected at 1 year after completion of the programme.
Denominator – the number of children and young people who complete a lifestyle weight management programme.
Data source: Local data collection.

What the quality statement means for providers of lifestyle weight management programmes and commissioners

Providers of lifestyle weight management programmes for children and young people ensure that they collect and report data to monitor and evaluate the programme.
Commissioners (including directors of public health, public health teams, local authority commissioners and clinical commissioning groups) ensure that sufficient resources are dedicated to monitoring and evaluation, that they evaluate lifestyle weight management programmes for children and young people using data on outcomes, and use the data to amend and improve the programme.

What the quality statement means for children and young people and their parents or carers

Children and young people (and their parents or carers) attend lifestyle weight management programmes that are regularly monitored and evaluated so that the programmes can be improved.

Source guidance

Definitions of terms used in this quality statement

Data on attendance, outcomes and the views of participants and staff
The data to be collected include:
  • Numbers recruited, percentage completing the programme and percentage followed up at 6 months and at 1 year after completing the programme.
  • For all those recruited, BMI and BMI z score measured at:
    • recruitment
    • completion of the programme
    • 6 months after completing the programme
    • 1 year after completing the programme.
  • referral routes
  • outcomes related to the aim of the programme and related to factors that can support or contribute to a reduction in BMI, for example:
    • improvements in diet
    • improvements in physical activity
    • reduction in sedentary behaviour
    • improvements in self-esteem.
  • variations in outcomes, according to age, gender, ethnicity and socioeconomic status
  • views of participants (including children, young people and their families and/or carers who have participated in the programme, as well as those who did not complete the programme)
  • views of staff delivering the programme. [Adapted from (NICE guideline PH47, recommendations 2 and 15]
(See Public Health England’s Standard evaluation framework for weight management interventions for examples of other possible outcome measures.)

Lifestyle weight management programme

Lifestyle weight management programmes focus on diet, physical activity and behaviour change to help people who are overweight or obese. They are usually based in the community and may be run by the public, private or voluntary sector. [Adapted from NICE guideline PH47]

Equality and diversity considerations

When monitoring and evaluating lifestyle weight management programmes, information also needs to be captured to ensure that the programmes are suitable for minority groups, for example, by family origin, religion and disability, and that reasonable adaptations are being made to the programmes to make them accessible to these groups and to assess their impact on health inequalities.

Reducing sedentary behaviour: placeholder statement

This quality statement is taken from the obesity: prevention and lifestyle weight management in children and young people quality standard. The quality standard defines clinical best practice in obesity prevention and lifestyle weight management in children and young people and should be read in full.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence based guidance to be developed in this area.

Rationale

Decreasing the levels of sedentary behaviour in children and young people is a different issue to increasing physical activity in this group, as noted in Start active, stay active: a report on physical activity from the four home countries' Chief Medical Officers. There is a need to specify interventions and actions that can be carried out to achieve a reduction in sedentary behaviour in children and young people and also methods that can be used to easily and successfully measure sedentary activity.

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Effective interventions library

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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.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

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: July 2015

© NICE 2015

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