Preventing type 2 diabetes

Short Text

Preventing type 2 diabetes: population and community-level interventions in high-risk groups and the general population

Introduction

In this pathway, early intervention to prevent type 2 diabetes is considered 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 recommendations will benefit adults aged up to 74, in particular those from black and minority ethnic groups and those from lower socioeconomic groups.
Prevention involves maintaining or achieving a healthy weight, by balancing 'calories in' (from food and drink) and 'calories out' (from being physically active).
Dietary and physical activity interventions aimed at individuals can halve the number with impaired glucose tolerance who go on to develop type 2 diabetesGillies CL, Abrams KR, Lambert PC et al. (2007) Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ 334: 299-307..
However, the greatest impact on the levels – and associated costs – of type 2 diabetes is likely to be achieved by addressing these behavioural risk factors in whole communities and populationsHarding A, Griffin SJ, Wareham NJ (2006) Population impact of strategies for identifying groups at high risk of type 2 diabetes. Preventative Medicine 42 (5): 364-8..

Source guidance

The NICE guidance that was used to create the pathway.
Preventing type 2 diabetes: population and community interventions. NICE public health guidance 35 (2011)

Quality standards

Quality statements

Effective interventions library

Successful effective interventions library details

Implementation

Assessment tools

The baseline and self-assessment tools are Excel spreadsheets that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
Preventing type 2 diabetes - population and community interventions: self-assessment tool

Costing support

Costing support includes national cost impact reports that summarise the national costs and savings and discuss the assumptions used; costing templates to assess the impact on local budgets; and costing statements when the impact is not significant or impossible to quantify at a national level.
Preventing type 2 diabetes - population and community interventions: costing statement

Slide sets

Slide sets provide a framework for discussion and assist in local dissemination of the guidance. The slides contain the key messages from NICE guidance and can be tailored for local presentations.
Preventing type 2 diabetes - population and community interventions: slide set

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.

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.

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 obesity guidance. For example, although some South Asian 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.

Supporting behaviour changeThis is an edited extract from Behaviour change (2007). NICE public health guidance 6. It should be read in conjunction with those recommendations.

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.
  • 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.

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, .
Factors which influence someone's risk of type 2 diabetes include: weight, waist circumference, age, physical activity and whether or not they have a previous history of gestational diabetes or a family history of type 2 diabetes.
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.
25 October 2011 minor maintenance updates

Supporting information

The national recommendations on physical activity for everyone are:
  • To achieve general health benefits: accumulate at least 30 minutes of at least moderate intensity physical activity on 5 or more days of the weekDepartment of Health (2004) At least five a week: evidence on the impact of physical activity and its relationship to health. London: The Stationery Office..
  • 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.

Glossary

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.
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 6.5% (48 mmol/mol) for HbA1c as the cut-off point for diagnosing type 2 diabetes in non-pregnant adults.
Impaired glucose tolerance is characterised by blood glucose levels higher than the normal limit 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?..
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.
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.
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.
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.
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.

Preventing type 2 diabetes

Preventing type 2 diabetes

Type of recommendation

What type of recommendation are you interested in?

Strategy, policy and commissioning to prevent type 2 diabetes

View the 'National strategy, policy and commissioning to prevent type 2 diabetes' path

Local action

View the 'Local action to prevent type 2 diabetes, including strategy, policy and commissioning' path

Training to promote a healthy lifestyle

Training to promote a healthy lifestyle

Training to promote a healthy lifestyle

Who should take action?

Commissioners and providers of national and local public health services in partnership with:
  • royal colleges and professional associations, further and higher education training institutions, and other organisations responsible for competencies and continuing professional development programmes for health professionals
  • other local authority departments including education and leisure services
  • voluntary sector, not-for-profit and non-governmental practitioners
  • the commercial sector.

What action should be taken?

Ensure training programmes for those responsible for, or involved in, promoting a healthy lifestyle cover:
  • diversity, including cultural, religious and economic issues, delivering health promotion interventions in a non-judgemental way, and meeting age, gender, language and literacy needs
  • how to identify communities at increased risk of developing type 2 diabetes
  • strategies for changing behaviour (for those devising health promotion interventions)
  • how to provide advice on healthy eating, physical activity and weight management in relation to the prevention of type 2 diabetes and related non-communicable diseases
  • how to challenge stigma and dispel myths around type 2 diabetes.
Ensure those responsible for, or involved in, promoting healthy lifestyle choices are given time and support to develop and maintain the skills described above.
Monitor health professionals' knowledge and awareness of how to encourage people to adopt a healthy lifestyle. Use, for example, personal development plans and annual reviews. Ensure they keep their knowledge and practical skills up-to-date.
Ensure training programmes for all health professionals (including undergraduate, continuing professional development and, where appropriate, post-graduate training):
  • incorporate the knowledge and skills needed to ensure health promotion interventions are culturally sensitive
  • cover nutrition, physical activity and weight management in relation to the prevention of type 2 diabetes
  • are focused, structured and based on proven models and evaluation techniques
  • offer opportunities to practice new skills in the community
  • encourage the sharing of knowledge among colleagues
  • provide up-to-date information on topics such as nutrition advice and physical activity (information should be updated regularly).

Source guidance

Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-node
PH35

Type 2 diabetes treatment

View the 'Managing type 2 diabetes' path

Diet

View the 'Diet overview' path

Paths in this pathway

Pathway created: August 2011 Last updated: October 2011

Copyright © 2012 National Institute for Health and Clinical Excellence. All Rights Reserved.

Recently viewed

(Clear all)