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Preventing type 2 diabetes

About

What is covered

This pathway covers preventing type 2 diabetes using interventions aimed at individuals, populations and communities.
Preventing 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 that 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 under 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.

Updates

Updates to this pathway

17 August 2016 Diabetes in adults (NICE quality standard 6) added.
18 January 2016 Obesity in adults: prevention and lifestyle weight management programmes (NICE quality standard 111) added.
22 July 2015 Obesity in children and young people: prevention and lifestyle weight management programmes (NICE quality standard 94) added.
2 July 2013 BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups (NICE guideline PH46) added.
12 July 2012 Type 2 diabetes: prevention in people at high risk (NICE guideline PH38) added.

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this pathway is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the pathway does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

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 prevention (2006) NICE guideline CG43. The last bullet point is adapted from a recommendation in physical activity in the workplace (2008) NICE guideline PH13.. 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 prevention (2006) NICE guideline CG43.:
  • 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 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 prevention and BMI: preventing ill health and premature death in 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.

World Health Organization 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 WHO. 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, 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 diabetesWHO (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 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: general approaches (2007) NICE guideline PH6. 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 aboveWHO (2011) Use of glycated haemoglobin - HbA~1c~ - in the diagnosis of diabetes mellitus. . A type 2 diabetes diagnosis can also be made byWHO (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 OGTT.
In patients without symptoms, the test must be repeated to confirm the diagnosis using WHO 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 WHO 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

Everything NICE has said on preventing type 2 diabetes in an interactive flowchart

What is covered

This pathway covers preventing type 2 diabetes using interventions aimed at individuals, populations and communities.
Preventing 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 that 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 under 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.

Updates

Updates to this pathway

17 August 2016 Diabetes in adults (NICE quality standard 6) added.
18 January 2016 Obesity in adults: prevention and lifestyle weight management programmes (NICE quality standard 111) added.
22 July 2015 Obesity in children and young people: prevention and lifestyle weight management programmes (NICE quality standard 94) added.
2 July 2013 BMI: preventing ill health and premature death in black, Asian and other minority ethnic groups (NICE guideline PH46) added.
12 July 2012 Type 2 diabetes: prevention in people at high risk (NICE guideline PH38) added.

Sources

NICE guidance and other sources used to create this pathway.
Diabetes in adults (2011 updated 2016) NICE quality standard 6

Quality standards

Quality statements

Preventing type 2 diabetes

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults at high risk of type 2 diabetes are offered a referral to an intensive lifestyle-change programme.

Rationale

Many cases of type 2 diabetes are preventable through changes to a person’s diet and physical activity levels. Evidence-based intensive lifestyle-change programmes can significantly reduce the risk of developing the condition for those at high risk.

Quality measures

Structure
Evidence of local arrangements to ensure that adults at high risk of type 2 diabetes are offered a referral to an intensive lifestyle-change programme.
Data source: Local data collection.
Process
a) Proportion of adults at high risk of type 2 diabetes who are referred to an intensive lifestyle-change programme.
Numerator – the number in the denominator who are referred to an intensive lifestyle-change programme.
Denominator – the number of adults at high risk of type 2 diabetes.
Data source: Local data collection.
b) Proportion of adults at high risk of type 2 diabetes who attend an intensive lifestyle-change programme after a referral.
Numerator – the number in the denominator who attend an intensive lifestyle-change programme.
Denominator – the number of adults at high risk of type 2 diabetes who are referred to an intensive lifestyle-change programme.
Data source: Local data collection.
Outcome
a) Weight loss of participants in intensive lifestyle-change programmes.
Data source: Local data collection.
b) Incidence of type 2 diabetes in adults.
Data source: Local data collection.

What the quality statement means for service providers, health and public health practitioners, and commissioners

Service providers (such as local authorities who provide the NHS Health Check programme) ensure that systems are in place for adults at high risk of type 2 diabetes to be offered a referral to an intensive lifestyle-change programme.
Health and public health practitioners (such as those carrying out diabetes risk assessments and other health checks, GPs and pharmacists) ensure that they offer adults at high risk of type 2 diabetes a referral to an intensive lifestyle-change programme.
Commissioners (such as local authorities and NHS England) ensure that they commission services in which adults at high risk of type 2 diabetes are offered a referral to an intensive lifestyle-change programme.

What the quality statement means for patients, service users and carers

Adults who have been told they are at high risk of getting type 2 diabetes are offered a referral to a programme that will help them to change their lifestyle (for example, by become more physically active and improving their diet) and so reduce their risk.

Source guidance

Definitions of terms used in this quality statement

High risk of type 2 diabetes
A fasting plasma glucose level of 5.5–6.9 mmol/litre or an HbA1c level of 42–47 mmol/mol (6.0–6.4%) indicates that a person is at high risk of type 2 diabetes.
Fasting plasma glucose or HbA1c tests should be offered to adults with high risk scores from a validated computer-based risk-assessment tool or a validated self-assessment questionnaire. A blood test should also be considered for those aged 25 and over of South Asian or Chinese descent whose BMI is greater than 23 kg/m2.
[Adapted from NICE's guideline on Type 2 diabetes: prevention in people at high risk, recommendations 4 and 5]
Intensive lifestyle-change programme
A structured and coordinated range of interventions provided in different venues for people identified as being at high risk of developing type 2 diabetes. It should be local, evidence-based and quality-assured. The aim is to help people to become more physically active and 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.
[Adapted from NICE's guideline on Type 2 diabetes: prevention in people at high risk, recommendation 5 and glossary]

Equality and diversity considerations

Information should be provided in an accessible format (particularly for people with physical, sensory or learning disabilities and those who do not speak or read English) and educational materials should be translated if needed.
Programmes should be offered at times, and in locations, that meet the needs of groups such as older people, people from minority ethnic backgrounds and vulnerable or socially disadvantaged people. Provision should also be made for people who may have difficulty accessing services in conventional healthcare venues.

Structured education programmes for adults with type 2 diabetes

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults with type 2 diabetes are offered a structured education programme at diagnosis.

Rationale

Type 2 diabetes is a progressive long-term medical condition that the person predominantly self-manages. Managing type 2 diabetes involves lifestyle changes, and treatment can be complex. Structured education programmes can help adults with type 2 diabetes to improve their knowledge and skills and also help to motivate them to take control of their condition and self-manage it effectively.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with type 2 diabetes are referred for a structured education programme at diagnosis.
Data source: Local data collection.
Process
a) Proportion of adults with type 2 diabetes who are referred for a structured education programme at diagnosis.
Numerator – the number in the denominator who are referred for a structured education programme at diagnosis.
Denominator – the number of adults newly diagnosed with type 2 diabetes.
Data source: Local data collection. National data are collected in the Quality and Outcomes Framework indicator DM014 and the National Diabetes Audit.
b) Proportion of adults with type 2 diabetes who attend a structured education programme after a referral.
Numerator – the number in the denominator who attend a structured education programme.
Denominator – the number of adults with type 2 diabetes who are referred for a structured education programme at diagnosis.
Data source: Local data collection. National data are collected in the National Diabetes Audit.
c) Proportion of adults with type 2 diabetes who complete a structured education programme.
Numerator – the number in the denominator who complete a structured education programme.
Denominator – the number of adults with type 2 diabetes who attend a structured education programme.
Data source: Local data collection.
Outcome
Patient satisfaction with ability to self-manage their type 2 diabetes after attending a structured education programme.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and community healthcare providers) ensure that systems are in place for adults with type 2 diabetes to be offered a structured education programme at diagnosis.
Healthcare professionals (such as GPs, practice nurses and community healthcare providers) ensure that they offer a structured education programme to adults with type 2 diabetes at diagnosis.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission structured education programmes for adults with type 2 diabetes.

What the quality statement means for patients, service users and carers

Adults with type 2 diabetes are offered a course to help them improve their understanding of type 2 diabetes and how to manage it in their everyday life. This course should be offered at the time of diagnosis.

Source guidance

Definitions of terms used in this quality statement

Structured education programme
Should include the following components:
  • It is evidence-based, and suits the needs of the person.
  • It has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self-manage diabetes.
  • It has a structured curriculum that is theory-driven, evidence-based and resource-effective, has supporting materials, and is written down.
  • It is delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the person, and who are trained and competent to deliver the principles and content of the programme.
  • It is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency.
  • The outcomes are audited regularly.
Further information on these components can be found in the Department of Health's Structured patient education in diabetes: report from the Patient Education Working Group.
Information given to adults with type 2 diabetes should cover aspects of lifestyle modification that may be necessary, such as dietary advice, and weight loss for adults who are overweight.
[Adapted from NICE's guideline on Type 2 diabetes in adults: management, recommendations 1.2.2, 1.3.2 and 1.3.4, and expert opinion]

Equality and diversity considerations

Structured education programmes should meet the cultural, linguistic, cognitive and literacy needs in the local area. Information should be provided in an accessible format (particularly for people with physical, sensory or learning disabilities and those who do not speak or read English) and educational materials should be translated if needed.
Alternative programmes of equal standard should be made available for people unable to participate in group education.

Structured education programmes for adults with type 1 diabetes

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults with type 1 diabetes are offered a structured education programme 6–12 months after diagnosis.

Rationale

Adults with type 1 diabetes need to acquire a large range of new skills and knowledge, such as how to manage their insulin therapy. Patient education enables self-management, which is important in diabetes management. It allows adults with type 1 diabetes to adapt their diabetes management to changes in their daily lives and to maintain a good quality of life. The first few months after diagnosis involve considerable adjustment, so although information should be given from diagnosis, a more intensive structured education programme will be more beneficial 6–12 months after diagnosis.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with type 1 diabetes are referred for a structured education programme 6–12 months after diagnosis.
Data source: Local data collection.
Process
a) Proportion of adults with type 1 diabetes who are referred for a structured education programme 6–12 months after diagnosis.
Numerator – the number in the denominator who are referred for a structured education programme 6–12 months after diagnosis.
Denominator – the number of adults diagnosed with type 1 diabetes in the last 12 months.
Data source: Local data collection. National data are collected in the Quality and Outcomes Framework indicator DM014 and the National Diabetes Audit.
b) Proportion of adults with type 1 diabetes who attend a structured education programme after a referral.
Numerator – the number in the denominator who attend a structured education programme.
Denominator – the number of adults with type 1 diabetes who are referred for a structured education programme.
Data source: Local data collection. National data are collected in the National Diabetes Audit.
c) Proportion of adults with type 1 diabetes who complete a structured education programme.
Numerator – the number in the denominator who complete a structured education programme.
Denominator – the number of adults with type 1 diabetes who attend a structured education programme.
Data source: Local data collection.
Outcome
Patient satisfaction with ability to self-manage their type 1 diabetes after attending a structured education programme.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and secondary care providers) ensure that systems are in place for adults with type 1 diabetes to be offered a structured education programme 6–12 months after diagnosis.
Healthcare professionals (such as GPs, diabetologists and diabetes specialist nurses) ensure that they offer a structured education programme to adults with type 1 diabetes 6–12 months after diagnosis.
Commissioners (clinical commissioning groups) ensure that they commission structured education programmes for adults with type 1 diabetes.

What the quality statement means for patients, service users and carers

Adults with type 1 diabetes are offered a course to help them improve their understanding of type 1 diabetes and how to manage it in their everyday life. This should cover checking their blood glucose levels, using insulin and advice about having a healthy lifestyle. The course should be offered between 6 months and a year after they are diagnosed.

Source guidance

Definitions of terms used in this quality statement

Structured education programme
Should include the following components:
  • It is evidence-based, and suits the needs of the person.
  • It has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self-manage diabetes.
  • It has a structured curriculum that is theory-driven, evidence-based and resource-effective, has supporting materials, and is written down.
  • It is delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the person, and who are trained and competent to deliver the principles and content of the programme.
  • It is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency.
  • The outcomes are audited regularly.
Further information on these components can be found in the Department of Health's Structured patient education in diabetes: report from the Patient Education Working Group.
An example is the DAFNE (dose-adjustment for normal eating) programme.
[Adapted from NICE's guideline on Type 1 diabetes in adults: diagnosis and management, recommendations 1.3.1 and 1.3.4]

Equality and diversity considerations

Structured education programmes should meet the cultural, linguistic, cognitive and literacy needs in the local area. Information should be provided in an accessible format (particularly for people with physical, sensory or learning disabilities and those who do not speak or read English) and educational materials should be translated if needed.
Alternative programmes of equal standard should be made available for people unable to participate in group education.

First intensification of blood glucose lowering therapy in type 2 diabetes

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment are offered dual therapy.

Rationale

Good blood glucose control in people with type 2 diabetes is important for mitigating the risk of microvascular and macrovascular complications associated with hyperglycaemia, such as damage to the eyes, kidneys and nerves. If HbA1c levels are not well controlled with single-drug treatment, it is important to offer intensification of drug treatment, as well as reinforcing advice about diet, lifestyle and adherence to drug treatment and supporting the person to aim for an HbA1c level of 53 mmol/mol (7.0%). A timescale of 6 months allows time to improve diet, lifestyle and adherence to drug treatment, while also ensuring that first intensification is not unnecessarily delayed. Timely first intensification can delay the need for second intensification, which may involve insulin therapy.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with type 2 diabetes are offered dual therapy if their HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment.
Data source: Local data collection.
Process
Proportion of adults with type 2 diabetes who are started on dual therapy when their HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment.
Numerator – the number in the denominator who are started on dual therapy.
Denominator – the number of adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment.
Data source: Local data collection.
Outcome
a) Adults with type 2 diabetes feel supported to aim for an HbA1c level of 53 mmol/mol (7.0%) or less.
Data source: Local data collection.
b) Incidence of diabetes-related complications.
Data source: Local data collection. National data are collected in the National Diabetes Audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and community healthcare providers) ensure that processes are in place so that adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment are offered dual therapy.
Healthcare professionals (such as GPs, practice nurses and community healthcare providers) ensure that they offer dual therapy to adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment. They also reinforce advice about diet, lifestyle and adherence to treatment.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with type 2 diabetes whose HbA1c level is 58 mmol/mol (7.5%) or above after 6 months with single-drug treatment are offered dual therapy.

What the quality statement means for patients, service users and carers

Adults with type 2 diabetes who need medication to control their blood glucose levels usually start off by taking a single medicine. If after 6 months this first medicine doesn’t help or their diabetes gets worse over time, despite advice about diet, lifestyle and taking the medicine properly, they are offered another type of medicine as well as the one they already take.

Source guidance

Definitions of terms used in this quality statement

Dual therapy
Consider dual therapy with:
  • metformin and a DPP-4 inhibitor or
  • metformin and pioglitazoneWhen prescribing pioglitazone, exercise particular caution if the person is at high risk of the adverse effects of the drug. Pioglitazone is associated with an increased risk of heart failure, bladder cancer and bone fracture. Known risk factors for these conditions, including increased age, should be carefully evaluated before treatment: see the manufacturers’ summaries of product characteristics for details. Medicines and Healthcare products Regulatory Agency (MHRA) guidance (2011) advises that ‘prescribers should review the safety and efficacy of pioglitazone in individuals after 3–6 months of treatment to ensure that only patients who are deriving benefit continue to be treated’. or
  • metformin and a sulfonylurea.
If metformin is contraindicated or not tolerated, consider dual therapyBe aware that the drugs in dual therapy should be introduced in a stepwise manner, checking for tolerability and effectiveness of each drug. with
  • a DPP-4 inhibitor and pioglitazone or
  • a DPP-4 inhibitor and a sulfonylurea or
  • pioglitazone and a sulfonylurea.
Treatment with combinations of medicines including sodium–glucose cotransporter 2 (SGLT 2) inhibitors may be appropriate for some people with type 2 diabetes; see the NICE guidance on canagliflozin in combination therapy for treating type 2 diabetes, dapagliflozin in combination therapy for treating type 2 diabetes and empagliflozin in combination therapy for treating type 2 diabetes.
[Adapted from NICE's guideline on Type 2 diabetes in adults: management, recommendations 1.6.25 and 1.6.26]

Equality and diversity considerations

An individualised approach to diabetes care should be taken that is tailored to the needs and circumstances of each adult with type 2 diabetes. The target HbA1c level may need to be relaxed on a case-by-case basis. Examples include adults who have a reduced life expectancy, adults for whom tight blood glucose control poses a high risk of the consequences of hypoglycaemia and adults with significant comorbidities for whom intensive management would not be appropriate. Particular consideration should be given for people who are older or frail.

Referral for adults at moderate or high risk of diabetic foot problems

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults at moderate or high risk of developing a diabetic foot problem are referred to the foot protection service.

Rationale

Referring people at moderate or high risk of developing a diabetic foot problem to the foot protection service allows their feet to be assessed at an early stage and then reassessed at regular intervals. This can reduce the likelihood of them getting foot ulcers or other foot problems.

Quality measures

Structure
Evidence of local arrangements to ensure that adults at moderate or high risk of developing a diabetic foot problem are referred to the foot protection service.
Data source: Local data collection. Contained in the National Diabetes Foot Care Audit.
Process
Proportion of adults at moderate or high risk of developing a diabetic foot problem who are referred to the foot protection service.
Numerator – the number in the denominator who are referred to the foot protection service.
Denominator – the number of adults at moderate or high risk of developing a diabetic foot problem.
Data source: Local data collection.
Outcome
Incidence of foot and lower limb amputations in people with diabetes.
Data source: The National Diabetes Audit collects information on minor and major amputations in people with diabetes.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GPs and community services) ensure that adults at moderate or high risk of developing a diabetic foot problem are referred to the foot protection service.
Healthcare professionals (such as podiatrists, GPs, practice nurses and district nurses) ensure that they refer adults at moderate or high risk of developing a diabetic foot problem to the foot protection service.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults at moderate or high risk of developing a diabetic foot problem are referred to the foot protection service.

What the quality statement means for patients, service users and carers

Adults with diabetes have regular foot checks, and if a check shows that they have a moderate or high risk of having a foot problem related to their diabetes, they are referred to see another healthcare professional in the foot protection service.

Source guidance

Definitions of terms used in this quality statement

Moderate or high risk of developing a diabetic foot problem
Assess the person’s current risk of developing a diabetic foot problem or needing an amputation using the following risk stratification:
  • Moderate risk:
    • deformity or
    • neuropathy or
    • non-critical limb ischaemia.
  • High risk:
    • previous ulceration or
    • previous amputation or
    • on renal replacement therapy or
    • neuropathy and non-critical limb ischaemia together or
    • neuropathy in combination with callus and/or deformity or
    • non-critical limb ischaemia in combination with callus and/or deformity.
[Adapted from NICE's guideline on Diabetic foot problems: prevention and management, recommendation 1.3.6]
Foot protection service
A service for preventing diabetic foot problems, and for treating and managing them in the community. It should be led by a podiatrist with specialist training in diabetic foot problems and have access to healthcare professionals with skills in:
  • diabetology
  • biomechanics and orthoses
  • wound care.
[Adapted from NICE's guideline on Diabetic foot problems: prevention and management, recommendations 1.2.1 and 1.2.2]

Referral for urgent diabetic foot problems

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment.

Rationale

Rapid referral to specialist services for adults with a limb-threatening or life-threatening diabetic foot problem, so that they can be assessed and an individualised treatment plan put in place, can reduce the risk of amputation and death.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment.
Data source: Local data collection.
Process
a) Proportion of presentations of limb-threatening or life-threatening diabetic foot problems that are referred immediately for specialist assessment and treatment.
Numerator – the number in the denominator that are referred immediately for specialist assessment and treatment.
Denominator – the number of presentations of limb-threatening or life-threatening diabetic foot problems.
Data source: Local data collection.
b) Proportion of presentations of limb-threatening or life-threatening diabetic foot problems in which the multidisciplinary foot care service is informed.
Numerator – the number in the denominator in which the multidisciplinary foot care service is informed.
Denominator – the number of presentations of limb-threatening or life-threatening diabetic foot problems.
Data source: Local data collection.
Outcome
Incidence of foot and lower limb amputations in people with diabetes.
Data source: The National Diabetes Audit collects information on minor and major amputations in people with diabetes.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as foot protection services, GPs and community services) ensure that systems are in place so that adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment, and the multidisciplinary foot care service is informed.
Health and social care practitioners (such as podiatrists, GPs, practice nurses and district nurses) ensure that they refer adults with a limb-threatening or life-threatening diabetic foot problem immediately for specialist assessment and treatment, and inform the multidisciplinary foot care service.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission services in which adults with a limb-threatening or life-threatening diabetic foot problem are referred immediately for specialist assessment and treatment, and the multidisciplinary foot care service is informed.

What the quality statement means for patients, service users and carers

Adults with diabetes who have a serious foot problem are sent to hospital immediately, so that they can be assessed and treated straight away. Serious foot problems are those that might result in amputation or even death, and include a diabetic foot ulcer with a fever or any other symptoms of blood poisoning (the medical name for this is sepsis), a problem with the blood supply to the foot, gangrene, or a severe foot or bone infection.

Source guidance

Definitions of terms used in this quality statement

Limb-threatening or life-threatening diabetic foot problem
Limb-threatening and life-threatening diabetic foot problems include:
  • ulceration with fever or any signs of sepsis
  • ulceration with limb ischaemia (see the NICE guideline on lower limb peripheral arterial disease)
  • clinical concern that there is a deep-seated soft tissue or bone infection (with or without ulceration)
  • gangrene (with or without ulceration).
[Adapted from NICE's guideline on Diabetic foot problems: prevention and management, recommendation 1.4.1]
Specialist assessment and treatment
The specialist service should be the multidisciplinary foot care service wherever possible. However, if the multidisciplinary foot care service is not available (for example, if the person presents out of hours) then, in order to avoid any delay in treatment, the person should be referred immediately to acute services and the multidisciplinary foot care service informed.
The multidisciplinary foot care service should be led by a named healthcare professional, and consist of specialists with skills in the following areas:
  • diabetology
  • podiatry
  • diabetes specialist nursing
  • vascular surgery
  • microbiology
  • orthopaedic surgery
  • biomechanics and orthoses
  • interventional radiology
  • casting
  • wound care.
The multidisciplinary foot care service should have access to rehabilitation services, plastic surgery, psychological services and nutritional services.
[Adapted from NICE's guideline on Diabetic foot problems: prevention and management, recommendations 1.2.3 and 1.2.4, and expert opinion]

Inpatient care for adults with type 1 diabetes

This quality statement is taken from the diabetes in adults quality standard. The quality standard defines clinical best practice in diabetes in adults and should be read in full.

Quality statement

Adults with type 1 diabetes in hospital receive advice from a multidisciplinary team with expertise in diabetes.

Rationale

Adults with type 1 diabetes may be admitted to hospital for diabetes-related or unrelated conditions. This can disturb normal routines, affecting carbohydrate intake and insulin therapy, and special regimens may be needed in response to procedures that affect the usual management of diabetes. The person’s expertise in managing their own diabetes should be respected, and the specialist multidisciplinary team has the knowledge to help the person understand how to best to adapt management when in hospital. The person should be supported to continue to self-manage their diabetes and administer their own insulin if they are willing and able and it is safe for them to do so. Input from a multidisciplinary specialist team can reduce the length of hospital stay for adults with type 1 diabetes and improve their experience of hospital.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with type 1 diabetes in hospital receive advice from a multidisciplinary team with expertise in diabetes.
Data source: Local data collection.
Process
Proportion of hospital admissions for adults with type 1 diabetes in which they receive advice from a multidisciplinary team with expertise in diabetes.
Numerator – the number in the denominator in which the person receives advice from a multidisciplinary team with expertise in diabetes.
Denominator – the number of hospital admissions for adults with type 1 diabetes.
Data source: Local data collection. Contained in the National Diabetes Inpatient Audit.
Outcome
a) Length of hospital stay.
Data source: Local data collection.
b) Patient satisfaction that staff met their diabetes needs while in hospital.
Data source: Local data collection. Contained in the National Diabetes Inpatient Audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (hospitals) ensure that adults with type 1 diabetes in hospital receive advice from a multidisciplinary team with expertise in diabetes.
Healthcare professionals (members of the multidisciplinary team) ensure that they provide advice to adults with type 1 diabetes who are in hospital, and enable them to continue to administer their own insulin if they are willing and able and it is safe for them to do so.
Commissioners (clinical commissioning groups) ensure that they commission services in which adults with type 1 diabetes in hospital receive advice from a multidisciplinary team with expertise in diabetes.

What the quality statement means for patients, service users and carers

Adults with type 1 diabetes who go into hospital if they are ill or need an operation get advice from a team of specialists in diabetes, who will respect their expertise in managing their own diabetes. They are supported to carry on injecting their own insulin if they want to and can do so safely, although sometimes intravenous insulin will be needed instead (for example, if they can’t eat or are having an operation that affects blood glucose levels).

Source guidance

Definitions of terms used in this quality statement

Multidisciplinary team with expertise in diabetes
The basic structure of a specialist inpatient diabetes team should comprise:
  • for every 300 beds, at least 1 diabetes inpatient specialist nurse whose focus is predominantly on inpatient care
  • a consultant specialist in diabetes management.
There should also be access to a diabetes specialist:
  • podiatrist
  • dietitian.

Vending machines

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

Quality statement

Adults 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 adults using them.

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.
Data source: Local data collection.
Process
Proportion of local authority and NHS venues with 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 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 offer healthy food and drink options.

What the quality statement means for adults

Adults have a choice of healthy food and drink options available from vending machines in local authority and NHS venues such as 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 follow Public Health England’s eatwell plate advice, and that 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 in adults: prevention and lifestyle weight management programmes quality standard. The quality standard defines clinical best practice in obesity prevention in adults and should be read in full.

Quality statement

Adults see details of nutritional information on menus at local authority and NHS venues.

Rationale

Providing details about the nutritional content of food will allow people 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.
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 provide details about the nutritional content of menu items.

What the quality statement means for adults

Adults selecting meals in catering facilities in local authority and NHS venues such as hospitals, clinics and leisure centres 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 Type 2 diabetes prevention (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 people with sensory impairment.

Prominent placement of healthy options

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

Quality statement

Adults 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 people will consider healthier options when they are choosing food and drink.

Quality measures

Structure
Evidence that local authority and NHS venues 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 adults

Adults can easily find healthy foods and drinks when using catering facilities in local authority or NHS venues such as hospitals, clinics and leisure centres.

Source guidance

Definitions of terms used in this quality statement

Healthy food and drink choices
Food and drink that helps people to meet Public Health England’s eatwell plate advice, and that 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 in adults: prevention and lifestyle weight management programmes quality standard. The quality standard defines clinical best practice in obesity prevention in adults and should be read in full.

Quality statement

Adults have access to a publicly available, up-to-date list of local lifestyle weight management programmes.

Rationale

Effective lifestyle weight management programmes for adults can be delivered by a range of organisations and in different locations. 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 locally provided programmes is important to ensure that the public know about the programmes in their area and how to enrol in them. Increased public awareness may lead to more self-referrals to these programmes.

Quality measures

Structure
Evidence that an up-to-date list of local lifestyle weight management programmes for adults is publicly available.
Data source: Local data collection.
Outcome
Number of self-referrals of overweight or obese adults to locally commissioned lifestyle weight management programmes.
Data source: Local data collection.

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

Providers of lifestyle weight management programmes ensure that they provide local authorities with up-to-date information about local lifestyle weight management programmes for overweight and obese adults.
Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that information about lifestyle weight management programmes is available across all health and care services.
Local authorities ensure that they maintain a publicly available, up-to-date list of local lifestyle weight management programmes for overweight and obese adults.

What the quality statement means for adults

Adults can easily find information about lifestyle weight management programmes in their area and how to enrol in them.

Source guidance

Definitions of terms used in this quality statement

Lifestyle weight management programmes
Lifestyle weight management programmes for overweight or obese adults are multicomponent programmes that aim to reduce a person’s energy intake and help them to be more physically active by changing their behaviour and working towards achievable goals. They should last for at least 3 months, with sessions that are offered at least weekly or fortnightly and include a ‘weigh-in’ at each session. They may include weight management programmes, courses or clubs that:
  • accept adults through self-referral or referral from a health or social care practitioner
  • are provided by the public, private or voluntary sector
  • are based in the community, workplaces, primary care or online.
Although local definitions vary, these are usually called tier 2 services and form part of a comprehensive approach to preventing and treating obesity.
[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53) recommendation 9, glossary and expert opinion]
List of local lifestyle weight management programmes
The list should include details of programmes that have been commissioned by the local authority or clinical commissioning group and other public, private or voluntary evidence-based programmes.
[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53) recommendation 9, glossary and expert opinion]

Equality and diversity considerations

Local authorities should take into account the cultural and communication needs of the local population when providing a publicly accessible list of local lifestyle weight management programmes.

Publishing performance data on local lifestyle weight management programmes

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

Quality statement

Adults can access data on attendance, outcomes and views of participants and staff from locally commissioned lifestyle weight management programmes.

Rationale

It is important that providers of lifestyle weight management programmes 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 adults using the programmes. It will also help adults to select lifestyle weight management programmes.

Quality measures

Structure
a) Evidence that commissioners and providers of lifestyle weight management programmes 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 have used data from monitoring and evaluation to amend and improve programmes.
Data source: Local data collection.
Process
a) Proportion of adults recruited to a locally commissioned lifestyle weight management programme who have information on attendance, outcomes and views of participants and staff collected at recruitment and completion.
Numerator – the number in the denominator who have information on attendance, outcomes and views of participants and staff collected at recruitment and completion.
Denominator – the number of adults recruited to a locally commissioned lifestyle weight management programme.
Data source: Local data collection.
b) Proportion of adults who complete a lifestyle weight management programme who have data on outcomes collected 6 months after completion of the programme.
Numerator – the number in the denominator who have data on outcomes collected 6 months after completion of the programme.
Denominator – the number of adults who complete a lifestyle weight management programme.
Data source: Local data collection.
c) Proportion of adults who complete a lifestyle weight management programme who have data on outcomes collected 1 year after completion of the programme.
Numerator – the number in the denominator who have data on outcomes collected 1 year after completion of the programme.
Denominator – the number of adults who complete a lifestyle weight management programme.
Data source: Local data collection.
Outcome
Improved performance of local lifestyle weight management programmes.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as local authorities and providers of lifestyle weight management programmes) ensure that they publish data on attendance, outcomes and views of participants and staff. Providers of lifestyle weight management programmes should use the data to monitor and evaluate their programmes. Data sharing should be in line with the Department of Health’s information governance and data protection requirements.
Healthcare professionals (such as GPs, dietitians and practice nurses) consider data on attendance, outcomes and views of participants and staff for local lifestyle weight management programmes before offering information or a referral.
Commissioners (such as NHS England, clinical commissioning groups and local authorities) agree key performance indicators for lifestyle weight management programmes providers, and ensure the data are published. Commissioners use the data on attendance, outcomes and views of participants and staff to improve local provision of lifestyle weight management services.

What the quality statement means for adults

Adults can find published information about their local lifestyle weight management programmes, including how many people enrol in them, how much weight people lose and how good people think the programme is.

Source guidance

Definitions of terms used in this quality statement

Lifestyle weight management programmes
Lifestyle weight management programmes for overweight or obese adults are multicomponent programmes that aim to reduce a person’s energy intake and help them to be more physically active by changing their behaviour and working towards achievable goals. They should last for at least 3 months, with sessions that are offered at least weekly or fortnightly and include a ‘weigh-in’ at each session. They may include weight management programmes, courses or clubs that:
  • accept adults through self-referral or referral from a health or social care practitioner
  • are provided by the public, private or voluntary sector
  • are based in the community, workplaces, primary care or online.
Although local definitions vary, these are usually called tier 2 services and form part of a comprehensive approach to preventing and treating obesity.
[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53) recommendation 9, glossary and expert opinion]
Data on attendance, outcomes and views of participants and staff
Providers of lifestyle weight management programmes should use the standard evaluation framework for weight management programmes and validated tools to monitor interventions.
As a minimum, information on participants at the end of the programme should be collected and assessed, in line with the Department of Health's Best practice criteria for weight management services. Details of how each participant’s weight has changed 12 months after the programme is completed should also be collected.
[Weight management: lifestyle services for overweight or obese adults (2014) NICE guideline PH53, recommendation 17]

Equality and diversity considerations

When monitoring and evaluating lifestyle weight management programmes, information also needs to be collected on the programmes’ suitability for minority groups, for example groups with different family origins or religions and groups with disabilities. Reasonable adaptations should be made to the programmes to make them accessible to these groups and to assess their impact on health inequalities.

Raising awareness of lifestyle weight management programmes

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

Quality statement

Adults identified as being overweight or obese are given information about local lifestyle weight management programmes.

Rationale

When adults are identified as being overweight or obese it is important that they are given information about local lifestyle weight management programmes. Actively raising the possibility of participation in one of these programmes will support people who choose to take positive action to lose weight by self-referring to a suitable programme.

Quality measures

Structure
Evidence of local arrangements to give adults who are identified as being overweight or obese information about local lifestyle weight management programmes.
Data source: Local data collection.
Process
Proportion of adults identified as being overweight or obese who are given information about local lifestyle weight management programmes.
Numerator – the number in the denominator who are given information about local weight management programmes.
Denominator – the number of adults identified as being overweight or obese.
Data source: Local data collection. Data on BMI values are included in the Health and Social Care Information Centre care.data extract.
Outcome
a) Number of self-referrals of overweight or obese adults to lifestyle weight management programmes.
Data source: Local data collection.
b) Obesity prevalence.
Data source: Local data collection.
c) Prevalence of obesity-related comorbidities.
Data source: Local data collection. The numbers of people with type 2 diabetes, hypertension and coronary heart disease are shown in the Quality and outcomes framework indicators DM001, HYP001 and CHD001.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers provide information about local lifestyle weight management programmes to adults identified as being overweight or obese.
Healthcare professionals (such as GPs, practice nurses, secondary healthcare professionals, dietitians and community pharmacists) ensure that they provide information about local lifestyle weight management programmes to adults identified as being overweight or obese.
Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that they commission services that provide information about local lifestyle weight management programmes to adults identified as being overweight or obese.

What the quality statement means for adults

Adults who are overweight or obese are given information about local lifestyle weight management programmes, including what the programmes involve and how to take part.

Source guidance

Definitions of terms used in this quality statement

Adults who are overweight or obese
Adults are assessed to see if they are overweight or obese using their body mass index (BMI). The following table shows the cut-off points for a healthy weight or being overweight or obese.
Classification
BMI (kg/m2)
Healthy weight
18.5–24.9
Overweight
25.0–29.9
Obesity I
30.0–34.9
Obesity II
35.0–39.9
Obesity III
40.0 or more
BMI is a less accurate indicator of adiposity in adults who are highly muscular, so it should be interpreted with caution in this group.
Waist circumference can also be used to assess whether someone is at risk of health problems because they are overweight or obese (up to a BMI of 35 kg/m2). For men, a waist circumference of less than 94 cm is low risk, 94–102 cm is high risk and more than 102 cm is very high risk. For women, a waist circumference of less than 80 cm is low risk, 80–88 cm is high risk and more than 88 cm is very high risk.
Using lower BMI thresholds to trigger action to reduce the risk of conditions such as type 2 diabetes has been recommended for adults of black African, African-Caribbean or Asian family origin. The lower thresholds are 23 kg/m2 to indicate increased risk and 27.5 kg/m2 to indicate high risk.

Equality and diversity considerations

Service providers and healthcare professionals should take into account the cultural and communication needs of people who are overweight or obese when giving information about lifestyle weight management programmes.
Healthcare professionals should ensure that people of black African, African-Caribbean or Asian family origin who have higher comorbidity risk factors are given information about lifestyle weight management programmes if they have a BMI of 23 kg/m2 or more.
Providers of lifestyle weight management programmes should have an inclusive approach that encourages people from all backgrounds to participate. This includes using a respectful and non-judgemental approach to engage people. Particular attention should be given to people who may be less likely to participate, such as people with learning difficulties or mental health problems and those from lower socioeconomic groups.
Providers of lifestyle weight management programmes should be able to meet the specific needs of women who are pregnant, planning to become pregnant or are trying to lose weight after pregnancy.

Referral to a lifestyle weight management programme for people with comorbidities

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

Quality statement

Adults identified as overweight or obese with comorbidities are offered a referral to a lifestyle weight management programme.

Rationale

It is important for general practice teams and other healthcare professionals to offer a referral to a local lifestyle weight management programme to adults who are overweight or obese with comorbidities in order to improve their health outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults who are identified as overweight or obese with comorbidities are offered a referral to a lifestyle weight management programme.
Data source: Local data collection.
Process
Proportion of adults who are identified as overweight or obese with comorbidities who are referred to a lifestyle weight management programme.
Numerator – the number in the denominator who are referred to a lifestyle weight management programme.
Denominator – the number of adults who are identified as overweight or obese with comorbidities.
Data source: Local data collection.
Outcome
a) Number of adults who are identified as overweight or obese with comorbidities enrolling in lifestyle weight management services.
Data source: Local data collection.
b) Obesity prevalence among adults with comorbidities.
Data source: Local data collection.
c) Obesity-related comorbidities
Data source: Local data collection. The number of people with type 2 diabetes, hypertension and coronary heart disease is shown in the Quality and outcomes framework indicators DM001, HYP001 and CHD001.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as local authorities and providers of lifestyle weight management programmes) ensure that a referral to a locally commissioned suitable lifestyle weight management programme is offered to adults who are identified as overweight or obese and who have comorbidities.
Healthcare professionals (such as GPs, practice nurses and dietitians) offer a referral to a locally commissioned lifestyle weight management programme to adults who are identified as overweight or obese and who have comorbidities.
Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that adults who are identified as overweight or obese and who have comorbidities are offered a referral to a locally commissioned lifestyle weight management programme and that there is sufficient capacity to meet demand.

What the quality statement means for adults

Adults who are overweight or obese and have other conditions such as type 2 diabetes, high blood pressure, high cholesterol, arthritis, heart disease or sleep apnoea are offered a referral to a local lifestyle weight management programme to help them improve their overall health.

Source guidance

Definitions of terms used in this quality statement

Adults who are overweight or obese
Adults are assessed to see if they are overweight or obese using their body mass index (BMI). The following table shows the cut-off points for a healthy weight or being overweight or obese.
Classification
BMI (kg/m2)
Healthy weight
18.5–24.9
Overweight
25.0–29.9
Obesity I
30.0–34.9
Obesity II
35.0–39.9
Obesity III
40.0 or more
BMI is a less accurate indicator in adults who are highly muscular, so it should be interpreted with caution in this group.
Waist circumference can also be used to assess whether someone is at risk of health problems because they are overweight or obese (up to a BMI of 35 kg/m2). For men, a waist circumference of less than 94 cm is low risk, 94–102 cm is high risk and more than 102 cm is very high risk. For women, a waist circumference of less than 80 cm is low risk, 80–88 cm is high risk and more than 88 cm is very high risk.
Using lower BMI thresholds to trigger action to reduce the risk of conditions such as type 2 diabetes has been recommended for adults of black African, African–Caribbean and Asian family origin. The lower thresholds are 23 kg/m2 to indicate increased risk and 27.5 kg/m2 to indicate high risk.
Adults with comorbidities
Adults with any other comorbidities in addition to being overweight or obese, such as type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia and sleep apnoea.
[Adapted from Obesity: identification, assessment and management (2014) NICE guideline CG189]

Equality and diversity considerations

Healthcare professionals should take into account the cultural and communication needs of adults who are overweight or obese with comorbidities when making a referral to a lifestyle weight management programme.
Healthcare professionals should ensure that people of black African, African-Caribbean or Asian family origin are offered a referral to a lifestyle weight management programme if they have a BMI of 23 kg/m2 or more because of their increased health risk.
Providers of lifestyle weight management programmes should have an inclusive approach that encourages people from all backgrounds to participate. This includes using a respectful and non-judgemental approach. Particular attention should be given to engaging people who may be less likely to participate, such as people with learning difficulties or mental health problems and those from lower socioeconomic groups.
Providers of lifestyle weight management programmes should be able to meet the specific needs of women who are pregnant, planning to become pregnant or are trying to lose weight after pregnancy.

Preventing weight regain

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

Quality statement

Adults about to complete a lifestyle weight management programme agree a plan to prevent weight regain.

Rationale

It is important to ensure that adults who are about to complete a lifestyle weight management programme have a plan to help them maintain a healthy weight and avoid weight regain. This will enable them to self-manage their weight and make it less likely that they will need further lifestyle weight management interventions in the future.

Quality measures

Structure
Evidence of local arrangements to ensure that adults about to complete a lifestyle weight management programme agree a plan to prevent weight regain.
Data source: Local data collection.
Process
Proportion of adults completing a lifestyle weight management programme who agree a plan to prevent weight regain.
Numerator – the number in the denominator who agree a plan to prevent weight regain.
Denominator – the number of adults about to complete a lifestyle weight management programme.
Data source: Local data collection.
Outcome
a) Obesity prevalence.
Data source: Local data collection.
b) Prevalence of obesity-related comorbidities.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (providers of lifestyle weight management programmes) ensure that adults about to complete a lifestyle weight management programme agree a plan to prevent weight regain.
Healthcare professionals (such as GPs, dietitians and practice nurses) ensure that they make referrals to and promote lifestyle weight management programmes that include agreeing a plan to prevent weight regain on completion.
Commissioners (such as NHS England, clinical commissioning groups and local authorities) ensure that a plan to prevent weight regain is agreed with adults who are about to complete a lifestyle weight management programme. This could be provided by the lifestyle weight management programme provider or commissioned separately.

What the quality statement means for adults

Adults who are about to finish a lifestyle weight management programme agree a plan to help them avoid putting weight back on.

Source guidance

Definitions of terms used in this quality statement

Lifestyle weight management programmes
Lifestyle weight management programmes for overweight or obese adults are multicomponent programmes that aim to reduce a person’s energy intake and help them to be more physically active by changing their behaviour and working towards achievable goals. They should last for at least 3 months, with sessions that are offered at least weekly or fortnightly and include a ‘weigh-in’ at each session. They may include weight management programmes, courses or clubs that:
  • accept adults through self-referral or referral from a health or social care practitioner
  • are provided by the public, private or voluntary sector
  • are based in the community, workplaces, primary care or online.
Although local definitions vary, these are usually called tier 2 services and form part of a comprehensive approach to preventing and treating obesity.
[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53) recommendation 9, glossary and expert opinion]
Plan to prevent weight regain
A plan to prevent weight regain should:
• encourage independence and self-management (including self-monitoring)
• identify a suitable weight target that is sustainable in the long term
• identify sources of ongoing support once the programme has ended, such as online resources, support groups, other local services or activities, and family and friends
• include goals to maintain new dietary habits and increased physical activity levels and strategies to overcome any difficulties encountered
• identify dietary habits that will support weight maintenance and are sustainable in the long term
• promote ways of being more physically active and less sedentary which are sustainable in the long term.
[Adapted from Weight management: lifestyle services for overweight or obese adults (NICE guideline PH53) recommendations 9 and 10]

Equality and diversity considerations

Providers of lifestyle weight management programmes should take into account the cultural and communication needs of people who are completing a lifestyle weight management programme when agreeing a plan to prevent weight regain.
Providers of lifestyle weight management programmes should have an inclusive approach that encourages people from all backgrounds to agree a plan to prevent weight regain. This includes using a respectful and non-judgemental approach. Particular attention should be given to engaging people with learning difficulties or mental health issues and those from lower socioeconomic groups.
Providers of lifestyle weight management programmes should be able to meet the specific needs of women who are pregnant, planning to become pregnant or are trying to lose weight after pregnancy when developing a plan to prevent weight regain.

Vending machines

This quality statement is taken from the obesity in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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 in children and young people: prevention and lifestyle weight management programmes 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.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

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

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this pathway is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the pathway does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

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 prevention (2006) NICE guideline CG43. The last bullet point is adapted from a recommendation in physical activity in the workplace (2008) NICE guideline PH13.. 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 prevention (2006) NICE guideline CG43.:
  • 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 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 prevention and BMI: preventing ill health and premature death in 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.

World Health Organization 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 WHO. 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, 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 diabetesWHO (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 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: general approaches (2007) NICE guideline PH6. 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 aboveWHO (2011) Use of glycated haemoglobin - HbA~1c~ - in the diagnosis of diabetes mellitus. . A type 2 diabetes diagnosis can also be made byWHO (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 OGTT.
In patients without symptoms, the test must be repeated to confirm the diagnosis using WHO 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 WHO 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 prevention (2006) NICE guideline CG43..
  • 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 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.
  • 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 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

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.
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.
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) and gestational diabetes (diabetes of pregnancy)This is an edited extract from type 2 diabetes (2006) NICE guideline CG66.
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.
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.
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.
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.
includes adult social care, education, environmental health, planning and public transport
A 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 prevention.
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.
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.
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.
This includes people with severe mental health problems, learning disabilities and/or 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, or who are part of a mobile population such as travellers, asylum seekers and refugees or who are homeless.
In this pathway, the term weight management includes: assessing and monitoring body weight; preventing someone from becoming overweight (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.
World Health Organization

Paths in this pathway

Pathway created: August 2011 Last updated: November 2016

© NICE 2016

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