Ldr deakin:pd 2-col.qxd
Preventing diabetes: will NICE guidance do whatit says on the tin?Trudi Deakin
It is predicted that there will be 552 million people, or groups, respectively. This reduction in incidence equated
one adult in 10, diagnosed with diabetes in the world by
to one case of diabetes prevented for every seven people
2030, a 93% increase almost doubling the number of
with IGT treated for three years in the lifestyle interven-
those diagnosed with the condition in 2010 (285 million
tion group, compared with 14 for the metformin group.
people, prevalence 6.6%).1 In England, the prevalence of
In addition, a review has also indicated that the numbers
people with diabetes in 2011 was 3 million. It is alarming
needed to treat (NNT) to prevent one case of type 2 dia-
that the prevalence in England is set to increase beyond
betes with lifestyle intervention in people at risk of diabetes
the average world prevalence to 9.5%, i.e. 4.6 million is dramatically low at 6.4 (over 1.8 to 4.6 years).10 Further -people by 2030.2 Some 280 million people worldwide, or
more, since patients with the metabolic syndrome have an
6.5% of adults, were estimated to have impaired glucose
increased risk of cardiovascular disease (CVD) and mortal-
tolerance (IGT) in 2011. By 2030, the number of people
ity,11–13 lifestyle interventions in obese patients and those
with IGT is projected to increase to 398 million, or 7.1%
with evidence of hyperglycaemia are likely to be beneficial
in terms of overall health and life expectancy. It has been
The development of type 2 diabetes is often pre-
proposed that control of LDL cholesterol and blood pres-
ceded by a variety of altered metabolic states, including
sure to normal levels in patients with the metabolic syn-
impaired glucose regulation, dyslipidaemia and insulin
drome, could result in preventing 81% of CVD events.14
resistance.3 Although not all people with such metabolicabnormalities progress to diabetes, their risk of develop-
ing the disease is significantly enhanced. However, In the light of these impressive results, the NICE Guidancerandomised clinical trials have demonstrated that type 2
‘Preventing type 2 diabetes: risk identification and inter-
diabetes can largely be prevented through diet and
ventions for individuals at high risk’15 was published in July
2012. This guidance focuses on identifying people at highrisk of type 2 diabetes and on the provision of effective,
cost-effective and appropriate interventions for them. The
In the Swedish Malmo study, increased physical exercise
guidance does not advocate a national screening pro-
and weight loss prevented or delayed type 2 diabetes in
gramme for type 2 diabetes but includes recommendations
patients with IGT to less than half the risk in the control
to remind practitioners that age is no barrier to being at
high risk of, or developing, type 2 diabetes.
In a Chinese study, 577 individuals with IGT were ran-
The 20 NICE recommendations can be used alongside
domised into one of four groups: exercise only, diet only,
the NHS Health Check programme; they are extensive
diet plus exercise, and a control group. The cumulative
and consider: risk assessment and encouraging people
incidence of type 2 diabetes during six years was signifi-
to have an assessment; two-stage risk identification;
cantly lower in the three intervention groups than in the
matching interventions to risk and reassessing risk;
commissioning prevention services; intensive lifestyle-
In the Finnish Diabetes Prevention Study, a 5% reduc-
change programmes, weight management, dietary advice
tion in body weight, achieved through an intensive diet
and physical activity; vulnerable groups; audit and quality
and exercise programme, was associated with a 58%
assurance; training and professional development;
reduction in the risk of developing type 2 diabetes in over-
metformin and orlistat. The recommendations can be
weight middle-aged men and women with IGT.7 The
found online at: http://guidance.nice.org.uk/PH38.
reduction in the risk of progression to diabetes was
A structured and comprehensive literature review of
directly related to the magnitude of the changes in
the international evidence base was undertaken by the
lifestyle; none of the patients who had achieved at least
Programme Development Group (PDG), the NICE proj-
four of the intervention goals by one year developed type
ect team and external contractors in order to develop the
guidance. Where there are gaps in current knowledge, rec-
The US Diabetes Prevention Program (DPP), compar-
ommendations have been made for further research.
ing active lifestyle modification or metformin to standard
Much less is known about the progression to type 2 dia-
lifestyle advice combined with placebo, found that
betes using glycated haemoglobin versus the oral glucose
lifestyle modification reduced the incidence of type 2 dia-
tolerance test (OGTT) as a marker, especially as the HbA1c
betes by 58% in overweight American adults with IGT.9
assessment is much less sensitive to weight change. Thus,
The goal of the programme was to achieve a 7% reduc-
identifying which combination of risk-assessment tools and
tion in body weight and physical activity of moderate
blood tests are the most cost effective and effective at
intensity for at least 150 minutes per week. The cumula-
assessing the risk of type 2 diabetes is recommended.
tive incidence of diabetes was 4.8, 7.8 and 11.0 cases per
Other recommendations for further research include
100 person-years in the lifestyle, metformin and control
determining: the demographic characteristics and rates of
COPYRIGHT 2012 JOHN WILEY & SONS 1
progression to type 2 diabetes among people with a high
Pre-diabetes, diabetes and blood glucose control
risk score but with normal blood glucose levels; the most
• Benefits and challenges of adopting a healthy lifestyle.
cost-effective and effective methods of increasing uptake
• Nutrients, digestion and blood glucose control. • Exploring
of risk assessments; the components of an intensive
pre-diabetes and diabetes. • 7 lifestyle factors. • Health results: what
lifestyle-change programme that contribute most to the
do they mean? • Setting goals to reduce risk. • Diabetes risk score
effectiveness and cost effectiveness of diabetes preventioninterventions; the effectiveness of different types of dietary
and physical activity regimens; and the most effective and
• Energy balance and the ‘Fat Attack’ DVD. • Eating for good
cost-effective methods for identifying, assessing and man-
health – food groups/portions, myths and misconceptions.
aging the risk among high-risk vulnerable groups.
• Physical activity – benefits and FITT (frequency, intensity, time
and type). • Weight management and the 500-calorie deficit. • How to assess what I am eating. • Setting goals to reduce risk
The PDG considered and made provision for the fact thattype 2 diabetes affects people of South Asian, African-
Carbohydrate and saturated fat awareness
Caribbean, Chinese or black African descent up to a
• Carbohydrate – amount and type for good health. • Fat – amount
decade or more earlier than white Europeans. Although
and type for good health. • Quiz to estimate the amount and type
it is unclear what the prevalence of impaired glucose reg-
of carbs and fat in everyday foods. • How to assess my carb and fat
ulation and undiagnosed type 2 diabetes is among black,
Asian and minority ethnic people aged 25–39 years in theUK, they have recommended that risk assessments should
Reading and understanding food labels
be carried out in this age-specific sub-group and that
• Challenges when shopping. • How to read food labels.
health professionals provide advice and monitor accord-
• Understanding the traffic light system and guideline daily
ing to each person's particular risk profile.
amounts (GDAs). • What do the nutritional claims mean?
People identified as being at high risk of developing
• Identifying high and low risk foods. • Setting goals to reduce risk
type 2 diabetes in the international diabetes prevention trials were identified by blood glucose tests, not by risk
My health check
score. The guidance acknowledges that it may not be effec-
• Body mass index. • Waist circumference. • Blood glucose.
tive to intervene with all people identified as being at high
• Blood pressure. • Blood cholesterol. • Troubleshooting for
risk using a risk assessment tool as only a small proportion
prevention. • Revisit food and activity diaries. • Setting goals to
of people may have impaired glucose regulation. It has
therefore issued two stages of risk identification. Stage 1acknowledges that while the risk scores can identify those
Choices and consequences
at high risk and those who may have undiagnosed type 2
• X-PERT Game. • Revisit the health profile. • Questions and
diabetes, they cannot be used to give a diagnosis of type 2
answers. • Setting goals to reduce risk. • Diabetes risk score.
diabetes. If people refuse a blood test, they should be
offered brief advice and/or a place on an intensivelifestyle-change programme instead.
X-POD Programme Summary (website: www.xperthealth.org.uk)
The PDG considered that people over age 74 from all
ethnic groups might benefit from type 2 diabetes risk
in a range of settings, such as community pharmacies,
assessment and prevention as the risk increases with age.
occupational health departments, community and faith-
However, it recognised that many of the risk-assessment
based centres where these people are more likely to visit
tools are not validated for this age group and that comor-
regularly. However, this raises a communication chal-
bidities may prevent participation in lifestyle programmes.
lenge to ensure that the data are passed securely to the
Nevertheless, there is evidence that older people can ben-
person’s GP and that the person is monitored and
efit from being more physically active and improving their
diet, and the recommendations advise that people should
A possible further limitation is the recommendation
not be excluded on the basis of age.
that a variety of practitioners and organisations be
The recommendations acknowledge that not all people
involved in the diabetes prevention services. While this
identified as being at high risk will develop diabetes.
may assist in raising awareness and improving the stan-
However, informing them of the risk will not harm them
dard and continuity of care for all risk groups, it may
and may even have a beneficial effect on their lifestyle.
also cause problems as no single organisation or service
Frequency of follow up is identified and included in the
may take the lead. This could result in unnecessary
recommendations for low, moderate and high-risk individ-
duplication, unstructured care or the service being omit-
uals. This will assist practitioners in providing good quality,
Another communication challenge for practitioners
considering an individual’s level of risk could be in the
limitations of the health care computer systems. These
There has also been consideration of people from lower
have Read codes for recording impaired fasting plasma
socioeconomic groups who may be less likely to attend
glucose and OGTT but there is none for impaired HbA1c
for a risk assessment or a blood test. This has led to a rec-
nor for recording that someone has had a risk assessment,
ommendation that prevention services do not have to be
what their level of risk is, and whether they have been
carried out by GPs or in GP surgeries but can be offered
referred to an intensive lifestyle-change programme. Also,
PRACTICAL DIABETES VOL. 29 NO. 7
although the waist circumference clinical indicator is a
Dr Trudi Deakin,
X-PERT Health registered charity,
very important type 2 diabetes risk factor, it is not taken
into account in the NHS Health Check programme.
Therefore there is a need to raise awareness and train
Declaration of interests
staff to measure waist circumference as an initial step in
The author is Chief Executive of the charitable not-for-
Unfortunately, there are no recommendations for
reducing type 2 diabetes in children and young adultsalthough the prevalence of type 2 diabetes in this age
International Diabetes Federation (IDF). IDF Diabetes Atlas, 5th edn. Brussels,
Belgium: International Diabetes Federation. www.idf.org/diabetesatlas [accessed 1
The guidance states that further research is required
to identify effective dietary regimens in the prevention of
Adler A, et al. APHO Diabetes Prevalence Model: Key Findings for England.
Associated Pubic Health Observatory, 2012.
type 2 diabetes. However, the literature did not include
Knowler WC, et al. Preventing non-insulin-dependent diabetes. Diabetes
nutritional epidemiology research already undertaken
which has been summarised in a diabetes prevention 4. Ahmad LA, Crandall JP. Type 2 diabetes prevention: a review. Clin Diabeteseducator’s manual.16
Eriksson KF, Lindgarde F. Prevention of type 2 (non-insulin-dependent) diabetes mel-
The X-PERT Prevention of Diabetes (X-POD)
litus by diet and physical exercise. The 6-year Malmo feasibility study. Diabetologia
Programme is an evidence-based, quality-assured inten-
sive lifestyle-change programme that fully meets NICE
Pan XR, et al. Effects of diet and exercise in preventing NIDDM in people withimpaired glucose tolerance: the Da Qing IGT and Diabetes Study. Diabetes Care
guidance. It involves the delivery of person-centred,
empowering lifestyle education initially over six consecu-
Tuomilehto J, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle
tive weekly sessions with follow up at three to six months,
among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343–50.
Lindstrom J, et al. The Finnish Diabetes Prevention Study (DPS): lifestyle intervention
12 months and thereafter every year by trained educators.
and 3-year results on diet and physical activity. Diabetes Care 2003;26:3230–6.
An overview of the content of the programme is 9. Knowler WC, et al. Reduction in the incidence of type 2 diabetes with lifestyle inter-summarised in Table 1.
vention or metformin. N Engl J Med 2002;346:393–403.
10. Gillies CL, et al. Pharmacological and lifestyle interventions to prevent or delay type
2 diabetes in people with impaired glucose tolerance. BMJ 2007;334:299–302.
11. Isomaa B, et al. Cardiovascular morbidity and mortality associated with the meta-
The NICE guidance for preventing type 2 diabetes is a
bolic syndrome. Diabetes Care 2001;24:683–9.
much-needed and ambitious strategy to combat the rising
12. Lakka HM, et al. The metabolic syndrome and total and cardiovascular disease mor-
tality in middle-aged men. JAMA 2002;288:2709–16.
prevalence of type 2 diabetes. Will it achieve what it rec-
13. Ford ES. The metabolic syndrome and mortality from cardiovascular disease and all-
ommends or will it be largely ignored and gather dust in
causes: findings from the National Health and Nutrition Examination Survey II
the fight for competing resources? Only time will tell. If
Mortality Study. Atherosclerosis 2004;173:309–14.
organisations were monitored and held accountable for
14. Wong ND, et al. Preventing coronary events by optimal control of blood pressure and
lipids in patients with the metabolic syndrome. Am J Cardiol 2003;91:1421–6.
implementing the guidance, it is likely to have much
15. National Institute for Health and Clinical Excellence (NICE). Preventing type 2 dia-
more impact. In the meantime, it is hoped that commis-
betes: risk identification and interventions for individuals at high risk. NICE public
sioners, managers and practitioners will see the huge
health guidance 38. London: National Institute for Health and Clinical Excellence,London, 2012. http://guidance.nice.org.uk/PH38 [accessed 1 august 2012].
opportunity to prevent the diabetes pandemic by imple-
16. Deakin TA. The X-PERT Prevention of Diabetes (X-POD) Educator’s Manual. Hebden
menting simple and cost-effective interventions.
COPYRIGHT 2012 JOHN WILEY & SONS 3
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