NICE has today (Thursday 12 July) published new guidance on identifying people at high risk of developing type 2 diabetes and the provision of clinically and cost effective interventions to help reduce the risk or delay the onset of the condition.

Type 2 diabetes is a long-term (chronic) condition that occurs when the body does not produce enough insulinⁱ for it to function properly, or when the body's cells do not use insulin properly. Diabetes currently affects almost 3 million people in the UKⁱⁱ, of which about 90% will have type 2 diabetes. This is estimated to rise to 5 million - that is, nearly 10% of the population - by 2025. The cost of treatment and long term care for diabetes is estimated to account for a tenth of the NHS budget each yearⁱⁱⁱ.

Professor Mike Kelly, Director of the Centre for Public Health Excellence at NICE said: “Almost three million people are currently affected by diabetes, and it is likely to affect many more in the future. Our new guidance includes some large-scale recommendations, such as the setting up of a new accreditation body to oversee effective practice in type 2 diabetes prevention. We also want health and wellbeing boards and public health commissioners to work with clinical commissioning groups to ensure that type 2 diabetes prevention is central to their health improvement strategies.

“Type 2 diabetes is a very large-scale problem and it is important for people to know that it is preventable, and there are simple steps that can be taken to help reduce the risk of developing the disease. This guidance will help people to identify their own personal risk and highlights that by losing weight, being more active and improving their diet, they can prevent or delay type 2 diabetes.”

The new NICE guidance outlines the best ways of identifying people at high risk of developing type 2 diabetes, encouraging them to take steps to reduce their risk and maintain a healthier lifestyle. Consistent good quality evidence shows that individual risk can be reduced by nearly 60%^iv.

The recommendations can be used alongside the NHS Health Check programme, the national vascular risk assessment and management programme for people aged 40-74 years^v.

The guidance recommends that the following groups should be encouraged to have a risk assessment for diabetes, so they can be offered advice to help them prevent or delay the condition:

• all adults aged 40 and above (except pregnant women),
• those aged 25-39 and of South Asian, Chinese, African-Caribbean or Black African descent, and other high risk and minority ethnic (BME) groups^vi (except pregnant women), and
• adults with conditions that increase the risk of type 2 diabetes^vii.

Health and community services, workplaces, job centres, community pharmacies, faith centres, libraries and shops are encouraged to offer risk assessments so that everyone can understand their level of risk and get advice about reducing it.

The new recommendations focus on two major activities:

• Identifying people at risk of developing type 2 diabetes using a staged (or stepped) approach. This involves a validated risk-assessment score and a blood test - either the fasting blood glucose or, importantly, the HbA_1c test^viii to confirm high risk.
• Providing those at high risk with a quality-assured, evidence-based, intensive lifestyle-change programme to prevent or delay the onset of type 2 diabetes.

Recommendations include encouraging adults to:

• assess their risk of type 2 diabetes using a validated self-assessment questionnaire (paper based or online)^{ix ,}or GP practices can use a computerised risk score based on information contained in patient records.
• if they are assessed as high risk, to contact their GP or practice nurse for a blood test, either the fasting blood glucose or the HbA_1c test to confirm their level of risk and discuss how to reduce it, or whether they already have type 2 diabetes.

Measuring HbA_1c levels has been used for diabetes management for a number of years, but it has not been used for the identification of people who are at high risk of developing diabetes.

People who have been assessed as high risk and have had their risk confirmed by a blood test should be offered a referral to a local, evidence-based, quality-assured intensive lifestyle-change programme^x which provides ongoing, practical, tailored advice, support and encouragement to help people be more physically active, achieve and maintain a healthy weight and eat a healthier diet.

Providers of type 2 diabetes risk assessments should explain to those attending the implications of being at high risk and the consequences of developing the condition, and that it can be prevented or delayed by making long term lifestyle changes. It is also important to explain to people why, even though they feel healthy, they can still be at risk of developing type 2 diabetes. The guidance also recommends that providers of intensive lifestyle change programmes should use a tailored approach, which is sensitive and flexible to the needs, ability, and cultural and religious norms of black and minority ethnic and vulnerable groups.

Professor Kamlesh Khunti, Professor of Primary Care, Diabetes and Vascular Medicine, Department of Health Sciences, University of Leicester, and chair of the programme development group said: “Type 2 diabetes is a serious problem in England, and it can be devastating for those affected. I was pleased to Chair the group which developed this guidance, which sets out clear, evidence- based recommendations that, if implemented, can help prevent the onset of this condition.”

Christine Cottrell, Clinical Lead for Diabetes at Education for Health, Warwick, and member of the programme development group said: “This new NICE guidance sets out a practical, sensible approach to help stem the rising tide of diabetes in this country. Evidence shows us that changes in exercise and diet work, and can prevent the development of type 2 diabetes.”

Jill Hill, Diabetes Nurse Consultant, Birmingham Community Healthcare Trust and member of the programme development group said: “As a diabetes nurse, I have seen first-hand how the condition can affect a person's life. People may not be aware that diabetes is the most common cause of visual impairment and blindness, kidney failure and non-traumatic lower limb amputations. This guidance focuses on risk assessment and providing those at high risk with evidence-based, effective interventions that can delay or prevent this condition.”

Barry Cassidy, community member of the programme development group said: “I was diagnosed with diabetes 15 years ago, and in that time I have had to make important changes to my lifestyle. I've improved my eating habits and increased the amount of exercise I do. I would urge anyone who is worried about developing this condition to act now. Diabetes is preventable; people just need to be better informed about the simple steps they can take to halt the onset of this serious condition.”

The guidance is available from 00:01hrs on Thursday 12 July on the NICE website

Ends

Notes to Editors

References and explanation of terms

i. Insulin is a hormone made by the pancreas, and is central to regulating carbohydrate and fat metabolism in the body.

ii. Diabetes UK. For more information, please see: http://www.diabetes.org.uk/Professionals/Publications-reports-and-resources/Reports-statistics-and-case-studies/Reports/Diabetes-in-the-UK-2012/

iii. Diabetes is a major risk factor for cardiovascular disease and stroke among people of working age. An estimated 850,000 people in the UK may have diabetes but don't know it and may remain undiagnosed. Many more may have blood glucose levels above the normal range, (impaired glucose regulation) but not high enough for a diabetes diagnosis.

iv. Long-term benefits from lifestyle interventions for type 2 diabetes prevention, Diabetes Care, 2011. For more information, please see: http://care.diabetesjournals.org/content/34/Supplement_2/S210.full.pdf+html

v. The NHS Health Check programme aims to help prevent heart disease, stroke, diabetes and kidney disease. For more information please see: http://www.healthcheck.nhs.uk/

vi. In the UK, type 2 diabetes is more prevalent among people of South Asian, Chinese, African-Caribbean and black African descent than among the white population. People in these groups tend to develop it at a younger age. They also tend to progress from impaired glucose tolerance to diabetes much more quickly (more than twice the rate of white populations).

vii. 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 thoseattending accident and emergency, emergency medical admissions units, vascular and renal surgery units and ophthalmology departments may be at high risk.

viii. Glycated haemoglobin (HbA_1c) forms when red cells are exposed to glucose in the plasma. The HbA_1c test reflects average plasma glucose over the previous eight to 12 weeks. Unlike the oral glucose tolerance test, an HbA_1c test can be performed at any time of the day and does not require any special preparation such as fasting. HbA_1c 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 HbA_1c as the cut-off point for diagnosing type 2 diabetes in non-pregnant adults. For the purposes of this guidance, the range 42-47 mmol/mol (6.0-6.4%) is considered to be ‘high risk‘.

ix. An example is the Diabetes UK online diabetes risk score at: http://www.diabetes.org.uk/Riskscore/

x. Intensive lifestyle-change programmes are specially designed for groups of 10-15 people at high risk of developing type 2 diabetes. The groups should meet at least eight times over a period of 9-18 months and participants should have at least 16 hours of contact time, either within a group, on a one-to-one basis or a mixture of both approaches, or they may use telephone or computer-based interactive media.

About the guidance

1. The new guidance, Preventing type 2 diabetes: risk identification and interventions for individuals at high risk, is available from 00:01hrs on Thursday 12 July on the NICE website.

Embargoed copies are available on request; please contact the press office.

This guidance complements recommendations published in May 2011 by NICE, Preventing type 2 diabetes - population and community interventions.

2. The NICE public health guidance development process: An overview for stakeholders including public health practitioners, policy makers and the public (second edition, 2009) is available on the NICE website.

3. NICE public health guidance applies to England and is not subject to a mandatory requirement regarding funding. The NHS, local authority and the wider public, private and voluntary community sectors in England should take it into account.

Related guidance

1. Preventing type 2 diabetes - population and community interventions. NICE public health guidance 35 (2011).

2. Type 2 diabetes - newer agents. NICE clinical guideline 87 (2009).

3. Type 2 diabetes: the management of type 2 diabetes (update). NICE clinical guideline 66 (2008).

4. Diabetes (type 1 and 2) - patient education models. NICE technology appraisal guidance 60 (2003).

5. Diabetic foot problems - inpatient management. NICE clinical guideline 119. (2011).

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health.

2. NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

3. NICE produces standards for patient care:

• quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services.
• Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients.

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research andinformation to help health professionals deliver the bestpatient care through NHS Evidence