1 Recommendations

The evidence statements underpinning the recommendations are listed in appendix C.

The Programme Development Group (PDG) considers that the recommended interventions are cost effective.

For the research recommendations and gaps in research, see section 5 and appendix D respectively.

Background

In January 2011, the World Health Organization (WHO) recommended that glycated haemoglobin (HbA1c) could be used as an alternative to standard glucose measures to diagnose type 2 diabetes among non-pregnant adults.

HbA1c levels of 48 mmol/mol (6.5%) or above indicate that someone has type 2 diabetes. However, WHO did not provide specific guidance on HbA1c criteria for people at increased risk of type 2 diabetes (WHO 2011).

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 risk (John et al. 2012).

Focus of the recommendations

The 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 the HbA1c test 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.

The flowchart provides an overview of the recommendations on risk assessment, blood tests and interventions for people at different levels of risk.

Who will benefit?

The recommendations aim to help adults who are at high risk of developing type 2 diabetes. When a particular at-risk group is being targeted, this is cited in the recommendation.

Please also see Assessing thresholds for body mass index (BMI) and waist circumference in black and minority ethnic groups (NICE public health guidance 46) for additional groups at risk.

Flowchart: identifying and managing risk of type 2 diabetes

Recommendation 1 Risk assessment

Who should take action?

  • Providers of public health services.

  • GPs, practice nurses and other health professionals and managers in primary and secondary healthcare and community venues. This includes those working in community pharmacies, dental surgeries, occupational health departments, optical practices, eye hospitals and prison health services.

  • Staff delivering the NHS Health Check programme.

  • Managers of adult social, residential and community services and local authority leisure services.

  • Voluntary, not-for-profit and non-government organisations (including faith and community groups, diabetes support groups and charities).

What action should they take?

  • GPs and other health professionals and community practitioners in health and community venues should implement a two-stage strategy to identify people at high risk of type 2 diabetes (and those with undiagnosed type 2 diabetes). First, a risk assessment should be offered (see recommendation 3). Second, where necessary, a blood test should be offered to confirm whether people have type 2 diabetes or are at high risk (see recommendation 4).

  • Service providers including pharmacists, managers of local health and community services and voluntary organisations, employers and leaders of faith groups should offer validated self-assessment questionnaires or validated web-based tools (for examples, see the Diabetes UK website). They should also provide the information needed to complete and interpret them. The tools should be available in local health, community and social care venues. Examples of possible health venues include: community pharmacies, dental surgeries, NHS walk-in centres and opticians. Examples of community and social care venues include: workplaces, job centres, local authority leisure services, shops, libraries, faith centres, residential and respite care homes and day centres (for older adults and for adults with learning disabilities).

  • Public health, primary care and community services should publicise local opportunities for risk assessment and the benefits of preventing (or delaying the onset of) type 2 diabetes. The information should be up-to-date and provided in a variety of formats. It should also be tailored for different groups and communities. For example, by offering translation services and information in languages used locally.

  • Where risk assessment is conducted by health professionals in NHS venues outside general practice (for example, in community pharmacies) the professionals involved should ensure the results are passed on to the person's GP.

  • GPs should keep records of all risk assessment results to ensure appropriate follow-up and continuity of care.

  • Where self-assessment is offered in community venues, health professionals and community practitioners in those venues should encourage people with an intermediate or high risk score to visit their GP to discuss how to manage their risk. Those at high risk should be offered a blood test by their GP.

  • Ensure health professionals and community practitioners involved with risk assessments in community venues communicate closely with, and receive support from, NHS diabetes risk-assessment and prevention services. They should aim to ensure continuity of care and avoid unnecessary duplication of risk assessments.

  • Managers in primary and secondary healthcare should ensure staff actively seek out and offer risk assessments to people who might not realise they could be at high risk. This includes people with particular conditions that can increase the risk such as: 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.

Recommendation 2 Encouraging people to have a risk assessment

Who should take action?

  • Providers of public health services.

  • GPs, practice nurses, and other health professionals in primary and secondary healthcare and community venues. This includes those working in community pharmacies, dental surgeries, occupational health departments, optical practices, eye hospitals and prison health services.

  • Staff delivering the NHS Health Check programme.

  • Managers of adult social, residential and community services and local authority leisure services.

  • Voluntary, not-for-profit and non-government organisations (including faith and community groups, diabetes support groups and charities).

What action should they take?

  • Encourage the following to have a risk assessment:

    • all eligible adults aged 40 and above, except pregnant women

    • people aged 25–39 of South Asian, Chinese, African-Caribbean, black African and other high-risk black and minority ethnic groups, except pregnant women

    • adults with conditions that increase the risk of type 2 diabetes[1].

  • Explain to people why, even though they feel healthy, they can still be at risk of developing type 2 diabetes. Explain the implications of being at risk and that this can be reduced by making lifestyle changes.

  • Tell people how and where they can be assessed, including at their GP surgery or community pharmacy. Make people aware that they can use a validated self-assessment questionnaire or validated web-based tools (for examples, see the Diabetes UK website). Explain that those who are eligible can be assessed by the NHS Health Check programme. (This programme is for people aged 40–74 who are not on a disease register and have not been diagnosed with coronary heart disease, hypertension, atrial fibrillation, stroke, transient ischaemic attack, type 2 diabetes or kidney disease[2].

  • Encourage people who are less likely to attend a GP surgery to go elsewhere for a risk assessment. Possibilities include community pharmacies, dental surgeries, NHS walk-in centres and opticians. Assessments may also be offered in community venues. Examples include: workplaces, job centres, local authority leisure facilities, shops, libraries, faith centres, residential and respite care homes and day centres (for older adults and for adults with learning disabilities).

  • Advise people with type 2 diabetes to encourage family members to have their risk assessed.

Recommendation 3 Risk identification (stage 1)

Who should take action?

  • GPs and practice nurses.

  • Other practitioners and managers in primary, secondary and community care, including those working in:

    • community pharmacies

    • dental surgeries

    • occupational health departments

    • optical practices and eye hospitals

    • prison health services

    • services providing healthcare for people with conditions which increase the risk of type 2 diabetes[1].

  • Staff delivering the NHS Health Check programme.

What action should they take?

  • GPs and other primary healthcare professionals should use a validated computer-based risk-assessment tool to identify people on their practice register who may be at high risk of type 2 diabetes. The tool should use routinely available data from patients' electronic health records. If a computer-based risk-assessment tool is not available, they should provide a validated self-assessment questionnaire, for example, the Diabetes Risk Score assessment tool. This is available to health professionals on request from Diabetes UK.

  • GPs and other primary healthcare professionals should not exclude people from assessment, investigation or intervention on the basis of age, as everyone can reduce their risk, including people aged 75 years and over.

  • Pharmacists, opticians, occupational health nurses and community leaders should offer a validated self-assessment questionnaire to adults aged 40 and over, people of South Asian and Chinese descent aged 25–39, and adults with conditions that increase the risk of type 2 diabetes[1], other than pregnant women. Or they should tell people how to access specific, validated online self-assessment tools, such as the Diabetes Risk Score featured on the Diabetes UK website.

  • Pharmacists, opticians, occupational health nurses and community leaders involved in risk assessments should advise people with a high risk score to contact their GP or practice nurse for a blood test. The aim is to check if they have type 2 diabetes or to confirm their level of risk and discuss how to reduce it.

  • All providers of risk assessments should explain to those attending for a type 2 diabetes risk assessment the implications of being at high risk and the consequences of developing the condition.

  • All providers of risk assessments should discuss with those attending for a type 2 diabetes risk assessment how to prevent or delay the onset of the condition. This includes being more physically active, achieving and maintaining a healthy weight, eating less fat and eating more dietary fibre. They should also tell people where to get advice and support to maintain these lifestyle changes in the long term.

Recommendation 4 Risk identification (stage 2)

Who should take action?

  • GPs and nurses working in primary care and the community.

  • Health professionals in secondary care who treat particular conditions where the risk of type 2 diabetes is high[1].

What action should they take?

  • Trained healthcare professionals should offer venous blood tests (fasting plasma glucose [FPG] or HbA1c) to adults with high risk scores (stage 2 of the identification process). They should also consider a blood test for those aged 25 and over of South Asian or Chinese descent whose body mass index (BMI) is greater than 23 kg/m2. The aim is to:

    • determine the risk of progression to type 2 diabetes
      (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) or

    • identify possible type 2 diabetes by using fasting plasma glucose, HbA1c or an oral glucose tolerance test (OGTT), according to World Health Organization (WHO) criteria.

  • Ensure HbA1c tests, including point-of-care tests, conform to expert consensus reports on appropriate use and national quality specifications (see NHS Diabetes website and WHO guidance). The tests should only be carried out by trained staff.

Recommendation 5 Matching interventions to risk

Who should take action?

  • Health professionals and healthcare assistants carrying out diabetes risk assessments in NHS or non-NHS venues.

  • Staff delivering the NHS Health Check programme.

  • Local public health services, in partnership with primary and secondary healthcare teams and providers of intensive, lifestyle-change programmes.

What action should they take?

  • For people at low risk (that is, those who have a low or intermediate risk score), tell the person that they are currently at low risk, which does not mean they are not at risk – or that their risk will not increase in the future.Offer them brief advice.

  • As part of brief advice:

    • Discuss their risk factors and how they could improve their lifestyle to reduce overall risk.

    • Offer encouragement and reassurance.

    • Offer verbal and written information about culturally appropriate local services and facilities that could help them change their lifestyle. Examples could include information or support to: improve their diet (including details of any local markets offering cheap fruit and vegetables); increase their physical activity and reduce the amount of time spent being sedentary (including details about walking or other local physical activity groups and low-cost recreation facilities). The information should be provided in a range of formats and languages.

  • For people with a moderate risk (a high risk score, but with a fasting plasma glucose less than 5.5 mmol/l or HbA1c of less than 42 mmol/mol [6.0%]):

    • Tell the person that they are currently at moderate risk, and their risks could increase in the future. Explain that it is possible to reduce the risk. Briefly discuss their particular risk factors, identify which ones can be modified and discuss how they can achieve this by changing their lifestyle.

    • Offer them a brief intervention to help them change their lifestyle: give information about services that use evidence-based behaviour-change techniques that could help them change, bearing in mind their risk profile. Services cited could include walking programmes, slimming clubs or structured weight-loss programmes. (See recommendations 11–14.)

    • Discuss whether they would like to join a structured weight-loss programme. Explain that this would involve an individual assessment and tailored advice about diet, physical activity and behaviour change. Let them know which local programmes offer this support – and where to find them.

  • For people confirmed as being 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%]):

    • Tell the person they are currently at high risk but that this does not necessarily mean they will progress to type 2 diabetes. Explain that the risk can be reduced. Briefly discuss their particular risk factors, identify which ones can be modified and discuss how they can achieve this by changing their lifestyle.

    • Offer them a referral to a local, evidence-based, quality-assured intensive lifestyle-change programme(see recommendations 8, 9 and 10). In addition, give them details of where to obtain independent advice from health professionals.

  • For people with possible type 2 diabetes(fasting plasma glucose of, 7.0 mmol/l or above, or HbA1c of 48 mmol/mol [6.5%] or above, but no symptoms of type 2 diabetes):

    • Carry out a second blood test. If type 2 diabetes is confirmed, treat this in accordance with NICE guidance on type 2 diabetes. Ensure blood testing conforms to national quality specifications.

    • If type 2 diabetes is not confirmed, offer them a referral to a local, quality-assured, intensive lifestyle-change programme (see recommendations 8, 9 and 10).

  • For people with a high risk score who prefer not to have a blood test, or who do not use primary healthcare services, discuss the importance of early diagnosis to help reduce the risk of long-term complications. Use clinical judgement, based on the person's risk score, to decide whether to offer them a brief intervention or a referral to an intensive lifestyle-change programme (see recommendations 8, 9 and 10).

Recommendation 6 Reassessing risk

Who should take action?

GPs and other primary healthcare providers.

What action should they take?

  • 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 recommendations 3 and 4).

  • Offer a reassessment based on the level of risk. Use clinical judgement to determine when someone might need to be reassessed more frequently, based on their combination of risk factors (such as their body mass index [BMI], relevant illnesses or conditions, ethnicity and age).

  • For people at low risk (with a low or intermediate risk score) offer to reassess them at least every 5 years to match the timescales used by the NHS Health Check programme. Use a validated risk-assessment tool.

  • For people at moderate risk (a high risk score, but with a fasting plasma glucose less than 5.5 mmol/l, or HbA1c less than 42 mmol/mol [6.0%]), offer to reassess them at least every 3 years.

  • 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.

Recommendation 7 Commissioning risk identification and intensive lifestyle-change programmes

Who should take action?

  • Commissioners of public health services.

  • Health and wellbeing boards.

  • Clinical commissioning groups.

What action should they take?

  • Health and wellbeing boards and public health commissioners should make type 2 diabetes prevention a priority in the joint health and wellbeing strategy. They should identify local needs by:

    • Using anonymised, regional and local health data and routinely collected surveillance data on specific population groups or geographical areas to inform the joint strategic needs assessment.

    • Mapping local diet, weight management and physical activity services and interventions (for example, slimming clubs). This should include details about locations, opening times and accessibility, staffing levels and the range of professional skills available. It should also include details of any tailored support provided by trained personnel.

  • Health and wellbeing boards and public health commissioners, working with clinical commissioning groups, should develop a comprehensive and coordinated type 2 diabetes prevention commissioning plan, based on the data collated. This should include:

    • Action to raise awareness of the risks of type 2 diabetes.

    • A proactive, two-stage approach to identifying people at high risk (and those with undiagnosed type 2 diabetes).

    • Evidence-based, quality-assured intensive lifestyle-change programmes.

  • Health and wellbeing boards and public health commissioners, working with clinical commissioning groups, should ensure the commissioning plan:

    • Sets out organisational responsibilities for local type 2 diabetes risk assessments. These could take place in primary care or community pharmacies as part of, or as a local addition to, the NHS Health Check programme, or as a self-assessment in community venues and workplaces.

    • Establishes arrangements to invite people of South Asian and Chinese descent aged 25 and over for a risk assessment at least once every 5 years. (Invitations and follow-up could be integrated within the NHS Health Check programme.)

    • Encourages employers in public and private sector organisations to include risk assessments in their occupational health service contracts.

    • Supports the development of coordinated referral pathways for evidence-based and quality-assured intensive lifestyle-change programmes that cover physical activity, weight management and diet, and which teach behaviour-change techniques.

    • Makes it clear that everyone (including older people, those from minority ethnic groups and vulnerable or socially disadvantaged people) should be offered risk assessments and intensive lifestyle-change programmes at times, and in locations, that meet their needs.

    • Makes provision for people who may have difficulty accessing, or are unlikely to access, services in conventional healthcare venues.

    • Makes it clear that risk-assessment services and intensive lifestyle-change programmes should be delivered by trained practitioners (see recommendation 18).

  • Health and wellbeing boards and public health commissioners, working with clinical commissioning groups, should integrate the commissioning plan with the joint health and wellbeing strategy. They should ensure it is delivered through services operating across the NHS, local authorities and other organisations in the private, community and voluntary sectors.

  • Health and wellbeing boards and public health commissioners should regularly evaluate services in the context of these recommendations and changing local needs. They should use local accountability mechanisms (for example, health scrutiny reports) to examine specific issues.

  • Health and wellbeing boards and public health commissioners should evaluate or compare the different service options and make the findings publicly available. Assessments should focus on changes in participants' physical activity levels, weight and dietary intake (of fat, saturated fat and fibre) over 12–24 months.

Recommendation 8 Quality-assured, intensive lifestyle-change programmes: design and delivery

Who should take action?

Providers of intensive lifestyle-change programmes. This includes primary healthcare teams and specialists who provide advice and support on physical activity, weight management and diet in the NHS and other public, private, voluntary and community organisations.

What action should they take?

  • Provide specially designed and quality-assured intensive lifestyle-change programmes for groups of 10–15 people at high risk of developing type 2 diabetes.

  • Involve the target community (including community leaders) in planning the design and delivery of the programme to ensure it is sensitive and flexible to the needs, abilities and cultural or religious norms of local people. For example, the programme should offer practical learning opportunities, particularly for those who have difficulties with communication or literacy or whose first language is not English.

  • Ensure programmes are delivered by practitioners with relevant knowledge and skills who have received externally accredited training (see recommendation 18). Where relevant expertise is lacking, involve health professionals and specialists (such as dietitians and health psychologists) in the design and delivery of services.

  • Ensure programmes adopt a person-centred, empathy-building approach. This includes finding ways to help participants make gradual changes by understanding their beliefs, needs and preferences. It also involves building their confidence and self-efficacy over time.

  • Ensure programme components are delivered in a logical progression. For example: discussion of the risks and potential benefits of lifestyle change; exploration of someone's motivation to change; action planning; self-monitoring and self-regulation.

  • Ensure groups meet at least eight times over a period of 9–18 months. Participants should have at least 16 hours of contact time either within a group, on a one-to-one basis or using a mixture of both approaches.

  • Offer more intensive support at the start of the programme by delivering core sessions frequently (for example, weekly or fortnightly). Reduce the frequency of sessions over time to encourage more independent lifestyle management.

  • Allow time between sessions for participants to make gradual changes to their lifestyle – and to reflect on and learn from their experiences. Also allow time during sessions for them to share this learning with the group.

  • Deliver programmes in a range of venues such as workplaces, leisure, community and faith centres, and outpatient departments and clinics. Run them at different times, including during evenings and at weekends, to ensure they are as accessible as possible.

  • Offer referral to, or seek advice from, people with specialist training where necessary. For example, refer someone to a dietitian for assessment and specialist dietary advice if required.

  • Offer follow-up sessions at regular intervals (for example, every 3 months) for at least 2 years following the initial intervention period. The aim is to reinforce the positive behaviour change and to provide support, in case of relapse. Larger group sizes may be feasible for these maintenance sessions.

  • Link the programmes with weight management and other prevention initiatives that help people to change their diet or become more physically active.

Recommendation 9 Quality-assured, intensive lifestyle-change programmes: content

Who should take action?

Providers of intensive lifestyle-change programmes. This includes primary healthcare teams and specialists who provide advice and support on physical activity, weight management and diet in the NHS and other public, private, voluntary and community organisations.

What action should they take?

  • Intensive lifestyle-change programmes should offer ongoing tailored advice, support and encouragement to help people:

    • undertake a minimum of 150 minutes of 'moderate-intensity' physical activity per week

    • gradually lose weight to reach and maintain a BMI within the healthy range

    • increase their consumption of wholegrains, vegetables and other foods that are high in dietary fibre

    • reduce the total amount of fat in their diet

    • eat less saturated fat.

  • Established behaviour-change techniques should be used (see NICE guidance on behaviour change: the principles for effective interventions), including at least all of the following:

    • Information provision: to raise awareness of the benefits of and types of lifestyle changes needed to achieve and maintain a healthy weight, building on what participants already know.

    • Exploration and reinforcement of participants' reasons for wanting to change and their confidence about making changes. This may include using motivational interviewing or similar techniques suitably adapted for use in groups.

    • Goal setting: prompting participants to set achievable and personally relevant short- and long-term goals (for example, to lose 5–10% of their weight in 1 year is a realistic initial target, or to be more physically active).

    • Action planning: prompting participants to produce action plans detailing what specific physical activity or eating behaviour they intend to change – and when, where and how this will happen. They should start with achievable and sustainable short-term goals and set graded tasks (starting with an easy task and gradually increasing the difficulty as they progress towards their goal). The aim is to move over time towards long-term, lifestyle change.

    • Coping plans and relapse prevention: prompting participants to identify and find ways to overcome barriers to making permanent changes to their exercise and eating habits. This could include the use of strategies such as impulse-control techniques (to improve management of food cravings).

  • Participants should be encouraged to involve a family member, friend or carer who can offer emotional, information, planning or other practical support to help them make the necessary changes. For example, they may be able to join the participant in physical activities, help them to plan changes, make or accept changes to the family's diet or free up the participant's time so they can take part in preventive activities. (It may sometimes be appropriate to encourage the participant to get support from the whole family.)

  • Participants should be encouraged to use self-regulation techniques. This includes self-monitoring (for example, by weighing themselves, or measuring their waist circumference or both). They should also review their progress towards achieving their goals, identify and find ways to solve problems and then revise their goals and action plans, where necessary. The aim is to encourage them to learn from experience.

Recommendation 10 Quality-assured, intensive lifestyle-change programmes: evaluation

Who should take action?

Managers and providers of intensive lifestyle-change programmes.

What action should they take?

  • Evaluate programmes by recording people's health outcomes at 12 months, or more frequently, if appropriate (for example, every 6 months). As a minimum, include the following measures:

    • number and demographics of adults registered

    • level of attendance

    • changes in the amount of moderate to vigorous physical activity undertaken each week

    • changes in dietary intake, with a focus on total intake of fat, saturated fat and fibre

    • changes in weight, waist circumference or BMI

    • changes in fasting plasma glucose or HbA1c levels.

  • Conduct an annual audit of how the programme was delivered For example[3], check the:

    • number of educators involved

    • level of training

    • number and demographics of adults registered

    • level of uptake for example, the percentage of those invited who attend the first session

    • programme content (for example, the use of behaviour-change techniques and empathy-building skills)

    • methods of delivery.

Recommendation 11 Raising awareness of the importance of physical activity

Who should take action?

  • Providers of intensive lifestyle-change programmes.

  • Primary healthcare teams.

What action should they take?

  • Find out what people already know about the benefits of physical activity and the problems associated with a sedentary lifestyle. Where necessary, provide this information. In addition, explain that being more physically active can help reduce their risk of type 2 diabetes, even when that is the only lifestyle change they make.

  • Explain that the government recommends a minimum of 150 minutes of 'moderate-intensity' activity per week which can be taken in bouts of 10 minutes or more. Explain that people can also meet the minimum recommendation by doing 75 minutes of 'vigorous-intensity' activity spread across the week – or by combining bouts of moderate and vigorous-intensity activity. Explain that this should include activities to increase muscle strength on 2 days a week. (See the full recommendations in Start active, stay active for examples.)

  • In cases where it is unrealistic to expect someone to meet the recommended minimum, explain that even small increases in physical activity will be beneficial – and can act as a basis for future improvements.

  • Explain that people should also reduce the amount of time they spend sitting at a computer or watching TV. Encourage them to be more active during work breaks, for example, by going for a walk at lunchtime.

  • Explain that some people may need to be more physically active to help lose weight or maintain weight loss (see NICE guidance on obesity).

Recommendation 12 Providing tailored advice on physical activity

Who should take action?

  • Providers of intensive lifestyle-change programmes.

  • Primary healthcare teams.

What action should they take?

  • Help people to identify which of their activities involve 'moderate' or 'vigorous' physical activity and the extent to which they are meeting the national minimum recommendation on physical activity. Use a validated tool such as the Department of Health's general practitioner physical activity questionnaire or the international physical activity questionnaire (IPAQ).

  • Encourage people to choose physical activities they enjoy or that fit easily within their daily lives. For example, they may choose to do specific activities such as walking, cycling, swimming, dancing or aerobics. Or they could build physical activity into their daily life – for example, by walking or cycling instead of using a car for short journeys, and by taking the stairs instead of the lift.

  • Encourage people to set short and long-term goals for example, on how far they walk or cycle, or the number or length of activities undertaken every week. In addition, encourage them to keep a record of their activity for example, by using a pedometer, and to record the things that make it easier or harder. Help them to find other ways to identify and overcome any barriers to physical activity.

  • Consider referring people who want structured or supervised exercise to an exercise referral scheme or supervised exercise sessions, as part of an intensive lifestyle-change programme.

  • Provide information on local opportunities for physical activity.

For more recommendations on increasing physical activity, see NICE guidance on promoting physical activity in the workplace; physical activity and the environment and four commonly used methods to increase physical activity.

Recommendation 13 Weight management advice

Whose health will benefit?

Adults at high risk of developing type 2 diabetes with a BMI of 25 kg/m2 or more (23 kg/m2 or more if the person is of South Asian or Chinese descent).

Who should take action?

  • Providers of intensive lifestyle-change programmes.

  • Primary healthcare teams.

What action should they take?

  • Advise and encourage overweight and obese people to reduce their weight gradually by reducing their calorie intake. Explain that losing 5–10% of their weight in 1 year is a realistic initial target that would help reduce their risk of type 2 diabetes and also lead to other, significant health benefits.

  • Use evidence-based behaviour-change techniques to help overweight and obese people eat less, be more physically active and make long term changes to their diet that result in steady weight loss (see recommendation 14).

  • Motivate and support overweight and obese people to continue to lose weight until they have achieved – and can maintain – a BMI within the healthy range. (For the general population, the healthy range is between 18.5 and 24.9 kg/m2. For people of South Asian or Chinese descent, the range is likely to be between18.5 and 22.9 kg/m2.)

  • Encourage people to check their weight and waist measurement periodically. Provide brief advice about how to measure their waist correctly (for an example, visit the British Heart Foundation website).

  • Offer people with a BMI of 30 kg/m2 or more (27.5 kg/m2 or more if South Asian or Chinese) a structured weight-loss programme as part of, or to supplement, the intensive lifestyle-change programme. Or, if more appropriate, offer them a referral to a dietitian or another appropriately trained health professional. Ensure they are given a personal assessment and tailored advice about diet, physical activity and what techniques to use to help change their behaviour.

  • GPs and other health professionals should continue to monitor, support and care for people with a BMI of 30 kg/m2 or more (27.5 kg/m2 or more if South Asian or Chinese) who join slimming clubs or other weight-loss programmes.

  • GPs should consider offering orlistat, in conjunction with a low-fat diet, to help those who are unable to lose weight by lifestyle-change alone (see recommendation 20).

  • If the above weight management interventions have been unsuccessful, refer people to a specialist obesity management service (see NICE guidance on obesity).

Recommendation 14 Dietary advice

Who should take action?

  • Providers of intensive lifestyle-change programmes.

  • Primary healthcare teams.

What action should they take?

  • Find out what people already know about the types and amounts of food and drink that can help reduce the risk of type 2 diabetes. Provide this information where necessary. Explain that increasing dietary fibre intake and reducing fat intake (particularly saturated fat) can help reduce the chances of developing type 2 diabetes.

  • Help people to assess their diet and identify where and how they could make it healthier, taking into account their individual needs, preferences and circumstances. (For example, take into account whether they need to lose weight or if they have a limited income.)

  • Encourage people to:

    • Increase their consumption of foods that are high in fibre, such as wholegrain bread and cereals, beans and lentils, vegetables and fruit.

    • Choose foods that are lower in fat and saturated fat, for example, by replacing products high in saturated fat (such as butter, ghee, some margarines or coconut oil) with versions made with vegetable oils that are high in unsaturated fat, or using low-fat spreads.

    • Choose skimmed or semi-skimmed milk and low-fat yoghurts, instead of cream and full-fat milk and dairy products.

    • Choose fish and lean meats instead of fatty meat and processed meat products (such as sausages and burgers).

    • Grill, bake, poach or steam food instead of frying or roasting (for example, choose a baked potato instead of chips).

    • Avoid food high in fat such as mayonnaise, chips, crisps, pastries, poppadums (papads) and samosas.

    • Choose fruit, unsalted nuts or low-fat yoghurt as snacks instead of cakes, biscuits, bombay mix or crisps.

Recommendation 15 Vulnerable groups: information and services

Whose health will benefit?

Adults from vulnerable groups whose risk of type 2 diabetes may be increased by a medical condition, or who may not realise they are at risk or who are less likely to access healthcare services. This includes people:

  • with severe mental health problems

  • with learning disabilities

  • with physical or sensory disabilities

  • who live in hostels, nursing and residential homes, residential mental health and psychiatric care units, secure hospitals, prisons and remand centres

  • who are part of a mobile population such as travellers, asylum seekers and refugees.

Who should take action?

  • Healthcare professionals working with people who have physical, sensory or learning disabilities or a mental health problem.

  • Providers of intensive lifestyle-change programmes.

What action should they take?

  • Provide up-to-date information in a variety of formats about local opportunities for risk assessment and the benefits of preventing (or delaying the onset of) type 2 diabetes. This should be tailored for different groups and communities. For example, messages could be provided in a visual, Braille or audio format.

  • Provide integrated risk-assessment services and intensive lifestyle-change programmes for prisons and residential homes, as appropriate.

  • Offer longer appointment times or outreach services to discuss the options following a risk assessment and blood test.

  • Ensure intensive lifestyle-change programmes are delivered by sensitive, well trained and dedicated people who are also trained to work with vulnerable groups.

  • Offer to refer travellers and people from other mobile populations to prevention initiatives in the area they are moving to. Or use electronic communications (for example, telephone or text messages as appropriate) to deliver programmes or provide ongoing support. Ensure confidentiality is maintained.

Recommendation 16 Vulnerable groups: supporting lifestyle change

Whose health will benefit?

See recommendation 15.

Who should take action?

See recommendation 15.

What action should they take?

  • Ensure all staff involved in the care of vulnerable groups understand the risk factors for type 2 diabetes and how they can help people reduce their risk. Staff should also be able to recognise and address (where possible) issues which mean someone gives their health a low priority.

  • Make all staff aware of the benefits of physical activity and reducing the time spent being sedentary. Where possible, encourage them to increase the opportunities for those in their care to be physically active.

  • Ensure staff offer to refer people to risk-assessment services and quality-assured, intensive lifestyle-change programmes in the community. Or, where necessary, arrange for them to be provided in convenient, familiar local venues such as residential care homes or day centres. (See also recommendations 1 to 10 for advice on risk assessment and intensive lifestyle-change programmes.)

  • Educate those involved in buying or preparing food in residential care, day centres and psychiatric units about what constitutes a healthy diet and how to prepare healthy meals[4].

Recommendation 17 Intensive lifestyle-change programmes: quality assurance

Who should take action?

Professional associations, royal colleges, academic centres, research institutes and community and voluntary sector organisations with an interest in type 2 diabetes prevention.

What action should they take?

Set up a national accreditation body to benchmark, audit, accredit and share effective practice in type 2 diabetes prevention. This body should:

  • Conduct research to establish and implement effective practice.

  • Provide a national, quality-assured training programme and a central database of effective curriculum resources for intensive lifestyle-change programmes. The programme and resources should meet criteria developed by the Department of Health and Diabetes UK Patient Education Working Group (PEWG).

  • Evaluate the effectiveness of the national training and accreditation programme. This includes its impact on practice and outcomes for participants.

Recommendation 18 Training and professional development

Who should take action?

  • National accreditation body for type 2 diabetes prevention (see recommendation 17).

  • Commissioners and providers of public health services.

  • Managers of type 2 diabetes risk-assessment and prevention services.

  • Schools of medicine, healthcare faculties, royal colleges and professional associations offering professional healthcare qualifications such as dietetics, nursing, physiotherapy, podiatry and occupational health.

  • Voluntary organisations.

  • Commercial training organisations.

What action should they take?

  • The national accreditation body for type 2 diabetes prevention (see recommendation 17) should work with those listed above to:

    • ensure training about risk factors for type 2 diabetes and how to prevent or delay it, is part of the core curriculum for healthcare undergraduates and postgraduates

    • provide training for health professionals and community practitioners on how to provide brief advice and brief interventions

    • provide accredited training which meets nationally defined criteria for health professionals and community practitioners who are delivering risk assessments and intensive lifestyle-change programmes, and for other providers of advice on diet and physical activity who may wish to develop a type 2 diabetes prevention programme

    • provide additional, specialised training for those working with vulnerable groups including, for example, people with mental health problems or learning disabilities, refugees and gypsy and traveller populations.

  • All the above should ensure training on delivering risk assessments, intensive lifestyle-change programmes, dietary and physical activity advice increases participants' understanding of type 2 diabetes and its complications. It should also cover: behaviour-change theories and techniques, awareness-raising, how to communicate risk and how to tailor interventions to meet individual need. In addition, participants should learn how to assess, audit and evaluate type 2 diabetes prevention programmes.

  • All of the above should establish competencies for practice and provide accredited training for other potential providers such as lay educators or voluntary sector organisations.

  • Managers of type 2 diabetes risk assessment and prevention services should provide opportunities at least every 3 years for staff to attend accredited training and refresher courses on how to deliver an intensive lifestyle-change programme. Training should be cascaded down through the team(s) via formal and informal in-service training. In addition, peer review processes should be used to encourage sharing of good practice.

  • Managers of type 2 diabetes risk assessment and prevention services should offer training to community and faith leaders, staff in local authority leisure services, day centres, residential and respite care homes and staff in occupational health departments. The training should cover:

    • how to carry out an initial risk assessment using validated self-assessment risk questionnaires

    • effective ways to communicate someone's level of risk, the consequences of type 2 diabetes and the benefits of change

    • how to give brief advice on reducing the risk of type 2 diabetes

    • how to refer on for appropriate interventions.

Recommendation 19 Metformin

Whose health will benefit?

  • Adults at high risk whose blood glucose measure (fasting plasma glucose or HbA1c) shows they are still progressing towards type 2 diabetes, despite their participation in an intensive lifestyle-change programme.

  • Adults at high risk who are unable to participate in lifestyle-change programmes because of a disability or for medical reasons.

Who should take action?

Doctors, non-medical prescribers and pharmacists in primary and secondary healthcare.

What action should they take?

  • Use clinical judgement on whether (and when) to offer standard-release metformin[5] to support lifestyle change for people whose HbA1c or fasting plasma glucose blood test results have deteriorated if:

    • this has happened despite their participation in an intensive lifestyle-change programme, or

    • they are unable to participate in an intensive lifestyle-change programme.

  • Discuss with the person the potential benefits and limitations of taking metformin, taking into account their risk and the amount of effort needed to change their lifestyle to reduce that risk. Explain that long-term lifestyle change can be more effective than drugs in preventing or delaying type 2 diabetes. Encourage them to adopt a healthy diet and be as active as possible. Where appropriate, stress the added health and social benefits of physical activity (for example, point out that it helps reduce the risk of heart disease, improves mental health and can be a good way of making friends). Advise them that they might need to take metformin for the rest of their lives and inform them about possible side effects.

  • Continue to offer advice on diet and physical activity along with support to achieve their lifestyle and weight-loss goals.

  • Check the person's renal function before starting treatment, and then twice yearly (more often if they are older or if deterioration is suspected).

  • Start with a low dose (for example, 500 mg once daily) and then increase gradually as tolerated, to 1500–2000 mg daily. If the person is intolerant of standard metformin consider using modified-release metformin.

  • Prescribe metformin for 6–12 months initially. Monitor the person's fasting plasma glucose or HbA1c levels at 3-month intervals and stop the drug if no effect is seen.

Recommendation 20 Orlistat

Whose health will benefit?

Adults who have a BMI of 28.0 kg/m2 or more, whose blood glucose measure (fasting plasma glucose or HbA1c) shows they are still progressing towards type 2 diabetes. In particular, this includes those who are not benefiting from lifestyle-change programmes, or who are unable to participate in physical activity because of a disability or for medical reasons.

Who should take action?

  • Doctors and non-medical prescribers in primary and secondary healthcare.

  • Community pharmacists and pharmacists in secondary healthcare.

What action should they take?

  • Use clinical judgement on whether to offer orlistat to people with a BMI of 28.0 kg/m2 or more, as part of an overall plan for managing obesity. Take into account the person's risk and the level of weight loss and lifestyle change required to reduce this risk.

  • Discuss the potential benefits and limitations of taking orlistat and its side effects.

  • Advise the person to follow a low-fat diet that provides 30% of daily food energy as fat, distributed over three main meals a day. Offer information and regular support from a dietitian or another appropriate healthcare professional.

  • Agree a weight-loss goal with the person and regularly review it with them[6].

  • Review the use of orlistat after 12 weeks. If the person has not lost at least 5% of their original body weight, use clinical judgement to decide whether to stop the orlistat. However, as with adults who have type 2 diabetes, those at high risk of the condition may lose weight more slowly than average, so less strict goals may be appropriate.

  • Use orlistat for more than 12 months (usually for weight maintenance) only after discussing the potential benefits, limitations and side effects with the person concerned.



[1] 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.

[2] They will be treated and managed using established health care pathways.

[3] This is an edited version of recommendation 7 in Behaviour change: the principles for effective interventions. (NICE public health guidance 6)

[4] This is from Preventing type 2 diabetes – population and community interventions (NICE public health guidance 35).

[5] At the date of publication (July 2012), metformin did not have UK marketing authorisation for this indication. Informed consent should be obtained and documented.

[6] This is part of a recommendation from Obesity (NICE clinical guideline 43).

  • National Institute for Health and Care Excellence (NICE)