NICE public health guidance
Issued: July 2012
PH38

Preventing type 2 diabetes: risk identification and interventions for individuals at high risk

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/ph38

Introduction: scope and purpose of this guidance

What is this guidance about?

This guidance focuses on identifying people at high risk of type 2 diabetes and the provision of effective, cost effective and appropriate interventions for them.

The guidance is not advocating a national screening programme for type 2 diabetes, rather the recommendations remind practitioners that age is no barrier to being at high risk of, or developing, type 2 diabetes. The recommendations can be used alongside the NHS Health Check programme. They cover:

  • risk assessment

  • encouraging people to have a risk assessment

  • risk identification (stage 1)

  • risk identification (stage 2)

  • matching interventions to risk

  • reassessing risk

  • commissioning risk identification and intensive lifestyle-change programmes

  • intensive lifestyle-change programmes:

    • design and delivery

    • content

    • evaluation

  • physical activity:

    • awareness-raising

    • providing tailored advice

  • weight management advice

  • dietary advice

  • vulnerable groups:

    • information and services

    • supporting lifestyle change

  • intensive lifestyle-change programmes: quality assurance

  • training and professional development

  • metformin

  • orlistat.

Who is this guidance for?

This guidance is for everyone who has a direct or indirect role in, and responsibility for, preventing or delaying the onset of type 2 diabetes. This includes GPs, nurses and other health professionals, as well as commissioners and managers within the NHS, local authorities and the wider public, private, voluntary and community sectors.

It is also for pharmacists, occupational health specialists, optical practitioners, those involved in the NHS Health Check programme and all those who deliver dietary, physical activity and weight management services.

In addition, it may be of interest to people at high risk of developing type 2 diabetes, their families and other members of the public.

Why is this guidance being produced?

The Department of Health (DH) asked the National Institute for Health and Clinical Excellence (NICE) to produce public health guidance on the prevention of type 2 diabetes among high-risk groups. The referral was divided into two separate pieces of complementary guidance.

Originally, this guidance focused on preventing or delaying the progression from 'pre-diabetes' to type 2 diabetes among individuals at high risk. The other guidance originally set out to address the prevention of 'pre-diabetes' among adults aged 18–74 years in communities at high risk of developing type 2 diabetes.

However, 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 – but there is no fixed point to indicate when someone has 'pre-diabetes'. A UK expert group has also recommended HbA1c for diagnosis of diabetes according to the WHO criteria. The group also recommended an HbA1c of 42−47 mmol/mol (6.0–6.5%) to classify someone as being at high risk of diabetes (John et al. 2012). The titles of the two, complementary pieces of guidance were changed to reflect a move away from describing 'pre-diabetes' as a separate condition. However, their overall range and scope remains the same.

The other guidance, published in May 2011, focuses on interventions aimed at shifting the degree of risk within the wider population. This guidance focuses on identifying people aged 18 years and over at high risk of type 2 diabetes and offering them effective lifestyle-change programmes to prevent or delay the condition. Together they provide a comprehensive approach which combines population-based primary prevention with interventions targeted at those who are at high risk.

This guidance can be used alongside the NHS Health Check programme, the national vascular risk assessment and management programme for those aged 40–74. This is an integrated approach to identifying and preventing four diseases: diabetes, cardiovascular disease, stroke and kidney disease (NHS Health Check Programme 2009). The programme is being rolled out throughout England. The aim is to ensure everyone aged 40–74 who has not already been diagnosed with one of these conditions is offered a risk assessment and given advice and support to help them reduce and manage that risk.

This guidance should be implemented alongside other guidance and regulations (for more details see sections 4 and 7 on implementation and related NICE guidance respectively).

How was this guidance developed?

The recommendations are based on the best available evidence. They were developed by the Programme Development Group (PDG).

Members of the PDG are listed in appendix A.

The guidance was developed using the NICE public health programme process. See appendix B for details.

Supporting documents used to prepare this document are listed in appendix E.

What evidence is the guidance based on?

The evidence that the PDG considered included: reviews of the evidence, economic modelling, the testimony of experts, commissioned reports, stakeholder comments and fieldwork. Further detail on the evidence is given in the considerations section (section 3) and appendices B and C.

In some cases the evidence was insufficient and the PDG has made recommendations for future research.

More details of the evidence on which this guidance is based, and NICE's processes for developing public health guidance, are on the NICE website.

The recommendations support, but do not replace, the clinical assessment of someone's risk of type 2 diabetes taking into account of all their conditions and personal circumstances, and the provision of appropriate advice and monitoring.

The guidance complements, but does not replace, other NICE guidance on how to prevent or manage type 2 diabetes. It also complements NICE guidance on: behaviour change, cardiovascular disease, community engagement, obesity, physical activity and weight management before, during and after pregnancy (for further details, see section 7).

Hyperlinked terms are explained in the glossary.