NICE issue new diabetes guidelines

‘Everyone over 40 should be tested for diabetes, says health watchdog,’ the Daily Mail has announced. The Mail is one of several news sources to have highlighted major new guidelines that aim to reduce the impact of type 2 diabetes on people.

The new guidelines have been published by the National Institute of Health and Clinical Excellence (NICE) and provide recommendations that are designed to:

identify people at a potential high risk of developing the condition
assess their individual risk with testing, and, if necessary
offer lifestyle advice (such as advice on diet and exercise), to help prevent the condition in people who are at high risk, and advise on such things as dietary changes and increased physical activity

Type 2 diabetes is a long-term and typically preventable condition that results in too much glucose (a type of sugar) in the blood. Symptoms include:

feeling very thirsty
going to the toilet a lot, especially at night
extreme tiredness
weight loss and loss of muscle bulk

There are a wide range of risk factors for type 2 diabetes, such as obesity and ethnicity and there are several serious complications, including other cardiovascular diseases (such as heart attack and stroke). It can also lead to visual impairment, kidney failure and lower limb amputations due to foot ulcers.

Preventing type 2 diabetes from occurring in the first place would have a significant positive impact in terms of public health and the life of millions of people in this country.

The NICE guidelines report that diabetes currently affects almost 3 million people in the UK. Of these, 90% will have type 2 diabetes. The number of people with diabetes is estimated to rise to 5 million by 2025. A further 850,000 people in the UK are thought to have diabetes without knowing it.

What do the new NICE guidelines on type 2 diabetes say?

The NICE guidelines contain 20 detailed recommendations. These outline the best ways to identify people at high risk of type 2 diabetes and to encourage them to take steps to reduce their risk. In particular, it’s recommended that the following groups should be encouraged to have a risk assessment for type 2 diabetes so they can be offered advice to help prevent or delay the condition:

All adults aged 40 and above (except pregnant women)
Those aged 25-39 who are of South Asian, Chinese, African-Caribbean or Black African descent and other ethnic groups considered at high risk (except pregnant women)
Adults with conditions that increase the risk of diabetes, such as high blood pressure, being very overweight (with a body mass index of 30 or above), or having a history of stroke

Will they really screen for type 2 diabetes at my local job centre?

Certainly not at first, and it is important to make clear that screening will not be compulsory. What NICE are trying to achieve is to provide access to screening for type 2 diabetes in a range of more accessible places, not just your GP surgery or local hospital.

Screening for type 2 diabetes is relatively straightforward and does not require access to specially trained staff. So there is no reason that screening cannot be offered at:

your job centre
your local library
your pharmacist
your community centre
your dentist
your optician

If the results of your screening do suggest you are at a higher risk, you can then be referred for a follow-up blood test.

How will this work in practice?

The NICE diabetes guidelines focus on identification and risk reduction. They call for the identification of people at risk of type 2 diabetes, using a staged (or stepped) approach. This involves using ‘validated risk assessment tools’ and questionnaires, and, where necessary, a blood test to confirm if someone is at high risk. The blood test, which measures glucose levels, would be based on either fasting blood glucose or a test called the HbA1c test, which measures how much glucose is stuck to haemoglobin.

For people identified as being at high risk, NICE calls for a ‘quality-assured, evidence-based intensive programme’ to change their lifestyle and prevent or delay the onset of type 2 diabetes. This would include a programme to:

increase physical activity
achieve and maintain weight loss
increase dietary fibre and reduce fat intake, particularly saturated fat

Medication such as metformin can also be used for people whose blood sugar levels remain high despite making lifestyle changes.

Those found to have possible type 2 diabetes would be offered further tests and, if diagnosed, enter a ‘care pathway’ to be treated for the disease.

To implement these, NICE recommends national and local NHS bodies to act. NICE provides detailed ‘interactive pathways’ for professionals involved in diabetes prevention to help them offer the right care to people at risk of diabetes.

How do the new guidelines differ from the previous recommendations?

The new guidelines complement but do not replace previous recommendations from NICE on how to prevent or manage type 2 diabetes. This includes guidelines, published in May 2011, on reducing risk in the wider adult population, and other guidance on areas connected with diabetes, such as:

cardiovascular disease
obesity
physical activity
weight management

The main focus of these guidelines is to try to and adopt a more preventative approach to type 2 diabetes, accurately identifying those at a higher risk of developing the disease and then offering treatment that can potentially reduce that risk.

The guidelines are intended to be used alongside the NHS Health Check programme and the national vascular risk assessment programme for those aged 40-74. These programmes are currently being rolled out in England and aim to identify and treat diabetes, cardiovascular disease, stroke and kidney disease.

What will happen as the result of the guidelines?

NICE wants major initiatives nationally and locally, aimed at preventing type 2 diabetes. It hopes that these initiatives will include a body to oversee effective practice in type 2 diabetes prevention. Local NHS organisations will be expected to ensure that prevention of diabetes type 2 is a central part of their work.

What is the evidence that the guidelines are based on?

NICE says that the guidelines are based on the best available evidence, and included:

reviews of the evidence
economic modelling
the testimony of experts
commissioned reports
comments from stakeholders
fieldwork

In some areas, the evidence was lacking and NICE has made recommendations for future research, such as which combination of risk-assessment tools and blood tests (HbA1c or fasting blood glucose) are most cost-effective and effective. More details of the evidence on which these guidelines are based and the process for developing public health guidance, can be found on the NICE website.

How will these guidelines affect me?

The NICE guidelines are aimed at healthcare professionals rather than the public. However, in response to NICE’s recommendations, your GP or nurse may encourage you to identify your personal risk factors and encourage you to adopt or maintain a healthy lifestyle. If you are in an at risk group (for example, if you are over 40) you will be encouraged to assess your risk of this condition. One option open to you is to use the NHS Choices type 2 diabetes check tool.

If you are assessed at high risk you will probably be asked to contact your GP or practice nurse for a blood test (either the fasting glucose test or the HbA1c) to confirm the level of risk and to discuss how to reduce it through lifestyle changes. If you are diagnosed with type 2 diabetes, you should be placed on a ‘care pathway’ involving lifestyle changes and, where necessary, drug treatment.

Professor Mike Kelly, director of the Centre for Public Health Excellence at NICE said: "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."