Key learning points:
– The importance of prevention of type 2 diabetes and early intervention
– Being able to explain to patients their risk of developing type 2 diabetes
– Understanding the importance of monitoring patient progress, goal-setting and signposting
Diabetes is the fastest growing health threat of our time. Currently there are 3.3 million people diagnosed with diabetes in the UK1 and a further 590,000 people who have the condition but do not realise it.2 This equates to one-in-16 people living with the condition in the UK,3 and it is estimated that by 2025 five million people will have diabetes.4 Approximately 10% have type 1 diabetes and 90% have type 2 diabetes.5
Type 1 diabetes is a lifelong condition that cannot be prevented or ‘reversed’. It often, but not always, develops in childhood and is not linked to lifestyle.
While there is nothing that can be done to prevent type 1 diabetes, 80% of type 2 diabetes cases can be prevented or the onset delayed.6 This can be done by screening and identifying those at high risk of developing type 2 diabetes and implementing effective risk reduction interventions within a diabetes prevention programme. There are currently 11.5 million people in the UK identified as being at increased risk of developing type 2 diabetes due to waist circumference or being overweight7 and of these, an estimated 4.75 million are said to be at high risk.8
Identifying those at high risk of type 2 diabetes
The main risk identification programme – the NHS Health Check (see Resources section) – is still not being fully implemented and referral to intervention programmes for those identified as being at high risk is inconsistent. The National Institute for Health and Care Excellence (NICE) PH38 guidance is clear that healthcare professionals and those commissioning services should be engaged in risk identification and providing proven interventions to help reduce risk.9
Diabetes UK have been working with Public Health England and NHS England to deliver a national evidence-based type 2 diabetes prevention programme.10 Pilot sites across England were chosen earlier this year and were aimed to identify the best way of targeting people at high risk of type 2 diabetes to help them reduce their risk. Once the findings from the pilot sites have been evaluated the programme will be rolled out across England. However, those working in areas of the UK not included in the pilot sites should still have the ability to refer any patient identified as being at high risk of type 2 diabetes to available intervention programmes right now, such as a weight management group programmes or a walking club. Therefore, it is important for the healthcare professional to be aware of what services and options are available in their area.
However, the first step is identification. Patients should be made aware of the symptoms of type 2 diabetes, for example, needing to go to the toilet more frequently especially at night, feeling thirsty, extreme tiredness, having wounds that take longer to heal and genital itching. They should be encouraged to ask for a test if they display symptoms. Patients should also be aware that the condition may remain undetected for a long time and they may not show symptoms even though they already have the condition. It is critical that patients know the risk factors for type 2 diabetes and understand the importance of understanding their risk.
The key risk factors for type 2 diabetes are as follows:
· Being overweight or having a high body mass index (BMI).
· Being from an African-Caribbean, Black African, Chinese or South Asian background and over 25 years of age.
· A parent, brother or sister having diabetes.
· Ever having high blood pressure, a heart attack or a stroke.
· A history of polycystic ovaries, gestational diabetes or giving birth to a baby over 10 pounds/4.5kg.
· Suffering from schizophrenia, bipolar illness or depression, or taking anti-psychotic medication.
If a patient has any of these risk factors then healthcare professionals should encourage them to have a risk assessment to identify their personal risk of type 2 diabetes. This can be done as part of the NHS Health Check service, if the patient is eligible, or they could be encouraged to use a web-based tool (see Resources section). If they are found to be at high risk they can have a blood test to confirm if they have the condition. If the test is negative, they should still continue to be given support to help them reduce their risk in the future.
Being overweight or obese is the most significant risk factor for type 2 diabetes and this is increasing. The latest figures show that almost two in every three people in the UK are overweight or obese (57% of women and 67% of men).11 This is an increase of 13% between 1980 and 2013. Being overweight or obese puts millions more people at increased risk. Often people have little or no idea of what is classified as being overweight or obese and how this affects their risk of developing the condition. It is really important to have a discussion with your patient about their body mass index (BMI) and waist measurement.9
The patient needs to understand that more than 80% of type 2 diabetes is lifestyle related and therefore, is potentially modifiable. Other risk factors, such as ethnicity, age or family history are not modifiable but many people can do something about their weight. Talking to the patient and explaining just how significant being overweight or obese is to their risk of developing type 2 diabetes could encourage them to start taking steps to reduce their risk.
Unsurprisingly the most dominant predictor for type 2 diabetes prevention is weight loss; every kilogram lost is associated with a 16% reduction in risk9 and it has been shown that weight loss of at least 5-7% is effective for type 2 diabetes prevention.9
It is also important to alert patients that type 2 diabetes is a serious condition that can result in complications such as blindness, kidney failure and amputation, if not detected early and managed properly. A patient may not be aware of the seriousness of the condition so understanding the possible complications may give them motivation.
Having an effective recall system in place to monitor a patient’s progress is vital, as is putting appropriate short-term and long-term goals in place with agreed targets in place for diet, exercise or both.
It is important to be able to signpost patients at high or increased risk to get the help and support they need. One of the most common issues brought up in calls to the Diabetes UK Careline is advice on diet for people living with diabetes. Even for those who do not yet have the condition, understanding what constitutes a healthy balanced diet is hugely significant. That is why Diabetes UK recommends advising patients who may need help and encouragement to lose weight to look at diabetes recipes for ideas and inspiration. Diabetes UK recipe site includes hundreds of healthy recipes featuring healthy alternatives to favourite dishes for people from different ethnicities (see Resources section). When it comes to combatting obesity, giving people the tools they need to shop, cook and eat healthily is one part of the jigsaw.
Exercise is also an effective tool when it comes to improving health and maintaining weight loss. It is important for patients to be encouraged to exercise regularly – especially if they are overweight or obese.9 But it may be necessary to tailor the activity according to the individual’s capabilities. Encourage patients to find an activity they enjoy or to set themselves goals – such as walking 10,000 steps a day. Incorporating more exercise in their day-to-day life can be a start to becoming more active. Leaving the car at home and walking instead or joining a local exercise group can literally be small steps to a more active lifestyle. By making such small but significant changes people can help to reduce their blood glucose levels and reduce their risk of developing type 2 diabetes.
There may be some individuals who are not responding to intensive lifestyle intervention or are unable to exercise due to disability or medical reasons. In this case it may be useful to consider medication. If the patient’s blood glucose levels show they are still progressing towards type 2 diabetes, it may be appropriate to prescribe Metformin, taking into account NICE guidance.9 For those with a BMI of more than 28.0kg/m² and blood glucose levels still progressing towards type 2 diabetes, Orlistat is an option if lifestyle intervention alone is not working or not appropriate.9
All patients, even if they are at lower risk, should be given advice and support based on their individual risk factors so that they can take action to reduce their overall risk of developing the condition.
Primary care nurses can play a crucial role in implementing NICE guidance to identify patients at high risk of developing type 2 diabetes and signpost them to intervention programmes or other sources of support. As the number of people with diabetes continues to rise, early intervention to avoid or delay the condition is vital to help patients take control and, ideally, avoid developing the condition for as long as possible.
Diabetes risk assessment tool:
Diabetes UK’s ‘Enjoy Food’ recipe finder:
NHS Health Check:
1. Quality and outcomes framework (QOF) 2012/2013 England.
www.hscic.gov.uk/catalogue/PUB15751/qof-1314-report.pdf (accessed 14 July 2015).
2. Diabetes UK. What is diabetes? diabetes.org.uk/Guide-to-diabetes/What-is-diabetes/ (accessed 19 August 2015).
3. Health & Social Care Information Centre. Quality and Outcomes Framework – Prevalence, Achievements and Exceptions Report 2013/2014. hscic.gov.uk/catalogue/PUB15751/qof-1314-report.pdf (accessed 19 August 2015).
4. Public Health England. Diabetes prevalence model. http://bit.ly/aphodiabetes (accessed 19 August 2015).
5. HSCIC: National Diabetes Audit 2012/13: Report 1: Care Processes and Treatment Targets. hscic.gov.uk/searchcatalogue?productid=15512&q=%22National+diabetes+audit%22&sort=Relevance&size=10&page=2#top (accessed 3 August 2015).
6. World Health Organization. Preventing Chronic Disease: A Vital Investment. Geneva: WHO. 2005. who.int/chp/chronic_disease_report/contents/part1.pdf?ua=1 (accessed 14 July 2015).
7. Mainous III AG, Tanner RJ, Coates TD, Baker R. Prediabetes, elevated iron and all-cause mortality: a cohort study. British Medical Journal 2014;4:e006491. DOI:10.1136/bmjopen-2014-006491 (accessed 18 August 2015).
8. Ng M, Fleming T, Robinson M, Thomson, B. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet 2014; 384 (9945): 766-781. DOI:10.1016/S0140-6736(14)60460-8 (accessed 14 July 2015).
9. National Institute for Health and Care Excellence. Preventing type 2 diabetes: risk identification and interventions for individuals at high risk. nice.org.uk/guidance/ph38 (accessed 14 July 2015).
10. NHS England. NHS Diabetes Prevention Programme. england.nhs.uk/ndpp (accessed 3 August 2015).
11. Hamman RF, Wing RR et al. Effect of weight loss with lifestyle intervention on the risk of diabetes, 2006. Diabetes Care 29(9);2102–7.
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