This site is intended for health professionals only

Recognising and treating pre-diabetes

Diabetes is a global health burden and is it is increasingly common for primary care nurses to work in partnership with people with diabetes on a daily basis within their practice. It is estimated that in the UK, one person is diagnosed with type 2 diabetes every three minutes.1 The evolution of this epidemic of type 2 diabetes, which is largely preventable, is really rather frightening. Primary care nurses need to be exceptionally vigilant and also curious about the possibility of diabetes with everyone undiagnosed person that they meet. This article is about pre-diabetes and how nurses can help those at risk and enable people to be knowledgeable to reduce both their diabetes and cardiovascular disease (CVD) risk.  

What is pre-diabetes and who is at risk?

As the name suggests, this condition places an individual at high risk of developing type 2 diabetes and also CVD. Other names for this condition are illustrated in Box 1. Pre-diabetes is, as the name suggests, an opportunity to work with individuals at risk to try to reduce their individual risk factors, so to assess and reduce risk rather than 'screen'. Therefore it is important to help enable people to engage in health promoting activities through education, enablement and effective personal goal setting,2 to lessen both their risk of developing type 2 diabetes and also CVD. This is exactly what the recently published 2012 NICE guidance, Preventing type 2 diabetes: risk identification and interventions for individuals at high risk, intended to achieve also.

Box 2 from the Wake Up study3 illustrates who is considered to be at increased risk of pre-diabetes. These individuals are identified to be highly likely to develop type 2 diabetes and CVD without intervention. However, nurses need to also consider that anyone can be at risk of diabetes, so to be vigilant and diabetes 'curious' in all consultations is prudent practice. This also provides nurses and fellow primary health care practitioners with an opportunity to intervene with primary public health messages during consultations.4 'Think Diabetes' at every consultation with every person is the key message to take home.

People with a raised fasting plasma glucose levels on two occasions (FPG 6.1-6.9 mmols/L) will be diagnosed with impaired glucose tolerance (IGT), and a third of these people will develop preventable type 2 diabetes within six years.3 Therefore, being knowledgeable and aware of pre-diabetes offers practitioners opportunities to screen and offer tailor-made public health advice to individuals to aim to prevent diabetes and CVD.

Testing for pre-diabetes

Firstly, the following are not very helpful:

A random glucose method is practical but not really very helpful; the results obtained can fluctuate depending on a person's food intake before testing.5 It is also inconvenient, as it requires further tests if an abnormal reading is obtained.

The fasting glucose test is inconvenient as it requires a person to fast for a minimum of eight hours before attending for the test (in reality most people are naturally fasting from midnight as they are usually asleep). This test also gives a poor indication of non-diabetes hyperglycaemia and raised postprandial blood glucose levels which occur first in type 2 diabetes.6 Like the previous test, this test also requires follow-up if it is abnormal. 

The oral glucose tolerance test (OGTT) is expensive, inconvenient for the person who is being tested and time-consuming for the individual and the health professional.5 Also, the test needs to be conducted correctly with the person resting quietly in the surgery between the blood tests, and not exercising or going out shopping for example.

The following may be considered helpful:

An HbA1c is recognised7 as the test of choice for diagnostic purposes for diabetes. The use of HbA1c is advocated due to its convenience, reproducibility and association with an individual's risk of developing CVD.8 However clinical judgement is essential and WHO (2011) accepted guidance for use of HbA1c and clinical interpretation of results. Once a diagnosis of pre-diabetes is made, tailored lifestyle advice and an annual follow-up HbA1c is recommended.

How to prevent pre-diabetes progressing

People who are found to have risk factors and an HbA1c resultwhich is indicative of pre-diabetes can be encouraged to look closely at their lifestyle and consider adaptations that can potentially reverse these abnormalities.1 Nurses with diabetes and/or CVD expertise are ideally placed to encourage people to be aware of the lifestyle changes they could make, for example increasing their physical activity, dietary changes, reducing alcohol intake, eating five a day and stopping smoking. This is really imperative as it is recognised that if people with pre diabetes do not lose weight and do not engage in moderate physical activity, 11% will progress to type 2 diabetes during the average three years of follow-up.9 NICE (2012) advocate that for diabetes prevention, brief interventions and advice might consist of a five-to-15 minute consultation with the aim to help someone make an informed choice about whether to make lifestyle changes to reduce their risk of diabetes. A 'shared decision-making' communication style can be used to encourage people to make choices and have a sense of 'ownership' of their lifestyle goals and individual action plans.2 Providers of brief interventions should be knowledgeable about local resources to support people in weight loss, physical activity engagement and stopping smoking. 

Role of nurses working in primary care

Nurses are essential in the support and engagement of people in all aspects of health care delivery. Engagement with people to enable education, honest discussion about lifestyle choices, motivation and help are essential aspects of diabetes care and prevention.4 Being knowledgeable about recent evidence and opportunities for people also helps change minds and reduces reluctance in lifestyle changes. Results of a cost-effective physical activity engagement pilot programme entitled 'New Life: New You' where through a very modest ≥5% weight loss, especially if maintained long term, have just published10 where people were able to reduce their pre diabetes risk significantly. It will be of great interest when the results of this pilot pre-diabetes intervention are fully researched and the results will be available to help to inform practice interventions with individuals and communities at risk.

 

Conclusion

Pre-diabetes offers nurses opportunities to practice primary public health interventions in disease prevention. As the evidence accumulates on how we can prevent and arrest the current epidemic of diabetes then timely and effective health promoting interventions are considered highly efficacious and cost-effective.

With the cost of diabetes to the NHS currently being over £1.5 million per hour, or over £25,000 every minute11 the public health messages about prevention and timely public health interventions with people at risk or with pre diabetes cannot be over emphasised. This can enable primary care nurses to undertake a strong public health focus in their practice to proactively prevent this disease rather than reactively deal with the consequences of it. 'Think diabetes' at every consultation or home visit is the message.

 

References

1. Diabetes UK. One person diagnosed with diabetes every three minutes in the UK. Press release. 6 January 2009. 

2. Furze G, et al. The clinician's guide to chronic disease management for long term conditions: A cognitive behavioural approach. Keswick: M&K Update Limited; 2008.

3. Campbell J, et al. The Wake up study - Ways to Address Knowledge Education and Understanding in Pre-Diabetes (WAKEUP). 2005. 

4. Phillips A. Principles of Diabetes Care: evidence-based management for health care professionals. UK: Quay Books; 2012.

5. Hiles S, Davies M, Khunti K. Diabetes and the vascular checks programme. Diabetes Update 2009:37-9.

6. Carnevale Schianca G, et al. The significance of impaired fasting glucose versus impaired glucose tolerance. Diabetes Care 2003;26(5):1333-7.

7. Use of Haemoglobin A1c (HbA1c) in the diagnosis of diabetes mellitus - The implementation of World Health Organisation (WHO) guidance 2011. 

8. Little R. Using the A1c test to diagnose diabetes. Diabetes in Control Newsletter 2009:463.

9. Knowler WC, et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403.

10.  Penn L, et al. Participant perspectives on a lifestyle intervention for the prevention of type 2 diabetes: a qualitative evaluation within the 'New life, New you' pilot study. Madrid, Spain: Minerva Endocrinologica; 2012.

11.   Diabetes in the NHS 26/02/13. Available at: www.york.ac.uk/news-and-events/features/diabetes-nhs