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Ldr deakin:pd 2-col.qxdPreventing diabetes: will NICE guidance do whatit says on the tin?Trudi Deakin It is predicted that there will be 552 million people, or groups, respectively. This reduction in incidence equated one adult in 10, diagnosed with diabetes in the world by to one case of diabetes prevented for every seven people 2030, a 93% increase almost doubling the number of with IGT treated for three years in the lifestyle interven- those diagnosed with the condition in 2010 (285 million tion group, compared with 14 for the metformin group. people, prevalence 6.6%).1 In England, the prevalence of In addition, a review has also indicated that the numbers people with diabetes in 2011 was 3 million. It is alarming needed to treat (NNT) to prevent one case of type 2 dia- that the prevalence in England is set to increase beyond betes with lifestyle intervention in people at risk of diabetes the average world prevalence to 9.5%, i.e. 4.6 million is dramatically low at 6.4 (over 1.8 to 4.6 years).10 Further -people by 2030.2 Some 280 million people worldwide, or more, since patients with the metabolic syndrome have an 6.5% of adults, were estimated to have impaired glucose increased risk of cardiovascular disease (CVD) and mortal- tolerance (IGT) in 2011. By 2030, the number of people ity,11–13 lifestyle interventions in obese patients and those with IGT is projected to increase to 398 million, or 7.1% with evidence of hyperglycaemia are likely to be beneficial in terms of overall health and life expectancy. It has been The development of type 2 diabetes is often pre- proposed that control of LDL cholesterol and blood pres- ceded by a variety of altered metabolic states, including sure to normal levels in patients with the metabolic syn- impaired glucose regulation, dyslipidaemia and insulin drome, could result in preventing 81% of CVD events.14 resistance.3 Although not all people with such metabolicabnormalities progress to diabetes, their risk of develop- NICE guidance
ing the disease is significantly enhanced. However, In the light of these impressive results, the NICE Guidancerandomised clinical trials have demonstrated that type 2 ‘Preventing type 2 diabetes: risk identification and inter- diabetes can largely be prevented through diet and ventions for individuals at high risk’15 was published in July 2012. This guidance focuses on identifying people at highrisk of type 2 diabetes and on the provision of effective, The evidence
cost-effective and appropriate interventions for them. The In the Swedish Malmo study, increased physical exercise guidance does not advocate a national screening pro- and weight loss prevented or delayed type 2 diabetes in gramme for type 2 diabetes but includes recommendations patients with IGT to less than half the risk in the control to remind practitioners that age is no barrier to being at high risk of, or developing, type 2 diabetes. In a Chinese study, 577 individuals with IGT were ran- The 20 NICE recommendations can be used alongside domised into one of four groups: exercise only, diet only, the NHS Health Check programme; they are extensive diet plus exercise, and a control group. The cumulative and consider: risk assessment and encouraging people incidence of type 2 diabetes during six years was signifi- to have an assessment; two-stage risk identification; cantly lower in the three intervention groups than in the matching interventions to risk and reassessing risk; commissioning prevention services; intensive lifestyle- In the Finnish Diabetes Prevention Study, a 5% reduc- change programmes, weight management, dietary advice tion in body weight, achieved through an intensive diet and physical activity; vulnerable groups; audit and quality and exercise programme, was associated with a 58% assurance; training and professional development; reduction in the risk of developing type 2 diabetes in over- metformin and orlistat. The recommendations can be weight middle-aged men and women with IGT.7 The found online at: http://guidance.nice.org.uk/PH38.
reduction in the risk of progression to diabetes was A structured and comprehensive literature review of directly related to the magnitude of the changes in the international evidence base was undertaken by the lifestyle; none of the patients who had achieved at least Programme Development Group (PDG), the NICE proj- four of the intervention goals by one year developed type ect team and external contractors in order to develop the guidance. Where there are gaps in current knowledge, rec- The US Diabetes Prevention Program (DPP), compar- ommendations have been made for further research.
ing active lifestyle modification or metformin to standard Much less is known about the progression to type 2 dia- lifestyle advice combined with placebo, found that betes using glycated haemoglobin versus the oral glucose lifestyle modification reduced the incidence of type 2 dia- tolerance test (OGTT) as a marker, especially as the HbA1c betes by 58% in overweight American adults with IGT.9 assessment is much less sensitive to weight change. Thus, The goal of the programme was to achieve a 7% reduc- identifying which combination of risk-assessment tools and tion in body weight and physical activity of moderate blood tests are the most cost effective and effective at intensity for at least 150 minutes per week. The cumula- assessing the risk of type 2 diabetes is recommended.
tive incidence of diabetes was 4.8, 7.8 and 11.0 cases per Other recommendations for further research include 100 person-years in the lifestyle, metformin and control determining: the demographic characteristics and rates of COPYRIGHT 2012 JOHN WILEY & SONS 1
progression to type 2 diabetes among people with a high Pre-diabetes, diabetes and blood glucose control
risk score but with normal blood glucose levels; the most • Benefits and challenges of adopting a healthy lifestyle. cost-effective and effective methods of increasing uptake • Nutrients, digestion and blood glucose control. • Exploring of risk assessments; the components of an intensive pre-diabetes and diabetes. • 7 lifestyle factors. • Health results: what lifestyle-change programme that contribute most to the do they mean? • Setting goals to reduce risk. • Diabetes risk score effectiveness and cost effectiveness of diabetes preventioninterventions; the effectiveness of different types of dietary Weight management
and physical activity regimens; and the most effective and • Energy balance and the ‘Fat Attack’ DVD. • Eating for good cost-effective methods for identifying, assessing and man- health – food groups/portions, myths and misconceptions. aging the risk among high-risk vulnerable groups.
• Physical activity – benefits and FITT (frequency, intensity, time Further considerations.
and type). • Weight management and the 500-calorie deficit. • How to assess what I am eating. • Setting goals to reduce risk The PDG considered and made provision for the fact thattype 2 diabetes affects people of South Asian, African- Carbohydrate and saturated fat awareness
Caribbean, Chinese or black African descent up to a • Carbohydrate – amount and type for good health. • Fat – amount decade or more earlier than white Europeans. Although and type for good health. • Quiz to estimate the amount and type it is unclear what the prevalence of impaired glucose reg- of carbs and fat in everyday foods. • How to assess my carb and fat ulation and undiagnosed type 2 diabetes is among black, Asian and minority ethnic people aged 25–39 years in theUK, they have recommended that risk assessments should Reading and understanding food labels
be carried out in this age-specific sub-group and that • Challenges when shopping. • How to read food labels. health professionals provide advice and monitor accord- • Understanding the traffic light system and guideline daily ing to each person's particular risk profile.
amounts (GDAs). • What do the nutritional claims mean? People identified as being at high risk of developing • Identifying high and low risk foods. • Setting goals to reduce risk type 2 diabetes in the international diabetes prevention trials were identified by blood glucose tests, not by risk My health check
score. The guidance acknowledges that it may not be effec- • Body mass index. • Waist circumference. • Blood glucose. tive to intervene with all people identified as being at high • Blood pressure. • Blood cholesterol. • Troubleshooting for risk using a risk assessment tool as only a small proportion prevention. • Revisit food and activity diaries. • Setting goals to of people may have impaired glucose regulation. It has therefore issued two stages of risk identification. Stage 1acknowledges that while the risk scores can identify those Choices and consequences
at high risk and those who may have undiagnosed type 2 • X-PERT Game. • Revisit the health profile. • Questions and diabetes, they cannot be used to give a diagnosis of type 2 answers. • Setting goals to reduce risk. • Diabetes risk score. diabetes. If people refuse a blood test, they should be offered brief advice and/or a place on an intensivelifestyle-change programme instead.
Table 1. X-POD Programme Summary (website: www.xperthealth.org.uk)
The PDG considered that people over age 74 from all ethnic groups might benefit from type 2 diabetes risk in a range of settings, such as community pharmacies, assessment and prevention as the risk increases with age.
occupational health departments, community and faith- However, it recognised that many of the risk-assessment based centres where these people are more likely to visit tools are not validated for this age group and that comor- regularly. However, this raises a communication chal- bidities may prevent participation in lifestyle programmes.
lenge to ensure that the data are passed securely to the Nevertheless, there is evidence that older people can ben- person’s GP and that the person is monitored and efit from being more physically active and improving their diet, and the recommendations advise that people should A possible further limitation is the recommendation not be excluded on the basis of age.
that a variety of practitioners and organisations be The recommendations acknowledge that not all people involved in the diabetes prevention services. While this identified as being at high risk will develop diabetes.
may assist in raising awareness and improving the stan- However, informing them of the risk will not harm them dard and continuity of care for all risk groups, it may and may even have a beneficial effect on their lifestyle.
also cause problems as no single organisation or service Frequency of follow up is identified and included in the may take the lead. This could result in unnecessary recommendations for low, moderate and high-risk individ- duplication, unstructured care or the service being omit- uals. This will assist practitioners in providing good quality, Another communication challenge for practitioners considering an individual’s level of risk could be in the .and challenges
limitations of the health care computer systems. These There has also been consideration of people from lower have Read codes for recording impaired fasting plasma socioeconomic groups who may be less likely to attend glucose and OGTT but there is none for impaired HbA1c for a risk assessment or a blood test. This has led to a rec- nor for recording that someone has had a risk assessment, ommendation that prevention services do not have to be what their level of risk is, and whether they have been carried out by GPs or in GP surgeries but can be offered referred to an intensive lifestyle-change programme. Also, 2 PRACTICAL DIABETES VOL. 29 NO. 7
although the waist circumference clinical indicator is a Dr Trudi Deakin, X-PERT Health registered charity,
very important type 2 diabetes risk factor, it is not taken into account in the NHS Health Check programme.
Therefore there is a need to raise awareness and train Declaration of interests
staff to measure waist circumference as an initial step in The author is Chief Executive of the charitable not-for- Unfortunately, there are no recommendations for reducing type 2 diabetes in children and young adultsalthough the prevalence of type 2 diabetes in this age References
International Diabetes Federation (IDF). IDF Diabetes Atlas, 5th edn. Brussels, Belgium: International Diabetes Federation. www.idf.org/diabetesatlas [accessed 1 The guidance states that further research is required to identify effective dietary regimens in the prevention of Adler A, et al. APHO Diabetes Prevalence Model: Key Findings for England.
Associated Pubic Health Observatory, 2012.
type 2 diabetes. However, the literature did not include Knowler WC, et al. Preventing non-insulin-dependent diabetes. Diabetes nutritional epidemiology research already undertaken which has been summarised in a diabetes prevention 4. Ahmad LA, Crandall JP. Type 2 diabetes prevention: a review. Clin Diabeteseducator’s manual.16 Eriksson KF, Lindgarde F. Prevention of type 2 (non-insulin-dependent) diabetes mel- The X-PERT Prevention of Diabetes (X-POD) litus by diet and physical exercise. The 6-year Malmo feasibility study. Diabetologia Programme is an evidence-based, quality-assured inten- sive lifestyle-change programme that fully meets NICE Pan XR, et al. Effects of diet and exercise in preventing NIDDM in people withimpaired glucose tolerance: the Da Qing IGT and Diabetes Study. Diabetes Care guidance. It involves the delivery of person-centred, empowering lifestyle education initially over six consecu- Tuomilehto J, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle tive weekly sessions with follow up at three to six months, among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343–50.
Lindstrom J, et al. The Finnish Diabetes Prevention Study (DPS): lifestyle intervention 12 months and thereafter every year by trained educators.
and 3-year results on diet and physical activity. Diabetes Care 2003;26:3230–6.
An overview of the content of the programme is 9. Knowler WC, et al. Reduction in the incidence of type 2 diabetes with lifestyle inter-summarised in Table 1.
vention or metformin. N Engl J Med 2002;346:393–403.
10. Gillies CL, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance. BMJ 2007;334:299–302.
11. Isomaa B, et al. Cardiovascular morbidity and mortality associated with the meta- The NICE guidance for preventing type 2 diabetes is a bolic syndrome. Diabetes Care 2001;24:683–9.
much-needed and ambitious strategy to combat the rising 12. Lakka HM, et al. The metabolic syndrome and total and cardiovascular disease mor- tality in middle-aged men. JAMA 2002;288:2709–16.
prevalence of type 2 diabetes. Will it achieve what it rec- 13. Ford ES. The metabolic syndrome and mortality from cardiovascular disease and all- ommends or will it be largely ignored and gather dust in causes: findings from the National Health and Nutrition Examination Survey II the fight for competing resources? Only time will tell. If Mortality Study. Atherosclerosis 2004;173:309–14.
organisations were monitored and held accountable for 14. Wong ND, et al. Preventing coronary events by optimal control of blood pressure and lipids in patients with the metabolic syndrome. Am J Cardiol 2003;91:1421–6.
implementing the guidance, it is likely to have much 15. National Institute for Health and Clinical Excellence (NICE). Preventing type 2 dia- more impact. In the meantime, it is hoped that commis- betes: risk identification and interventions for individuals at high risk. NICE public sioners, managers and practitioners will see the huge health guidance 38. London: National Institute for Health and Clinical Excellence,London, 2012. http://guidance.nice.org.uk/PH38 [accessed 1 august 2012].
opportunity to prevent the diabetes pandemic by imple- 16. Deakin TA. The X-PERT Prevention of Diabetes (X-POD) Educator’s Manual. Hebden menting simple and cost-effective interventions. COPYRIGHT 2012 JOHN WILEY & SONS 3
V Jornadas de Jóvenes Investigadores Eje Ciudadanía-Democracia-Representación Cidadania e constitucionalização da questão urbana no Brasil Ana Paula Soares Carvalho Doutoranda em sociologia no Instituto Universitário de Pesquisas do Rio de Janeiro - IUPERJ Nesse texto, faz-se uma breve cronologia dos fatos que influenciaram o surgimento dos intrumentos legais cuja finalidade express