A Healthier Future: type 2 Diabetes prevention, early detection and intervention: framework

What action will be taken at a local and individual level?

Action and success at a national level will be supported by the provision of services and engagement at local and individual levels.

Risk stratification and promotion

There are two main purposes of promoting individuals to understand their risk category.

• For the early detection of at risk groups such those known to have an increased risk of type 2 diabetes due to weight, family history or age, those with previous or current gestational diabetes, and those clinically viewed as having pre-diabetes, IGT or IFHG.
• To identify those who are undiagnosed with type 2 diabetes in order to provide appropriate support and care.

All health and social care professionals should promote the process of risk assessment^[33]. Further information on support for professionals to carry out this can be found here.

Opportunities for promoting risk assessment are encouraged and need not take place in a GP surgery. Other possibilities include community pharmacies, dental surgeries, NHS walk-in centres and opticians. Assessments may also be offered in community venue for example workplaces, job centres, local authority leisure facilities, shops, libraries, faith centres, residential and respite care homes and day centres (for older adults and for adults with learning disabilities).

A two stage approach to identify people at high risk of developing diabetes involves:

• Using a validated risk assessment score to identify people at high risk of developing type 2 diabetes.
• A blood test for those identified at high risk to assess more accurately their future risk of type 2 diabetes.

Risk assessment tools use routinely available patient level data and offer a non-invasive way of identifying those at high risk of developing type 2 diabetes. We recommend the use of the Diabetes UK risk assessment tool which can be accessed online by individuals and health care professionals via the Diabetes UK website^[34]. Health care professionals may also choose to use another of the tools available to them such as the Leicester practice score or the Cambridge diabetes risk score.

The Diabetes UK calculator requires the input of the following information:

• Gender
• Age
• Ethnicity
• Indication of relatives with diabetes
• Waist measurement
• BMI (height and weight)
• Indication of high blood pressure.

From this information individuals are categorised into low, increased, moderate or high risk. Those at moderate or high risk are encouraged to visit their GP where they will receive a diagnostic test to better understand their risk and/or be diagnosed with type 2 diabetes. GPs are encouraged to keep a record of risk assessment results.

Other opportunities for identifying ‘at risk’ individuals are through ‘case finding’ technologies such as a decision support tools and SPIRE (Scottish Primary care Information Resource). Exploring these options and any potential development will take place in the first year of implementation. During this period we will also consider the position on an individual’s reassessment of risk and the opportunity of technologies to help with this.

Pathways of care and single point of entry

Any individual should have access to a local comprehensive weight management service with a single point of entry. Individuals could chose to self-refer into weight management pathways or be referred to weight management by a healthcare professionals such as GPs, practice nurses, physiotherapists and diabetes specialists.

All referrals would be received by a central triage point, where individuals would then be referred to the weight management programme best suited to their needs. The referral to the appropriate programme would be carried out on a case-by-case basis by a trained clinician. The intervention recommended should be individualised and informed by an assessment of the individual’s physical and psychological comorbidities, and their individual preferences.

Patient Story

I have had a history of type 2 diabetes in my family, going back for years. And that kept me on edge with everything surrounding the disease.

I was at risk of being diagnosed, as I ticked every risk factor: age, family history, Black/Africa ethnicity, overweight. I knew there were predisposing factors but I was not well educated on the practicalities of reducing my level of risk and this no doubt impacted me negatively. I still ate in large portions and did not pay much attention to my activity levels.

After living a life of apprehension without action, I eventually stepped into a  pre-diabetic state as confirmed by my doctor. This was a few years before my final diagnosis. I had some guidance on steps to take but still remained largely uneducated on how to manage pre-diabetes condition and keep from becoming fully diabetic.

My diagnosis with diabetes was difficult to take in, due to its ugly prints throughout my family. I struggled with emotions of fear—both of the unknown and of what I knew could materialize. I was terrified and burdened. 

As time went on, I had an internal battle with changing my mind-set, altering my habits and adapting to a new lifestyle. The good news is that with the help of appropriate education, information and support, you can overcome this initial mountainous situation. As a result the burden becomes much lighter.

After diagnosis, I got diabetic education, registered with the diabetes UK and increased my knowledge on how to live better with diabetes. I must note at this point that my GP was a great support to me. We agreed that lifestyle changes rather than medication would be my initial approach to managing my diabetes. She called in the dietitian and we had a plan set up around weight-loss, health eating, more exercise and water intake, meaning no more orange juice (which I loved!), She gave me practical tips to get me there rather than an obligation. She introduced me to sparkling water and a method to ween me off by first diluting my orange juice with this. That has made all the difference and can proudly say I drink water now, and lots of it

I would say that apart from not being able to find a support group in Aberdeen at the time of diagnosis, I got a great deal of support and encouragement from my GP.

Diabetes UK has also been a tremendous support. I have benefited from the organisation through their helpline and lots of researched information on their website. Volunteering and creating awareness alongside them has also been very impactful and helpful for me.

I have also enjoyed great support from the NHS with diabetes education, leaflets and annual retinopathy and podiatry reviews, as well as my six-monthly diabetic review. We also have doctors and dietitians from the NHS come and speak to us in our support group and this is great.

Another avenue of support that has been essential is My Diabetes My way. It has truly been instrumental in how I manage my condition. It is holistic, patient centred and so empowering. With it I can set attainable goals, document progress and achieve my targets.

In conclusion, with the help of my doctor, my dietitian and all the modes of support mentioned above, I have been able to keep a positive outlook concerning my condition. Moreover, I have managed my diabetes for the past 4+ years without medication, but solely lifestyle changes. The most important benefit of this is that I am now living a more disciplined life in regards to my health. It has also enabled me to continually seek for knowledge and information as to how best to manage my condition. As they say, knowledge is power!

Comprehensive weight management service for the prevention, early detection and early intervention of type 2 diabetes.

In order to provide comprehensive pathway of weight management support for those at risk and with type 2 diabetes, we recommend adopting a tiered approach to weight management programmes which relates to the level of risk for an individual. 

Level 1 – Universal services, health promotion and early detection

Level 2 – Early detection and early intervention

Level 3 – Targeted intervention

Level 4 – Complex case management

Alongside this tiered approach, the following elements should be included for a comprehensive weight management service for the prevention, early detection and early intervention of type 2 diabetes. These elements will be further informed by the further work on this area being carried out by NHS Health Scotland.

General weight management programmes

At levels 2 and 3 weight management programmes (for those who are not specifically ‘at high risk’ of type 2 diabetes but have BMI ≥30 kg/m2) should be provided. These programmes will provide a treatment-based approach which includes behavioural change strategies to support individuals to make changes to eating and physical activity habits. At present these programmes should be informed by NICE and SIGN guidance, be person-centred and flexible in delivery.

Psychological support

Diabetes is a complex health condition which can affect psychological health and wellbeing. People with a diagnosis of diabetes have different levels of need for psychological support. It is common for people with complex type 2 diabetes to experience both physical and psychological comorbidities, including depression, anxiety and eating disorders. Approximately 25% of people with diabetes have diagnosed depression. Offering timely psychological support and treatment for diabetes self-management around diagnosis (for example peer support, stress management), can also help to improve control of the condition and reduce future psychological morbidity^[35].

Psychological knowledge and skills are key components of tiered weight management interventions.

An understanding of the relationship between cognitions, emotions and behaviours in essential in the promotion of behaviour change and self-management, while the ability to recognise and appropriately respond to psychological disorder – for example stress and anxiety disorders, depression and eating disorders – is necessary in a patient population where the risk of psychological co-morbidity is significantly higher than in the general population^[36].

A number of psychological models have been demonstrated to be effective in supporting weight management, including health behaviour change approaches, Cognitive Behavioural Therapy and Compassion Focused Therapy^[37]. Such approaches can be adapted to be offered in a range of modalities/intensities:

Tier 1: Self-help resources developed for delivery in written or online format, highlighting links to publicly available resources and support organisations.

Tier 2: Guided self-help (tailored recommendations delivered by an appropriately trained individual in 1:1 contact) and psycho-educational groups.

Tier 3: Groups with an explicitly therapeutic focus, 1:1 psychological intervention using an explicit and evidence-based therapeutic model.

Tier 4: Highly specialist 1:1 intervention with complex case management.

Allocating a patient to the appropriate tier is a specialist role, in which data about multiple factors (e.g. patients’ physical and psychological co-morbidities, psycho-social circumstances, level of cognitive functioning, motivations for and barriers to change etc.) and from a range of sources must be synthesised. There should be a clear and explicit pathway for triage, screening and assessment for all patients referred to the weight management service. The resulting treatment plan should be based on a formulation: a shared understanding between patient and clinicians of what has initiated and maintains their present difficulties, and of the rationale for the proposed intervention.

Pathways for infants and children

Each NHS board should ensure that they have a variety of child healthy weight interventions. These include a health promotion initiative in schools that is delivered in conjunction with local education services. At a national level, agreement with education on the importance of this delivery in curriculum time is essential to ensure that this can be taken forward locally.

It is important that all child healthy weight services work collaboratively with Health Visiting and School Nursing teams to ensure that early intervention is possible for children and young people. The recent introduction of the Health Visiting Universal Pathway and the School Nursing Pathway provide a unique opportunity to engage with children and families at the early to help inform and establish healthy weaning and a positive relationship with food that enables families to make healthier food choices.

As part of the Universal Pathway the child health review points at 13-15 months, 27-30 months and 4-5 years provide a great opportunity for enhanced engagement around the promotion of child healthy weight.

NHS boards should also have a weight management pathway for all children with a BMI ≥ 91st centile. Childhood and family based weight management programmes  available for children with a BMI ≥ 91st centile should be evidenced-based and delivered by appropriately trained individuals. Current good practice in Scotland should be looked at to inform NHS boards about successful programmes such as ‘Get Going’ ‘SCOTT’, ‘SCOTTLITE’ and ‘HENRY’. As mentioned previously there is currently work underway to set minimum standards for Child Healthy Weight interventions to ensure equitable provision of services across Scotland. These will be available in 2019.

Wider support for individuals

Wider support should be available for all individuals who have been identified as ‘at risk’, clinically viewed as having pre-diabetes, IGT or IFHG, those with current gestational diabetes and recently diagnosed. Health and Social care professionals should signpost individuals to support groups available to them.

On average, people with diabetes spend three hours a year with a healthcare professional^[38]. For the remaining 8,757 hours they manage their diabetes themselves. People therefore need to be given the tools and support to help prevent type 2 diabetes and its complications.

The ALISS (A Local Information System for Scotland) Programme is funded by the Scottish Government and delivered by the Health and Social Care Alliance Scotland (the ALLIANCE)^[39]. The objectives are to increase the availability of health and wellbeing information for people living with long-term conditions, disabled people and unpaid carers and to support people, communities, professionals and organisations that have information to share. This is a resource that can signpost people to services in their locality.

Diabetes UK supports a collection of local groups across Scotland^[40]. These groups help those adjusting to the knowledge that they or a family member has diabetes which is helped by meeting other people who have been through a similar situation. They can offer understanding, help, support and shared experiences at an important time. They are all run by volunteers and typically meet on a monthly basis, often with a speaker on a topic like diet or physical activity.

Community groups and peer support are helpful even if people are managing their health conditions well. Diabetes UK has a peer support network which has members with a range of experiences and share different approaches to managing their diabetes^[41].

Level 4 

Complex case management

• Advanced weight management input and specialist interventions

Level 3 

Targeted intervention (for those diagnosed with type 2 diabetes, at high risk, with pre-diabetes or gestational diabetes)

• Structured education for those with diabetes
• Intensive weight management for remission
• Weight management programmes
• Psychological support

Level 2 

Early intervention (for those at moderate or high risk)

• Pre-diabetes education programme
• Metabolic antenatal clinics
• Maternal and infant nutrition pathways
• Weight management programmes

Level 1 

Public health awareness and early detection

• Public Health campaign
• Targeted messaging with core messages
• ‘At risk’ stratification
• Case finding
• Local level action

Levels of a tiered approach

Level 1 - Universal services, health promotion and early detection of type 2 diabetes

Alongside the actions outlined in the National Level approach to awareness raising, messaging, risk assessment and case finding (here), there will be a need to continue support to local partnership working. This could be achieved through community planning partnerships in order to develop and champion a cross-sector, whole systems approach to improving diet and weight locally.

On a local level, additional messages focusing on prevention of type 2 diabetes and the risk stratification process.

When identifying opportunities for local action, strategies such as the Diet and Healthy Weight Delivery Plan, Physical Activity Delivery plan, and Public Health Priorities should be considered.

Actions looking at these areas could be adjusted and adopted.

• Review legislative and regulatory controls to create a food environment that supports healthier choices.
• Improve access and opportunities to make healthier food choices using community development model to increase engagement, capacity and skills to support local food initiatives including practical cooking.
• Nurseries and Schools – Create health promoting environment and provide education and skills to support making healthier food choices and physical activity as well as healthy choices of food within school canteens.
• Workplaces – Big employers in local areas could lead by example promoting health and wellbeing through initiatives such as the daily step challenge or awareness raising sessions.
• Involving people with lived experience of attending a weight management programme or who have been diagnosed is a powerful way in which to communicate the positive message of modifiable lifestyle choices to reduce risk or improve a long-term condition and increase overall mental and physical health and well-being.
• Physical activity strategy - including a range of local agencies to encourage participation and remove barriers to access. This should involve partners across the Community Planning Partnership such as Active Travel Teams, Park and recreation services and leisure services.

Level 2 – Early detection and  early intervention

Alongside the general weight management programmes, programmes at this level should be looking to identify early those who are at moderate and high risk (as identified through risk stratification), and provide specifically designed interventions for those who would be classed ‘at high risk’ of developing type 2 diabetes.

1. Specially designed, quality assured lifestyle programmes for individuals presenting with pre-diabetes (impaired fasting glucose or impaired glucose tolerance)

Up to 50% of individuals diagnosed in the pre-diabetes range (IGT, IFHG - showing evidence of abnormal glycaemic control) will develop type 2 diabetes within 10 years. Targeting interventions at this high risk group are likely to be the most clinically effective in preventing progression to type 2 diabetes. More awareness of susceptibility to developing diabetes may lead to increased motivation to make changes and/or greater anxiety.

Referral Criteria:

BMI ≥ 30
HbA1c level - 42-47mmol/mol
Possible evidence of Impaired Glucose Tolerance
Possible evidence of Impaired Fasting Hyperglycaemia

Specially designed quality assured intensive lifestyle – change programmes such as Let’s Prevent^[42] and X-PERT^[43] should be available for patients in this category as stand-alone programmes or a precursor to weight management programmes and comply with NICE PH38 recommendations^[44].

Specific targeted programmes could include onward progression for individuals to other non-specialist, evidence-based weight management interventions for example, Counterweight.

IJBs could work together and co-deliver with consideration of entering into service level agreements through a tendering process, giving free classes at the point of service of qualifying individuals. This allows flexibility for the individual and enables delivery at a more localised level. For example, a joint weight management programme with local leisure partners could allow 12-24 weeks initial programmes of intensive specific education – followed by local weight management intervention - usually 1 year duration with follow up at 6 , 9 and 12 months – which would enable adhering to 18 months treatment time as per NICE PH38.

All programmes for this population should include an element of structured education covering behavioural change, physical activity, advice on weight management and intensive education and information on condition specific risks such as those with pre-diabetes (IGT, IFHG) and development of type 2 diabetes. There should also be links made to services that support people around wider determinants on health, such as poverty, housing issues and adult literacy.

2. Gestational Diabetes

All women with gestational diabetes should be offered dietary advice and weight management during pregnancy as they are at higher risk of developing type 2 diabetes after pregnancy. All women who have gestational diabetes should also be offered dietary and lifestyle advice and on-going participation in weight management programme in the post-partum period to minimise weight gain during pregnancies, avoid future gestational diabetes and on-going progression to type 2 diabetes.

A study of women with maternal obesity prior to their first pregnancy found that a weight loss of at least 4.5 kg before the second pregnancy reduced the risk of developing gestational diabetes by up to 40%^[45]. Therefore, women who are overweight and obese should be eligible for weight management services to reduce risk of developing gestational diabetes in a future pregnancy and their lifetime risk of developing type 2 diabetes.

Women with PCOS may also benefit from accessing weight management services in this way and clinical judgement should be used to determine this.

Support in this area should be provided in line with guidance from NICE NG3^[46]. This guidance has been updated by the Royal College of Obstetrics and Gynaecology, this section will be updated once this guidance has been published.

Level 3 – Targeted intervention

Alongside the general weight management programmes, programmes at this level should be targeted at those recently diagnosed with type 2 diabetes or those with type 2 diabetes who have shown interest in losing weight for better control of their condition, who are motivated in losing weight for potential reversal, and/or for avoidance  of complications or reduction of oral hypoglycaemic agents.

1. Structured Education for those diagnosed with type 2 diabetes

People with diabetes should be enabled and empowered to safely and effectively self-manage their condition by accessing consistent, high quality education and by creating mutually agreed individualised care plans.

Structured education is central to diabetes care and to the self-management of long-term conditions. A structured patient education programme should be tailored to an individual’s clinical and psychological needs and be adaptable based on educational and cultural needs.

Patient education aims to support people with diabetes to improve their knowledge, skills and confidence, enabling them to take increasing control of their own condition and integrate effective self-management into their daily lives.

People with diabetes should have access to this support at the time of initial diagnosis and then as required on an on-going basis, based on a formal, regular assessment of need.

The criteria that define a structured education programme are:

1. A philosophy

2. An evidence-based curriculum

3. Aims and learning outcomes

4. Delivered by a trained educator

5. Quality Assured

6. Audited

Each Managed Clinical Network (MCN) responsible for diabetes care should - as per  the DIP- ensure patients have:

• timely and appropriate access to high quality patient education and self management support (eg. DESMOND, Conversation Maps, X-Pert); and
• have access to appropriate high quality education.

During consultations, healthcare professionals should actively support self-management by listening to what matters to individuals, providing relevant information and signposting to education and third sector and community resources as well as evidence-based weight management programmes.

Each MCN is required to ensure the provision of a range of educational solutions including quality assured structured education for people with diabetes. Each MCN maintains records of educational provision and reports their progress towards meeting this standard to the Scottish Diabetes Group.

2. Dietary assessment and targeted intensive weight management support through specialist weight management services

Patients with type 2 diabetes should have access to specialist teams, with dietetic and psychological assessments and treatment options for intensive weight and diabetes management including behaviour change programmes.

These should integrate dietary advice with a personalised diabetes management plan, including other aspects of lifestyle modification, such as increasing physical activity and losing weight. This should be available as a precursor to, or directly after structured education – with assessment for suitability for intensive weight management for potential remission of diabetes.

For those with type 2 diabetes who are overweight or obese, an initial body weight loss target of 5–10% is recommended with emphasis that lesser degrees of weight loss may still be of benefit to management of condition and well-being. More significant weight loss will have advantageous metabolic impact^[47].

3. Targeted intensive weight management for those with type 2 diabetes through total diet replacement.

Consistent evidence shows that weight loss is associated with extended life expectancy for people with diabetes, and that weight loss of around 15 kg often produces total biochemical remission of type 2 diabetes, restoring beta cell function^[48]. Recognition that type 2 diabetes is reversible, has raised awareness that remission is possible^[49] and media attention has encouraged increasing numbers of people with type 2 diabetes to lose weight and enter remission.

Lifestyle-based programmes generally achieve a 12 month mean weight loss of 3-5kg and only around 1% of the eligible population can or will access bariatric surgery^[50]. An ‘intervention gap’ therefore exists between bariatric surgery and typical weight management programmes. However, intensive weight management programmes which utilise an initial phase of formula Total Diet Replacement are generating promising results for those clinically suitable and where appropriate for the individual^[51].

A recent systematic review showed people with type 2 diabetes do equally well using this type of approach as people who do not have type 2 diabetes.

The recently published DiRECT study showed that use of Counterweight-Plus achieved remission rates of 89% and 73% with weight losses of >15kg and >10kg respectively. An interesting observation in DiRECT was the high percentage of men (56%) recruited into the weight management programme^[52].

Referral Criteria

BMI ≥ 27
Recently diagnosed – up to 6 years from initial diagnosis.
Age 18 and over
Psychological assessment

Referral Routes

Those on insulin must be referred to this programme through a diabetes specialist in order to close monitor progress while attending the programme.

Programme standards and operation:

For provision of a targeted intensive weight management intervention, the following components should be included:

• Total diet replacement for 12 weeks (for example Counterweight-PRO800 provided through Counterweight-Plus, Cambridge Weight Plan or Optifast 800)
• Food reintroduction 12-14 weeks
• Weight loss maintenance period up to 26 weeks as minimum (ideally to the 2 year period)

Counterweight-Plus could be used to deliver a targeted intensive weight management programme for those with type 2 diabetes. The Counterweight-Plus programme was originally developed and refined through funding from Scottish Government. The programme includes standard training and competency checks, screening and intervention protocol, medical management, patient resources available and evaluation methodologies. On-going evaluation shows consistent mean weight loss of ~14kg at 12m^[53] and would be suitable for use at this level.

Achieving remission:

To date there is no internationally agreed consensus on the definition of remission for type 2 diabetes. We will consider the following which is in line with the ADA consensus statement on remission^[54].

Initial remission status is achieved at six months where a patient has HbA1c of <48mmol/mol, and is no longer taking oral and injectable hyperglycaemic medications for treatment of diabetes. Remission is achieved in where the above criteria are sustained for a period of one year.

We recognise that there is on-going discussion and will keep the position in review, with use of clinical data from the first year of implementation and in light of any new evidence.

Consider the messaging of ‘Remission’

Achieving a state of ‘remission’ for individuals with type 2 diabetes can be both motivating for encouraging weight loss and potentially damaging if results are not witnessed. Healthcare professionals are asked to use the term carefully and understand the impact it can have on individuals.

Additionally, weight regain is common following periods of weight loss. This in turn is linked with the possibility of diabetes relapse. Individuals must be made aware of this risk and accompanying medical management.

Level 4 – Complex condition management

The use of drugs as part of intensive weight management

Metformin

The Diabetes Prevention Outcomes Study (DPPOS) is the best evidence we have for the use of metformin in those at high risk of diabetes^[55]. It is recommended^[56] for practitioners to use clinical judgement on whether (and when) to offer metformin to support lifestyle change for people whose HbA1c or fasting plasma glucose blood test results have deteriorated if:

• this has happened despite their participation in intensive lifestyle-change programmes, or
• they are unable to participate in an intensive lifestyle-change programme, particularly if they have a BMI greater than 35.

Use of metformin should be discussed with patient and potential benefits and limitations, taking into account their risk and the extent of lifestyle changes required to reduce that risk.

Focus should be promotion of benefits of long-term lifestyle change (healthy diet, weight loss, behaviours change and physical activity) which can be more effective and will be provided as part of weight management programmes.

Orlistat

The best evidence for the use of orlistat in those at high risk of diabetes comes from the XENDOS study^[57].

Clinical judgement is required on whether to offer orlistat to people with a BMI of 28.0 kg/m2 or more, as part of an overall weight management programme plan for managing obesity and preventing onset of type 2 diabetes^[58]. This should take into account the patients overall health and the level of weight loss and lifestyle change required to reduce this risk.

Bariatric Surgery

For those who wish to consider bariatric surgery as a treatment option, individuals should be assessed against the priority groups and the conditions as set out in the National Planning Forum best practice guide^[59]. This is the current guidance which is due to be reviewed. This section will be updated accordingly.