Whilst significant time and effort is spent looking after patients with diabetes, this is merely the tip of a larger iceberg of people at risk of diabetes and cardiovascular. This ‘iceberg’ forms the basis for recent (July 2012) NICE guidance on preventing type 2 diabetes, risk identification and interventions for individuals at high risk . This guidance follows the adoption by the WHO of the use of HbA1c as a diagnostic tool (HbA1c >48mmol/mol/ 6.5%) and the identification of people with HbA1c 42-47mmol/mol (6.1-6.4%) as being at high risk – although it is acknowledged that this elevated risk may extend to people with an even lower HbA1c.
The recommendations can be divided into two:
1. Identifying people at risk of developing type 2 diabetes using a staged approach. This involves a validated risk-assessment score as well as taking into account age, ethnicity and co-existing risk factors. This score is followed by a blood test – either the fasting blood glucose or the HbA1c.
2. Providing those at high risk with a lifestyle-change programme to prevent or delay the onset of type 2 diabetes. These programs include increasing exercise levels, dietary modification and weight loss (10-15%). There is a significant body of evidence demonstrating the benefit of lifestyle modification in reducing the progression to diabetes. For those at lower risk, recommendations are made for ongoing screening.
This guidance also takes into account the use of Metformin and Orlistat in high risk patients who have not yet developed T2DM. The former being suggested in patients who continue to progress to T2DM despite lifestyle changes or those who are unable to make the changes. Advice on dosage, renal function is also give. The latter, suggested for people with BMI>28 who are unable to make lifestyle changes.
Clearly the majority of this guidance is aimed at primary care. In most cases, this new guidance dovetails with NHS health checks that are already being performed and will clarify the diagnosis of T2DM. However, with increasing emphasis and recommendations regarding structured education, diet and exercise, implementation may prove challenging for the new clinical commissioning groups.
Dr Mark Freeman