Components of an effective type 2 diabetes prevention programme

Prevention and remission of type 2 diabetes (SIGN)
Healthcare Improvement Scotland
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The recommendations are adapted from section 1.9 of NICE PH38: Type 2 diabetes: prevention in people at high risk.35

 

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Lifestyle behaviour-change programmes should offer ongoing tailored advice, support and encouragement to help people:

  • lose weight towards a healthier body weight
  • eat regularly, and develop and maintain healthy eating behaviours
  • undertake at least a level of physical activity that is in line with government recommendations.

 

Supporting behavioural change

 

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Use defined behaviour-change techniques, including:

  • Providing information: check and build on what individuals already know about healthy behaviours that help to achieve and maintain a healthy weight.
  • Exploring and enhancing individuals’ motivation about behaviour change and their confidence about making changes.
  • Goal setting: identify what positive long-term outcomes people want, and help them to set short-term goals related to a specific eating behaviour or physical activity to achieve this.
  • Action planning: support individuals to develop a plan focusing on a specific eating behaviour or physical activity they intend to change, including when, where and how they will do this.
  • Coping plans and relapse prevention: support individuals to identify and problem-solve barriers to maintaining healthful eating habits and physical activity. The aim is to review progress, adjust goals and move towards long-term, sustainable healthy habits.

 

Incorporate psychological wellbeing support into all aspects of prevention and early management of type 2 diabetes.

Psychological support for people on a type 2 diabetes prevention programme can help explore and overcome barriers to success. Specific behaviour-change techniques are defined in Online Tools for Behaviour Change.30 Training in the use of health behaviour-change techniques is delivered by the NHS Education for Scotland (NES) Motivation, Action and Prompts (MAP) programme: Behaviour change for health | NHS Education for Scotland

Diet and weight management

People living with overweight or obesity are at increased risk of developing prediabetes and type 2 diabetes.35 Dietary guidance including healthful eating and weight management can impact on the prevention and remission of type 2 diabetes as well as improving glycaemic control, reducing the risk of complications and improving quality of life and life expectancy.42 No single diet or weight-management approach is recommended as the superior choice for the prevention of type 2 diabetes. The key aspects are about acceptability and sustainability for the individual.

Dietary guidance should promote self management and always consider an individual’s treatment goals alongside practical challenges, values, cultural appropriateness, preferences, social circumstances and income.

In addition to BMI, waist circumference and waist-to-height ratio can be used to measure overweight and obesity.26

Public Health Scotland standards for weight management set out standards for targeted lifestyle weight management interventions (Tier 2) and specialist services to manage complex cases (Tier 3). Pharmacological therapies may be used at any stage in the model (see Pharmacological interventions). NHS Boards should take account of these standards and the pathways of care outlined in the Framework for the prevention, early detection and early intervention of type 2 diabetes (see Figure 3).42, 43

The Standards for weight-management include the following criteria for weight management services:

  • include both tier 2 and tier 3 services as described by the tiered approach to prevention and management of overweight and obesity for adults (see Figure 3, below).(Essential)
  • adopt the following referral criteria: BMI:
    • Services should make provisions so that adults with a BMI ≥30 kg/m2 are eligible for referral to weight-management services. (Essential)
    • Where there is capacity, adults with a BMI ≥25 kg/m2 should be able to access the service. (Desirable)
    • Lower eligibility criteria should be applied for Black African, African-Caribbean and Asian groups. Individuals from these groups are at an increased risk of conditions such as type 2 diabetes at a lower BMI. BMI ≥23 kg/m2 indicates increased risk and BMI ≥27.5 kg/m2 indicates high risk. (Essential)
    • Services should make provisions so that adults with a BMI ≥25 kg/m2 who are at moderate and high risk (as identified through risk stratification) of developing type 2 diabetes are eligible for referral to weight-management services. (Essential)
    • In cases where BMI entry criteria differs from national guidance, NHS boards must offer clear justifications for doing so.42

Figure 3: Tiered approach to prevention and management of overweight and obesity for adults

Diagram of a 4-tiered approach for management of overweight and obesity in adults
Click image to open in new tab.
Reprinted with permission from Public Health Scotland, Standards for the delivery of tier 2 and tier 3 weight-management services for adults in Scotland 2019.42

A range of foods and dietary patterns are suitable for weight management (see Diabetes UK and the UK Government’s Eatwell guide). The focus is on including vegetables, whole fruits, wholegrains, beans, pulses, nut and seeds and non-hydrogenated fats and oils, and reducing highly processed meats and high-fat products, sodium, sugary foods and refined grains.

The following recommendations are adapted from sections 1.13–1.14 of of NICE PH38: Type 2 diabetes: prevention in people at high risk.

 

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Encourage people to:

  • increase their consumption of wholegrains, vegetables and other foods that are high in dietary fibre
  • reduce the total amount of fat in their diet
  • eat less saturated fat.

 

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Advise and encourage people living with overweight and obesity to reduce their weight by reducing their calorie intake. Explain that losing 5–10% of their weight is a realistic initial target that would help reduce their risk of type 2 diabetes and also lead to other significant health benefits.

The following recommendation is based on the expert opinion of the guideline development group.

 

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Offer people with prediabetes or type 2 diabetes a structured weight-loss programme, in line with Public Health Scotland standards for weight management.

Physical activity

The UK Chief Medical Officers’ physical activity guidelines outline the weekly minimum recommendation for adults, with a clear distinction between ‘moderate’ and ‘vigorous’ physical activity. As with other components of the prevention programme, if this aspect is not being achieved then a personalised approach that finds out more about the barriers and takes personal circumstances and physical ability into consideration will help to establish what is most achievable for the individual. Physical activity does not necessarily mean exercise; daily physical household tasks, for example, can also contribute to health improvements.

 

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Routinely discuss the individual’s level of physical activity. Where someone is not meeting the recommended minimum, explore the barriers to this. Explain that even small increases in physical activity, such as reducing sedentary behaviour, will be beneficial and can act as a basis for future improvements.

 

Use a validated tool, such as the Scottish Physical Activity Screening Questionnaire (SCOT-PASQ), to assess the individual’s level of physical activity. This can be remeasured frequently to assess progress.

 

In shared decision-making  discussions about someone’s options for physical activity, be sensitive to any individual barriers such as health conditions, physical disabilities or eating disorders (see SIGN 164: Eating disorders).

 

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Consider referring people who want structured or supervised exercise to an exercise referral scheme or supervised exercise sessions.

References

  1. 26       National Institute for Health and Care Excellence (NICE). Overweight and obesity management. [cited 22 Jan 2025]. Available from url: https://www.nice.org.uk/guidance/ng246

  2. 35       National Institute for Health and Care Excellence (NICE). Type 2 diabetes: prevention in people at high risk. [cited 11 Sep 2024]. Available from url: https://www.nice.org.uk/guidance/ph38

  3. 42        NHS Health Scotland. Standards for the delivery of tier 2 and tier 3 weight management services for adults in Scotland. [cited 11 Sep 2024]. Available from url: https://www.publichealthscotland.scot/media/25614/standards-for-the-delivery-of-tier-2-and-tier-3-weight-management-services-for-adults-in-scotland-english-oct2019.pdf

    43        The Scottish Government. A healthier future: type 2 diabetes prevention, early detection and intervention: framework. [cited 11 Sep 2024]. Available from url: https://www.gov.scot/publications/healthier-future-framework-prevention-early-detection-early-intervention-type-2/