This is one of those guidelines that you look at, makes you want to cry, then wouldn’t normally bother to read. But it is actually packed full of really useful information and advice to give patients about diet and exercise. I will try to summarise the most useful bits, but it’s a long document… I have also put weblinks to exercise referral programmes, walking for health and some handy patient information onto the microsite under ‘patient wiki’. There really isn’t anything earth shattering in this, but it formalises everything, so hopefully fewer patients will be missed.
Why do we need to do this?
Lots of research has shown that using risk assessment to find people at risk of diabetes and then giving advice and programmes to help, reduces the risk of diabetes by up to 50%. The more changes the individual makes, the bigger effect.
What is risk assessment?
This is using a validated tool to identify those who could be at higher risk. It is being done opportunistically in health centres, GP, pharmacies and lots of other places. Patients do a ‘self-assessment’ screen online or by questionnaire. In GP surgeries it will be done by the computer (ie we don’t need to worry about that…).
Patients are then given a ‘low’, ‘intermediate’ or ‘high’ risk score.
Who should we target for risk scoring?
- Anyone over 75
- Anyone 40 to 74 (though these are part of the ‘NHS Health Check’ Process, so should be pulled in at some point anyway – so you need to worry less about this age group).
- Anyone 25 to 39 of South Asian, Chinese, Afro-Caribbean, black African or other higher risk ethnic group. They have a much higher risk of diabetes and a faster progression from impaired fasting glycaemia (IFG) to diabetes.
- Comorbidities – QOF will warn you of these people (CVD, obesity, PCOS, psychotic mental health conditions, learning difficulties). They need an annual check.
How do you do a risk score?
If a patient requests a ‘health check’, then use an online tool to work out their risk eg:
http://www.diabetes.org.uk/riskscore (looks flashy and has nice pictures)
http://www.qdscore.org/index.php (not so flashy, but has a smiley face chart to show risk)
These tell you if a patient is low, intermediate or high risk.
For people of the ethnicities above, consider doing a blood test if their BMI is > 23, regardless of the risk score.
What do you do once you have a risk score?
Low or Intermediate Risk – Explain that risk can still increase with age, so stress the importance of a healthy lifestyle. Review the risk assessment every 5 years.
High Risk – Do a fasting glucose (FPG) or HbA1C:
- Moderate Risk – FPG <5.5 and HbA1C <42 (6%)
- High Risk – FPG >5.5 or HbA1C >42
How do you manage people at ‘Moderate Risk’?
Give advice on how to lower their risk. A single appointment would be adequate for this. Advice would be on diet / exercise etc, including information on Walking for Health and local slimming clubs.
Review the risk at least every 3 years.
How do you manage people at ‘High Risk’?
Explain what this means and how they can prevent onset of diabetes.
Refer to a ‘Lifestyle Change Programme’ which will help with:
- Physical Activity (150 mins a week of moderate exercise – eg brisk walking or strenuous housework, or 75 mins of vigorous exercise – eg jogging or swimming).
- Achieving and Maintaining a healthy weight
- Review annually (including bloods).
Is there a role for drugs?
You can consider the following in high risk patients who have a worsening FPG despite taking part in a Lifestyle Change Programme, or who were unable to take part (for health reasons), even if they do not yet have diabetes.
- Metformin – you should stop it if the HbA1c doesn’t improve over 6 to 12 months.
- Orlistat – you can consider this if the patient has a BMI > 28.
How should you give advice to patients?
- Help patients understand the consequences of their health related behaviour.
- How social contexts and relationships change behaviour
- Look at their reasons for wanting change
- Look at their confidence for making change
- Easy steps for change - examples
- 5 to 10% weight in 1 yr
- Increase how far they walk or cycle
- Increase number of times a week they exercise
- Reduce inactivity time
- Stairs instead of lifts
- Help them plan and record goals
- “What if…” contingency planning (eg what if I don’t do exercise one week?)
- Barriers to change (eg get friends / family involved in diet / time for exercise etc)
- Self-regulation techniques (eg monitoring their goals (eg weight / waist measurement), managing relapse etc)