National Institute for Health and Clinical Excellence (NICE)
Helping children and adults manage diabetes: NICE publishes updated suite of guidelines
Aiming for tighter blood sugar control is among the recommendations in a suite of updated guidelines from NICE to improve management of diabetes in children and adults.
Published today (Wednesday 26 August), the three NICE guidelines cover type 1 diabetes in adults, type 1 and 2 diabetes in children and young people anddiabetic foot problems.
“There are over 3 million people with diabetes in the UK. Around 10% have type 1 diabetes and 90% have type 2 diabetes. Diabetes is a long-term condition that has a serious impact on people who live with it. Everyone with the condition needs access to support and information, so that their condition can be managed successfully,” said Sir Andrew Dillon, NICE Chief Executive.
He continued: “The standard of diabetes care varies across the NHS. These updated guidelines are designed to help more people to receive the best treatment and support. They recommend effective and cost effective care and advice to NHS organisations on such things as setting up specialist services to reduce risk of diabetes-related amputation. Implementing these recommendations will help prevent serious illnesses linked to diabetes.”
Type 1 diabetes affects more than 370,000 adults in the UK. It occurs when the cells that normally make the hormone insulin are destroyed, and the loss of insulin results in high levels of glucose (sugar) in the blood. Over time, if type 1 diabetes is not detected and managed early it causes tissue damage which can result in blindness, kidney failure, foot ulcers which can lead to amputation, and also premature heart disease, stroke and death. Insulin replacement treatment (commonly insulin injections) that keeps blood glucose levels as near normal as possible, reduces tissue damage and in turn greatly reduces risk of all of these complications. This treatment is supported by actively managing other cardiovascular risk factors, such as high blood pressure and high cholesterol. Modern insulin replacement therapy aims to recreate normal changes in circulating insulin concentrations, with self-injected insulin doses adjusted to account for exercise, food intake and current blood glucose level, which the insulin user needs to test on a regular basis. The guideline on managing Type 1 diabetes in adults makes a wide range of recommendations including:
- Offer all adults with type 1 diabetes a structured education programme of proven benefit, for example the DAFNE (dose-adjustment for normal eating) programme. Offer this programme 6–12 months after diagnosis
- Support adults with type 1 diabetes to aim for a target HbA1c level of 48 mmol/mol (6.5%) or lower, to minimise the risk of long-term vascular complications
- Offer multiple daily injection basal–bolus insulin regimens, rather than twice-daily mixed insulin regimens, as the insulin injection regimen of choice for all adults with type 1 diabetes. Provide the person with guidance on using multiple daily injection basal–bolus insulin regimens.
Professor Stephanie Amiel, Professor of Diabetic Medicine at King’s College London and Chair of the NICE group which developed the type 1 guideline, said:“This NICE guideline provides evidence-based, practical advice on supporting adults with type 1 diabetes to live life to the full with few restrictions, and to avoid the serious complications linked to the condition and its treatment. Currently most adults with type 1 diabetes do not maintain the average amount of glucose in their blood (HbA1c) associated with fewer complications: life expectancy is reduced by over ten years and rates of kidney failure have increased. The new recommendations aim to ensure adults with type 1 diabetes can gain the information, support, skills and confidence they need to manage treatment regimens designed to improve HbA1c levels, and to make the most of technology improvements to support more normal blood glucose levels. These steps should result in improved outcomes for adults with type 1 diabetes – reduced complications and better health.”
Mike Kendall who has lived with type 1 diabetes for over 25 years and was one of two patient representatives in the group which developed the guideline, said: "I believe that the recommendations in this guideline have enormous potential to improve the lives of adults living with type 1 diabetes in the UK. The guideline acknowledges how infuriatingly individual and fickle type 1 diabetes can be for each person, and how important it is for people with the condition to be empowered in their own self-management. As a patient, the guideline allows me to measure my own care against an authoritative world-class standard. The version written specifically for patients and the public makes it easy to apply the guideline in my own situation and ask the right questions of my healthcare providers, while the full guideline offers the detail behind the recommendations if I need it."
For children and young people, type 1 and type 2 diabetes are covered in a single guideline. The 2013–14 National Diabetes Audit identified 26,500 children and young people with type 1 diabetes and 500 with type 2 diabetes, and both types of diabetes are becoming more common in the UK.
Dr Julie Edge, Consultant in paediatric diabetes at Oxford Children’s hospital and member of the group which developed the NICE guideline on diabetes in children and young people, said: “This national guideline is the first for children and young people with diabetes to recommend attempting to reach an HbA1c level near the normal range and nearly normal daily blood glucose readings. Achieving this tight control needs intensive insulin management from the time type 1 diabetes is diagnosed, which means multiple daily injections or insulin pump therapy. This is in addition to carbohydrate counting, which means matching the amount of insulin with the amount of carbohydrate eaten. We know that reaching and maintaining near normal blood glucose levels is difficult, but it reduces the tissue damage caused by high blood glucose, and so may avoid the long-term health problems caused by diabetes. It also reduces the risk of diabetic ketoacidosis which can be fatal. Because the ideal HbA1c target level of 48 mmol/mol (6.5%) or lower is hard to achieve, it is important that children and young people do not feel pressurised, and individual targets are discussed. Diabetes teams should provide all the help that children and young people need to stay as healthy as possible, including psychological support.”
Recommendations on managing type 1 and type 2 diabetes in children and young people include:
- Refer children and young people with suspected type 1 diabetes immediately (on the same day) to a multidisciplinary paediatric diabetes team with the competencies needed to confirm diagnosis and to provide immediate care
- Offer ongoing real-time continuous glucose monitoring with alarms to children and young people with type 1 diabetes who have: frequent severe hypoglycaemia (low blood sugar) or impaired awareness of hypoglycaemia associated with adverse consequences (for example, seizures or anxiety) orinability to recognise, or communicate about, symptoms of hypoglycaemia (for example, because of cognitive or neurological disabilities
- Offer children and young people with type 2 diabetes and their family members or carers (as appropriate) a continuing programme of education from diagnosis. Ensure that the programme includes the following core topics: HbA1c monitoring and targets, the effects of diet, physical activity, body weight and intercurrent illness on blood glucose control, the aims of metformin therapy and possible adverse effects, the complications of type 2 diabetes and how to prevent them.
Foot complications are common in people with diabetes: it’s estimated that 10% of people with diabetes will have a diabetic foot ulcer at some point in their lives. Diabetic foot problems mainly occur because of diabetic neuropathy (nerve damage or degeneration because of the high blood sugar levels) or peripheral arterial disease (poor blood supply due to diseased large- and medium-sized blood vessels in the legs), or both. Nerve damage can mean that injuries like cuts are unnoticed and can develop into an open sore on the foot – a diabetic foot ulcer. There is a risk that if the ulcer becomes infected that the foot tissue may die, and the foot might have to be amputated. Diabetes is the most common cause of non-traumatic limb amputation, with diabetic foot ulcers preceding more than 80% of amputations in people with diabetes.
Rachel Berrington, diabetes specialist nurse and NICE guideline developer said: “Diabetic foot problems are serious, and if not managed appropriately they can lead to minor or major amputations and even death. Mortality rates after diabetic foot ulceration and amputation are high, with up to 70% of people dying within 5 years of having an amputation and around 50% dying within 5 years of developing a diabetic foot ulcer. This guideline sets the standard for managing diabetic foot problems for all people with diabetes, including children and young people, in all NHS settings. For example the guideline identifies people who need immediate attention from the multidisciplinary foot care service or acute services. The guideline also highlights the need for clear information and education for all people with diabetes about diabetic foot problems, so they know what care to expect, the importance of foot care and who to contact in an emergency.”
- If a person has a limb-threatening or life-threatening diabetic foot problem, refer them immediately to acute services and inform the multidisciplinary foot care service so they can be assessed and an individualised treatment plan put in place. Examples of limb-threatening and life-threatening diabetic foot problems include ulceration with fever or any signs of sepsis, or with poor blood supply to the limb; possible deep-seated soft tissue or bone infection; or gangrene.
- For all other active diabetic foot problems, refer the person within 1 working day to the multidisciplinary foot care service or foot protection service for triage within 1 further working day
- Provide information and clear explanations about the risk of developing a diabetic foot problem to people with diabetes and/or their family members or carers when diabetes is diagnosed, during assessments, and if problems arise. Information should include basic foot care advice and the importance of foot care, foot emergencies and who to contact, footwear advice, and the person’s current individual risk of developing a foot problem.
The three updated guidelines are available at http://www.nice.org.uk.
For more information call Dr Tonya Gillis at the NICE press office on 0300 323 0142 or out of hours on 07775 583 813.
Notes to Editors
About the guidance
- The updated guidelines are:
- ‘Type 1 diabetes in adults: diagnosis and management’ –http://www.nice.org.uk/guidance/ng17.
- ‘Diabetes (type 1 and type 2) in children and young people: diagnosis and management’ – http://www.nice.org.uk/guidance/ng18.
- ‘Diabetic foot problems: prevention and management’ –http://www.nice.org.uk/guidance/ng19. Each guideline will be available at these links from Wednesday 26 August 2015.
- Diabetic foot problems mainly occur because of diabetic neuropathy (nerve damage or degeneration because of the high blood sugar levels) or peripheral arterial disease (poor blood supply due to diseased large- and medium-sized blood vessels in the legs), or both. Nerve damage can mean that injuries like cuts are unnoticed and can develop into an open sore on the foot – a diabetic foot ulcer. There is a risk that if the ulcer becomes infected that the foot tissue may die, and the foot might have to be amputated.
- Diabetic ketoacidosis is a serious short term acute complication of insulin deficiency, which can result in coma or even death if it is not treated quickly. It occurs when the body does not have enough insulin to allow enough glucose to enter cells to make energy, so the body switches to burning fatty acids.
- A special information leaflet for children and young people, “Type 1 Diabetes Technology: A guide for young people and families” has been jointly produced by Diabetes UK, INPUT Patient Advocacy and JDRF with input from NICE. It highlights new recommendations from NICE on treatments and technology for children and young people with type 1 diabetes. It also gives an update on some technologies that NICE hasn’t made recommendations on. It aims to help the young person or their family/carer when talking to their healthcare professionals about the technology they use to manage their diabetes. The leaflet is available at: www.jdrf.org.uk/type1techguide.
- The updated guideline on type 2 diabetes in adults will be published later this year.
The National Institute for Health and Care Excellence (NICE) is the independent body responsible for driving improvement and excellence in the health and social care system. We develop guidance, standards and information on high-quality health and social care. We also advise on ways to promote healthy living and prevent ill health.
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