National Institute for Health and Clinical Excellence (NICE)
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Updated NICE guideline published on the management of type 2 diabetes

The National Institute for Health and Clinical Excellence (NICE) and the National Collaborating Centre for Chronic Conditions (NCC-CC) this week (28 May 2008) issued updated guidance on the management of type 2 diabetes. The new guideline replaces existing NICE recommendations for the condition, revising areas where new information has become available, and will act as a single reference point for healthcare professionals on all aspects of the care and support that should be offered to people with type 2 diabetes.

Type 2 diabetes is associated with raised blood pressure and increased cardiovascular risk, and wide-ranging complications means that its management draws on many areas of healthcare. As a result, diabetes care is typically complex and time-consuming. The necessary lifestyle changes and side effects of therapy make education key in managing the condition.

The new guidance recommends that people with type 2 diabetes should receive structured and ongoing education from when they are first diagnosed, in order to help them understand and manage their condition. It also recommends that healthcare professionals should provide patients with information about a range of key issues including how best to keep glucose levels under control, how people can make sure they are safe to carry out normal activities such as driving, and individualised dietary advice so that people can make decisions that will keep them healthy.

Key recommendations are:

• Offer structured education to every person and/or their carer at and around the time of diagnosis - this can be in group sessions run by people who have been specially trained to do this

• Provide individualised and ongoing nutritional advice from a healthcare professional with specific expertise and competencies in nutrition.

• When setting a HbA1c target:

− Involve the person in decisions about their individual HbA1c target level, which may be above that of 6.5% set for people with type 2 diabetes in general

− Encourage the person to maintain their individual target unless the resulting side effects (including hypoglycaemia) or their efforts to achieve this impair their quality of life

− Offer therapy (lifestyle and medication) to help achieve and maintain the HbA1c target level

− Inform a person with a higher HbA1c that any reduction in HbA1c towards the agreed target is advantageous to future health

− Avoid pursuing highly intensive management to levels of less than 6.5%.

• Offer self-monitoring of plasma glucose to a person newly diagnosed with type 2 diabetes only as an integral part of his or her self-management education. Discuss its purpose and agree how it should be interpreted and acted upon.

• People who agree to start insulin therapy should be given:

− Education about how to use the insulin and the injection device prescribed, how insulin works, how it affects the body and how you need to think about and control what you eat and drink

− Information about hypoglycaemia, how to best avoid it and what to do if it happens

− Equipment to check blood glucose levels, and how to get helpful results and how to use them

− Support (on the phone and face-to-face) from a doctor or nurse with training and experience in managing insulin therapy.

Dr Gillian Leng, Deputy Chief Executive, and Executive Lead for this guidance says: “The medical care of someone with type 2 diabetes involves many different tests and check-ups which need to be repeated regularly and it can have a very disruptive impact on the lifestyle of the individual. This best-practice guidance brings together everything we know to help ensure that those with diabetes are supported to manage their condition and should ensure that the NHS is working to the same standards across England and Wales.”

Professor Jiten Vora, consultant physician endocrinologist and guideline development group member says:
“We know that people with type 2 diabetes are at a higher risk of a cardiovascular event - many have the same risk of a cardiovascular event as someone without diabetes who has already had their first heart attack. However, with the right care these risks can be minimised. The NICE guideline formalises care and sets out the level of information that needs to be provided by healthcare professionals to give people with diabetes the best chance of having a full and healthy life, for example by providing advice about losing weight. By bringing together everything we know on the care of people with diabetes, healthcare professionals will be best placed to offer individuals the very highest standard of care that they deserve.”

John Roberts, service user representative and guideline development group member says: “When I was diagnosed with type 2 diabetes twelve years ago, what I really wanted was a ‘hand book’ telling me all about the condition. This guideline takes the information-seeking and questioning that I had to do by myself and puts it into a package to give people the right level of support to help them manage their diabetes. Patient education programmes are already up and running in my area – these provide important advice, for example on diet and food portions and how insulin works. Many people I know have attended these sessions and have gone from knowing nothing about diabetes to being fully equipped to handle their condition.”

Kathryn Leivesley, specialist nurse and guideline development group member says:
“Being diagnosed with diabetes can throw up questions about how it fits into your lifestyle - from how it makes you feel to managing diabetes when you are exercising. Although there’s no known drug to cure the condition, clinicians can provide important practical help to individuals - for example, advice on how to ensure they are getting accurate and helpful blood glucose results. By putting a structured education programme in place, people with the condition and their carers will have access to good information when they need it most – this will mean they feel more confident in managing their condition.”

Dr Roger Gadsby, general practitioner and guideline development group member says:
“The incidence of type 2 diabetes is on the increase in England and Wales – and sadly so too are the complications of the disease. This guideline will help people suffering from type 2 diabetes, their carers and healthcare professionals make the best decisions about the steps that can be taken to effectively manage the condition and reduce the chances of these complications developing. Under this guidance, an individual’s doctor or nurse will assess their risk of cardiovascular disease at least once a year and provide tailored advice and support so that they can make necessary changes in their lifestyle and minimise their risk. ”

About NICE

1. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

2. NICE produces guidance in three areas of health:

public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector

health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS

clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.
About the guidance

3. The guidance is available at

4. Diabetes is a group of disorders with a number of common features, of which raised blood glucose is by definition the most evidence. The underlying disorder of type 2 diabetes is usually that of a background of insulin insensitivity plus a failure of pancreatic insulin secretion to compensate for this. The insulin deficiency is progressive over time, such that the high glucose levels usually worsen relentlessly over a timescale of years, requiring continued escalation of blood-glucose-lowering therapy

5. This guideline will update and replace the following existing NICE guidelines:

• Type 2 retinopathy
• Type 2 diabetes – renal disease
• Type 2 diabetes – blood glucose
• Type 2 diabetes – management of blood pressure and blood lipids

The guideline will also update and replace the recommendations on type 2 diabetes in the following NICE technology appraisals:

• Guidance on the use of long-acting insulin analogues – insulin glargine
• Guidance on the use of patient-education models
• Guidance on the use of glitazones

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