Position statements
Early identification of people with Type 2 diabetes
Diabetes UK welcomes recent Government commitment in Putting Prevention First to deliver a Vascular Checks: Risk Assessment and Management Programme (VRAM) in England (1).
The VRAM programme meets our long standing calls to establish proactive and systematic programmes to ensure early identification of more than half a million people with Type 2 diabetes who remain undiagnosed (2)(3)(4). With 67 per cent of men and 56 per cent of women being overweight or obese(5), the number of people with diabetes in the UK is expected to reach over four million by 2025(6) . It provides the NHS with a unique opportunity to make a significant difference to the lives of those who have Type 2 diabetes but do not know it and to those who are at risk of diabetes and other vascular diseases.
What is the Vascular Risk Assessment and Management (VRAM) Programme?
Diabetes is a disease of the vascular system along with coronary heart disease, stroke, and kidney disease. The VRAM programme aims to reduce the incidence of and premature death from vascular conditions. Adults between the ages of 40 and 74 years will be offered an individual assessment of their risk; to provide tailored advice, deliver appropriate support to change behaviours, detect undiagnosed diabetes and offer ongoing care and treatment. Currently more than 100,000 people are diagnosed with Type 2 diabetes every year in the UK(7) . Obesity, physical inactivity, smoking, poor diet, high blood pressure, high levels of fats in the blood (dyslipidaemia) and higher than normal levels of blood glucose levels but not high enough to be diagnosed as diabetes (Impaired Glucose Regulation) all increase the risk of vascular disease, including diabetes. The more risk factors a person has, the higher the chances of developing diabetes. The National Screening Committee produced The Handbook for Vascular Risk Assessment, Risk Reduction and Risk Management to support implementation using self-assessment, records based and opportunistic testing strategies(8).
Why is important for people with and at risk of diabetes?
National Diabetes Frameworks of England(9), Wales(10), Scotland(11)(12), and Northern Ireland(13) prioritise prevention and early identification of Type 2 diabetes. To date the NHS has not delivered on this public health challenge. Fewer Primary Care Trusts (57 per cent) were identified as having in place a programme for the early identification of diabetes in 2007(14) than in 2005(15) (60 per cent). Type 2 diabetes can be undetected for up to 12 years(16) resulting in up to 50 per cent of people presenting with complications at diagnosis(17). Evidence shows that there is a long and latent asymptomatic period in which the condition can be detected(18). Impaired glucose regulation (IGR) is associated with a 60 per cent increased risk of premature cardiovascular disease(19). Modelling has estimated that the Programme has the potential to prevent at least 4,000 people a year from developing diabetes(1). Evidence has shown that tailored lifestyle interventions lead to a 60 per cent reduction in progression to Type 2 diabetes in those with IGR(5)(13).
Calls to Action
Raising awareness of the Programme and healthy living is needed to increase public education and understanding of diabetes risk factors and how diabetes will be identified as part of a vascular programme, alongside communication of the continuum of risk. Diabetes UK Measure Up advertising and integrated awareness campaign has resulted in a 29 per cent increase in awareness of the risks of diabetes(20) amongst those at high risk of developing the condition. Risk is a complex concept and it will be necessary to develop better ways of communicating this to increase understanding about what it means and how to take appropriate action.
Impact on inequalities - Services must be designed to reach those communities with reduced access to mainstream health services, thereby working to reduce inequalities. Those living in deprived communities are 2.5 times more likely to have diabetes(21). People from South Asian communities are around three to six times more likely to have Type 2 diabetes(22)(23), and are more likely to develop diabetes at a younger age(24)(25)(26). Assessments will need to be delivered through a variety of settings, such as pharmacies and local outreach services, to increase accessibility.
Timing of assessments - Further research is required to identify the optimum timescale for assessing risk, testing for diabetes and review of those within medium and high risk groups. If a person has abnormal blood glucose readings but is not diagnosed as having diabetes (often referred to as IGR or pre diabetes), it is likely that reviews should be made more frequently. Until such evidence is available Diabetes UK recommends proactive case-finding every three years.
Improving access to tailored lifestyle interventions delivered by competent staff is key to supporting individuals to reduce their risks in an appropriate, safe and non-judgemental manner.
September 2008
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