Pre-diabetes and Type 2 diabetes: Risk-assessment tools for early detection and prevention
Submitting InstitutionUniversity of Leicester
Unit of AssessmentPublic Health, Health Services and Primary Care
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Summary of the impact
Around 2.5 million people in the UK have Type 2 diabetes, with many more
in a pre-diabetic state, Both conditions are hard to detect and frequently
remain undiagnosed and untreated for years. The cost burden to the NHS of
eventual treatment is estimated at £10 billion; 80% of which is spent on
complications that are, with good care, avoidable. Targeted diabetes
prevention programmes could aid in prevalence reduction and associated
costs. Leicester's Diabetes Research Centre has developed two risk scores,
both suitable for use with an ethnically diverse UK population, to detect
these conditions: a self-assessment questionnaire and a general practice
database tool. Recommended by NICE, they have been used successfully in
varied settings. Since July 2011, around 260,000 people have completed the
self-assessment score online and more than 40,000 through other means.
Benefits of early detection
Type 2 diabetes (T2DM) is one of the most common long-term conditions
globally; it is also non-communicable and potentially preventable. In the
UK around 10% of the adult population over 45 has T2DM, and diabetes
prevalence is increasing steadily due to an ageing population, high
obesity levels and a more ethnically diverse make-up. T2DM is preceded by
a pre-diabetic state called impaired glucose regulation (IGR).
Population-based screening studies have shown that around 20% of the adult
population over 45 has an undiagnosed glucose disorder and this prevalence
is significantly higher (up to six times) in those from black and minority
Need for novel screening strategies
Leicester's Diabetes Research Centre, one of the largest of its kind in
Europe, focuses on finding new ways of identifying people at high risk of
diabetes as well as developing effective interventions to stop, slow and
treat the condition.
In 2007, a study reported in the BMJ showed that timely treatment with
medication or modifications to lifestyle can delay or prevent progression
to T2DM in people with IGR, as well as the development of complications
such as heart and renal disease in people with T2DM (1). Despite
the evidence for these benefits, uptake in screening programmes is
generally low, and lower still in black and minority ethnic populations. A
qualitative study identified a number of barriers to uptake of screening:
the time commitment involved in attending a long appointment during
working hours, low self-perception of risk, difficulties with arranging
general practice appointments, and dislike of oral glucose tolerance tests
(2). The findings highlighted the need for novel screening
Two self-assessment scores for an ethnically diverse population
In 2008, the Centre offered screening within 20 general practices to
30,950 randomly selected people from Leicestershire, who had not been
previously diagnosed with T2DM (3). Of these, 6,390 took up the
offer, and a fifth were identified as either having undiagnosed T2DM or at
high-risk of developing the disease. A comprehensive set of data — sex,
BMI, waist circumference, family history of diabetes, history of high
blood pressure and ethnicity — as well as oral glucose tolerance tests,
was collected from all those attending.
This data was used to develop two scores to detect undiagnosed IGR or
T2DM in an ethnically diverse population; the results were published in
leading journals Diabetic Medicine and Diabetologia (4,5). The
Leicester Self-Assessment (LSA) score is based on factors known to the
patient and the Leicester Practice Risk (LPR) score is designed to enable
general practices to identify those at highest risk in their populations,
using routinely stored data (minus waist circumference). These are the
first scores that have been specifically developed or validated in a UK
multi-ethnic population. Both scores were externally validated using data
from a second screening study (6).
The tools have been successfully used to identify those at risk in
clinical studies led by the Centre: the Let's Prevent Diabetes trial used
the LPR score to rank people by risk of IGR/T2DM within general practices,
and those with the highest 10% of scores were then invited for
second-stage screening and a quarter of those screened were found to have
either IGR or T2DM (7). Similar results were seen for a study into
the Walking Away from Diabetes programme, a 3-hour course which offers
participants the opportunity to explore their risk of developing diabetes
and to identify the changes they need to make to remain healthy. The
self-assessment score is being used in two CLAHRC (Collaboration for
Leadership in Applied Health Research and Care) early detection studies,
ATTEND and PRISM, which have screened over 3,000 participants to date.
Key Leicester researchers: Melanie Davies, Professor of Diabetes
Medicine, 2006-present; Kamlesh Khunti, Professor of Primary Care Diabetes
and Vascular Medicine, 2007-present; Dr Laura Gray, Lecturer of Population
and Public Health Sciences, 2008-present
Other Leicester researchers: Dr Clare Gillies, Lecturer in Medical
Statistics, 2000-present; Dr Helen Eborall, Lecturer in Social Sciences,
2008-present; Dr Margaret Stone, Sen. Res. Fellow, 1999-present.
References to the research
1 Gillies CL, Abrams KR, Lambert PC, Cooper NJ, Sutton AJ, Hsu
RT, Khunti K. Pharmacological and lifestyle interventions to
prevent or delay type 2 diabetes in people with impaired glucose
tolerance: systematic review and meta-analysis. BMJ. 2007 Feb
10;334(7588):299. Epub 2007 Jan 19. Review.
2 Eborall HC, Stone MA, Aujla N, Taub N, Davies MJ, Khunti K:
Influences on the uptake of diabetes screening in primary care. Br J Gen
Pract 2012, 62(596):e204-11.
3 Webb DR, Gray L.J, Khunti K, Srinivasan B, Taub N,
Campbell S, Barnett J, Farooqi A, Echouffo-Tcheugui JB, Griffin SJ,
Wareham NJ, Davies MJ. Screening for diabetes using an oral
glucose tolerance test within a western multi-ethnic population identifies
modifiable cardiovascular risk: the ADDITION-Leicester study.
Diabetologia. 2011 Sep;54(9):2237-46
4 Gray L.J, Taub NA, Khunti K, Gardiner E, Hiles S, Webb
DR, Srinivasan BT, Davies MJ. The Leicester Risk Assessment score
for detecting undiagnosed Type 2 diabetes and impaired glucose regulation
for use in a multi-ethnic UK setting. Diabet Med. 2010 Aug;27(8):887-95.
5 Gray L.J, Davies MJ, Hiles S, Taub N, Webb DR,
Srinivasan BT, Khunti K. Detection of Impaired Glucose Regulation
and/or Type 2 Diabetes Mellitus, using primary care electronic data, in a
multi-ethnic UK community setting. Diabetologia. 2012 Apr;55(4):959-66.
6. Gray L.J., Tringham J.R., Davies M.J., Webb D.R.,
Jarvis, J.,Skinner T.C., Farooqi A.M., Khunti K. (2010). Screening
for type 2 diabetes in a multi-ethnic setting using known risk factors to
identify those at high risk: a cross-sectional study. Vascular Health and
Risk Management, 6:837- 42.
7 Gray L.J, Khunti K, Edwardson C, Goldby S, Henson J, Morris DH,
Sheppard D, Webb D, Williams S, Yates T, Davies MJ. Implementation
of the automated Leicester Practice Risk Score in two diabetes prevention
trials provides a high yield of people with abnormal glucose tolerance.
Diabetologia. 2012 Dec;55(12):3238-44.
NIHR. A community based primary prevention programme for Type 2 Diabetes
integrating identification, lifestyle intervention and community services
for prevention — the Let's Prevent Study. (June 2007-June 2014).
CLAHRC LNR. The Walking Away from Diabetes Study, The Leicester-self
assessment score, PRISM, ATTEND. (June 2008-June 2013). £10,234,278
NIHR: Development of a structured screening and lifestyle intervention
for prevention of Type 2 Diabetes Mellitus in a population with Learning
Disabilities. (Oct 2011-Oct 2016). £1,894,340
Details of the impact
Around 300,000 people have completed the self-assessment tools through
the Diabetes UK website, general practices, road shows, faith centres,
Boots and Tesco pharmacies and PCT-organised screening events. If T2DM
could be prevented in just 3% of these people as a result, this could
produce a gross saving for the NHS of £40m a year over four years.
Impact on policy
Both tools are now specifically recommended by NICE for identifying those
at high risk of T2DM (Khunti is Chair and Davies is a member of the NICE
guidance group; A,B).
The impact of the work around diabetes prevention led to Khunti and
Davies being invited, by the UK National Screening Committee, to lead on
developing the content and structure of The Handbook of Vascular Risk
Assessment, Risk Reduction and Risk Management (both the original 2008
version and updated 2012 version; C). Gray authored the section on
risk scores. The handbook is widely used within the Department of Health
and across the NHS and was also a major contributor to the development of
the Department of Health Best Practice Guidance (2009; D).
Impact on public expenditure
Modelling work by NICE showed that utilising risk scores in a screening
programme is cost-effective and is likely to be cost-saving in those from
black and minority ethnic backgrounds. Work carried out by the Centre
shows that the cost per case detected is lowered significantly, from £350
to around £200, by incorporating risk scores (E).
Impact on public health in the UK
Clinical commissioning groups: The self-assessment tool is being
used by clinical commissioning groups around the country at screening
events. It is also used to target people for the NHS Health Check, a
programme to prevent heart disease, stroke, diabetes and kidney disease.
Here it identifies those at high risk, who can then be given support and
lifestyle interventions to reduce their risk and prevent onset of these
Healthy Lifestyle roadshows: Diabetes UK has used the
self-assessment tool at local road shows since 2011. In 2012 (latest
available figures) they carried out 20,911 risk assessments and referred
10,945 visitors, 3,700 of whom were at high risk of having or developing
T2DM in the next 10 years. In a survey conducted in 2011, of those who
were in these higher risk categories, 69% had been to their general
practice or intend to go. Recall of the risk factors for T2DM and how to
reduce risk was high among visitors two months after attending the road
Evaluation of the use of the self-assessment score within Diabetes UK
activities showed that after being risk assessed: 41% had started to eat
more healthily and a further 44% intended to; 33% had increased their
physical activity levels and a further 43% intended to; and 44% of those
referred to their GP had been to their GP to seek a test. Bridget Turner
of Diabetes UK says: "The diabetes risk score plays an important part in
encouraging more people to take greater notice of their health and their
lifestyles — helping to tackle the growing public health challenge of Type
2 diabetes and working towards earlier diagnosis and prevention." (G).
Community Champions: Diabetes UK has embarked on a programme of
awareness-raising within black and minority ethnic communities by
recruiting 'Community Champions' — volunteers who are trained to deliver
healthy lifestyle and diabetes awareness messages, through information
stands and talks at community centres, places of worship and at festivals
and events. Over 100 champions have been trained in London, and the
programme is being rolled out in four other towns across England. Some
champions have been trained to undertake the risk assessments.
Faith centres: The test has been used with 200 people in three
faith centres in Leicester, by interpreters using iPads. It is being
adapted for use by non-English speaking Guajarati speakers.
Pharmacies: In conjunction with Diabetes UK the self-assessment
test is available in Boots and Tesco pharmacies: the latter is advertising
the service on buses, taxis, and London Underground carriages; on radio
stations and online; and in shopping centres and on high streets across
the UK In Northern Ireland during Diabetes Week 2011, Diabetes UK ran a
risk assessment event in 11 Boots stores: 140 risk assessments were
carried out, with 25 people referred to their GP. The Regional Pharmacy
Manager, Boots, said: "We were delighted with the success of our recent
work with Diabetes UK Northern Ireland. In helping to identify patients
who are at high risk of diabetes, we can work with other healthcare
professionals to ensure an early diagnosis is made and help people reduce
their risk." (H).
In Wales, the self-assessment score was used in 700 pharmacies as part of
a free health check initiative; the 10-day Diabetes UK Cymru/Community
Pharmacy Wales project 2011. This project involved an extensive media
campaign. More than 17,500 people visited their local pharmacy for the
assessment with 1,478 (8.4%) being referred to their GP for a diabetes
test after being found to be at high risk of developing the condition (I).
Online and TV: The test has been available on the Diabetes UK
website since 2011 and is now on the Boots and Tesco websites, free of
charge. It has been used by over 260,000 people since July 2011. It was
featured in the Embarrassing Bodies programme (Channel 4, 6 June 2011),
reaching around 2 million viewers. The automated tool allows for targeted
population-based screening within primary care and is available on the
University's website. It will soon be available through the Royal College
of General Practitioners website.
Khunti and Gray are part of the International Diabetes Federation's
PREDICT 2 project which is developing a global risk score to be used in
developing countries. Gray is currently developing risk scores for use in
Portugal and Spain.
Davies was awarded a prestigious NIHR Senior Investigator status in 2009
and this was renewed to the maximum term in 2012. The risk scores were
awarded gold at the national Quality in Care (QIC) Diabetes Awards 2011
for the best early detection/screening initiative, and Gray won the Best
Presentation Prize at the World Congress for the Prevention of Diabetes
Sources to corroborate the impact
A. Chatterton H, Younger T, Fischer A, Khunti K; Programme
Development Group (2012) Risk identification and interventions to prevent
type 2 diabetes in adults at high risk: summary of NICE guidance. BMJ.
2012 Jul 12; 345:e4624. doi: 10.1136/bmj.e4624.
B. National Institute for Health and Clinical Excellence (2012) Preventing
type 2 diabetes: risk identification and interventions for individuals
at high risk. Public health guidance, PH38. http://www.nice.org.uk/PH38.
C. UK National Screening Committee. The Handbook of Vascular Risk
Assessment, Risk Reduction and Risk Management (2012). www.screening.nhs.uk/getdata.php?id=14338
D. National Operations Manager, UK National Screening Committee/NHS
Screening Programmes. 10 July 2013
E. Khunti K, Gillies CL, Taub NA, Mostafa SA, Hiles SL, Abrams
KR, Davies MJ. A
comparison of cost per case detected of screening strategies for Type 2
diabetes and impaired glucose regulation: modelling study. Diabetes
Res Clin Pract. 2012 97(3):505-13. doi: 10.1016/j.diabres.2012.03.009.
Epub 2012 May 2.
F. Healthy Lifestyle road shows: http://www.diabetes.org.uk/Documents/Reports/nhs-health-
G. Director of Policy & Care Improvement, Diabetes UK. 14 June 2013
H. Diabetes UK Northern Ireland campaign: http://www.lurganmail.co.uk/news/boots-staff-help-identify-people-with-diabetes-risk-1-2911076.
I. Diabetes UK Wales campaign: