Entitled IMAGE (Development and Implementation of a European Guideline and Training Standards for Diabetes Prevention), the final recommendations produced by those involved in the project was launched at the 6th World Congress on Prevention of Diabetes and its Complications, Dresden, Germany on 9th April 2010. The IMAGE project involved experts from 20 countries, including diabetes specialists, GPs, nurses, patient organisations, public health and policy experts, health researchers, epidemiologists and behavioural scientists.
Prevention programmes aimed at preventing people who have high risk of type 2 diabetes from developing the illness have been proven to work, yet prevention strategies in Europe are fragmented. Programmes in Finland and Germany have led the way, but with the number of people with type 2 diabetes rising across Europe, the need for evidence based guidelines for putting prevention into practice is seen as a public health priority.
It is predicted that one in 10 Europeans aged 20-79 will have developed diabetes by 2030. Its reach is growing - once a disease of old age, diabetes is now affecting adolescents and children and the highest increase is in the 30-40 year old age group. Diabetes now accounts for up to 18 per cent of total healthcare expenditure in Europe and costs an estimated £9 billion per year in the UK.
However, recent evidence has proven that people who are on a 'metabolic trajectory' towards developing diabetes (which is largely driven by excess reserves of fat in the body) can be prevented from developing the disease. People who are at high risk of type 2 diabetes who can achieve relatively moderate changes in their lifestyle (5% weight loss, 150 minutes of moderate activity per week, changes in diet (fat and fibre intake) have a much lower chance of developing diabetes. In a number of recent, high quality trials, the rate of progression (after three to seven years) for people receiving interventions to support changes in diet and physical activity was halved (49%) compared with people receiving usual healthcare. Furthermore, the more lifestyle changes people made, the better they did - amongst people who made four of five lifestyle changes, the rate of progression to type 2 diabetes was 0 per cent.
The main result of the IMAGE project is a detailed evidence-based guideline (a set of evidence-based recommendations) on how to prevent type 2 diabetes in European countries. This includes recommendations on:
- How to define 'at-risk' and identify those people in the populations who are at risk for type 2 diabetes
- how to prevent type 2 diabetes in these people (through achieving changes in diet and physical activity as well as possible pharmaceutical-based strategies)
- how to support the changes in diet and physical activity needed to prevent type 2 diabetes, using both interventions with individuals or groups and through societal level /environmental changes.
The main conclusion of the guideline is: "Prevention using lifestyle modifications in high-risk individuals is cost-effective and should be embedded in evaluated models of care. Effective prevention plans are predicated upon sustained government initiatives comprising advocacy, community support, fiscal and legislative changes, private sector engagement and continuous media communication."
A further output from the work of the multidisciplinary team is "Take Action to Prevent Diabetes - the IMAGE Toolkit for the Prevention of Type 2 Diabetes in Europe". It is a practical guide on how to establish effective diabetes prevention programmes. Its collaborators have established a credible, concise, pragmatic and accessible document about how to effectively initiate and run a diabetes prevention programme.
The Toolkit provides those involved in healthcare and diabetes prevention a range of activities aimed at adults at risk of developing type 2 diabetes. It targets the following areas:
- Why is it time to act?
- How can I make a difference?
- How to budget and finance a prevention programme
- How to identify people at risk
- How to support behaviour change
- Physical activity to prevent diabetes
- Nutrition and dietary guidance to prevent diabetes
- Other behaviours to consider
- Evaluation and quality assurance
- Risks and adverse effects
Dr. Colin Greaves, Senior Research Fellow into Primary Health Care at the Peninsula Medical School and who contributed to the behavioural change chapters of the Guideline and the Toolkit, commented: "If politicians and healthcare providers were to use this guidance, to develop national strategies for the prevention of type 2 diabetes, this would be a quantum leap forward for health care policy across the region."
"Lifestyle interventions have been proven to work and the potential healthcare cost savings are immense. If high quality programmes, based on the IMAGE guideline are implemented to support lifestyle change in people at risk, the incidence of type 2 diabetes can potentially be halved.
"However, to deliver national strategies for diabetes prevention and reap these benefits would require substantial investments - well-trained prevention personnel working alongside GPs and nurses on a large scale. These systems could also be applied to managing cardiovascular risk. The question now is what will politicians and health services do with this information? In short, we know that diabetes prevention is possible and that the cost savings for health care and for society would be substantial - but do we have the courage to do it?"
He added: "By working with researchers and clinicians across Europe with a direct interest in diabetes, we have been able to create a practical guideline that can be implemented across the region with immediate positive effect on the health of the population and a longer term impact on the health services resources that will be needed to care for those with type 2 diabetes."
Gavin Terry, Healthcare Policy Manager at leading health charity Diabetes UK, said: "The enormous and worsening health challenge of Type 2 diabetes in the UK and Europe will only ever be tackled effectively with greater prioritisation of prevention strategies, coupled with vastly improved support for people to change their behaviours.
"Far greater numbers of people need to understand the symptoms and risk factors of this serious and costly condition. In the last ten years our risk assessment test, awareness road shows and pressure to improve early identification of Type 2 diabetes in primary care have helped half the figures of undiagnosed in the UK and prevented thousands from going on to develop the condition. Urgent investment in such schemes is needed if we are to stand any chance of reducing the future burden of Type 2 diabetes."
Anne-Marie Felton, President of the Federation of European Nurses in Diabetes, commented: "The imperative to establish sustained programmes for the primary prevention of type 2 diabetes in Europe is mandatory. The magnitude of the epidemic will overwhelm health care systems and failure to implement the evidence of the IMAGE programme will be a catastrophe for European society."
Professor Martin McKee, at the London School of Hygiene and Tropical Medicine, provided evidence on the importance of the environments in which people live, commenting that "the rapid increase in type 2 diabetes is a consequence of the remarkable changes in the ways we lead our lives during the past century. In so many ways, from cheap motorised transport to energy dense fast foods, we have created environments that are almost guaranteed to cause diabetes. Yet we also know that this is not inevitable. The IMAGE study has highlighted the contribution that prevention specialists can make to reduce the risk of diabetes but also why it is necessary for all levels of government to work together to develop policies that make it easier for everyone to make the healthy choice."
Collaborators based in the UK include:
Dr. Michael Hall, International Diabetes Federation
Colin McIntosh, Chelsea & Westminster Hospital and Kensington & Chelsea PCT
Kate Charlesworth, London School of Hygiene and Tropical Medicine
Professor Martin McKee, London School of Hygiene and Tropical Medicine
Dr. Colin Greaves, Peninsula College of Medicine and Dentistry
Dr. Philip Evans, Peninsula College of Medicine and Dentistry
Anne Felton, Federation of European Nurses in Diabetes
Deirdre Kyne-Grzbalski, Federation of European Nurses in Diabetes
Gavin Terry, Diabetes UK
The Peninsula College of Medicine and Dentistry