Why take action to prevent type 2 diabetes?
Diabetes is a growing problem. The incidence and prevalence of all types of diabetes has been steadily growing in the past 10 years in part due to better care and better detection of type 2 diabetes. In 2016, over 257,000 people were living with a diagnosis of type 2 diabetes across Scotland, with 17,000 new cases each year  . Not all those living with diabetes have been diagnosed. It is estimated that around 10% of cases of type 2 diabetes remain undiagnosed  . Diabetes Scotland also estimates that over 500,000 people in Scotland are at high risk of developing type 2 diabetes  .
It is possible to change this trajectory.
Excess weight is the main modifiable risk factor for type 2 diabetes.
Having a body mass index ( BMI) in the overweight or obese range ( BMI > 25 and > 30 respectively) is the most significant modifiable risk factor for developing type 2 diabetes  . At present 87% of those with type 2 diabetes aged 18-54 are above their ideal weight  and in the Scottish population 65% of adults have a BMI in the overweight range including 29% are obese  .
Furthermore, obesity, physical inactivity and an unhealthy diet are associated with deprivation  . People in social class V (unskilled manual) are three and a half times more likely to be ill as a result of the complications of diabetes than those in social class I (professional)  . Moreover, short term mortality risk from type 2 diabetes is higher among those living in more deprived areas  . All these factors are inextricably linked to the risk of diabetes or the risk of serious complications for those already diagnosed  .
It is possible to prevent diabetes through targeted weight management interventions, which provide individuals with the support, skills and resources to improve their health and delay the onset of type 2 diabetes. Recent studies have also shown it is also possible to reverse a diagnosis of type 2 diabetes in those ‘recently diagnosed’ through intensive weight management programmes, which would enable an individual to achieve ‘remission’  .
Treatment for people with type 2 diabetes has significant cost at around 9% of the NHS budget and is expected to grow as the result of an ageing population  . Our initial focus will be on a specific weight management pathway for people ‘at risk’ or diagnosed with type 2 diabetes – a group that can be clearly identified and monitored.
This framework is included in the ‘A Healthier Future – Scotland’s Diet and Healthy Weight Delivery Plan’  . Outcome 4 states that people have access to effective weight management services including a pathway for those with type 2 diabetes. The actions detailed in the delivery plan highlight the complex interactions at play in maintaining a healthy weight in the communities we live in. Influencing the environments and ways in which we live, work and spend time requires a whole systems approach and will require changes to take place in our homes and communities, in the places where we eat, live and work, and through the lives we lead. In all these places we must – together – make it easier to eat well and be active.
Every year 17,000 people are diagnosed with type 2 diabetes in Scotland. 
An estimated 500,000 people in Scotland are at high risk of developing type 2 diabetes. 
87% of people with type 2 diabetes are above their ideal weight. 
Being overweight and obese is the most significant risk factor for developing type 2 diabetes. 
The NHS spends around 9% of its total health expenditure treating type 2 diabetes. 
Up to 50% of women diagnosed with gestational diabetes develop type 2 diabetes within 5 years of the birth of their baby. 
What action has already been taken?
Published in 2014, the Diabetes Improvement Plan ( DIP)  set out eight priority areas to support improved patient care, drive improvements in clinical outcomes and improve experiences for people living with diabetes.
Prevention is Priority 1 within the DIP – to support the prevention and early detection of type 2 diabetes, rapid diagnosis of type 1 and to implement measures to promptly detect and prevent the complications of diabetes.
The DIP focus on prevention has been multi-stranded and includes:
- An emphasis on the prevention of diabetic ketoacidosis ( DKA) in new onset type 1 diabetes.
- Prevention of complications by improving glycaemic control through campaigns such as ‘Know Your Numbers’ 
- Improving equality, access and uptake of structured education such as DESMOND for type 2 diabetes and STEP and DAFNE for type 1 diabetes.
- CPR for feet a campaign which aims make sure all patients with diabetes who are admitted to hospital have their feet checked on admission, if they are at risk of developing a foot ulcer their feet are protected and if they have a current foot ulcer they are referred appropriately.
This framework will progress the work on the prevention agenda to specifically target ‘at risk’ and ‘at high risk’ groups and those recently diagnosed with type 2 diabetes. It will also support work on the wider prevention agenda by promoting good health and raising awareness on how to reduce risks to the whole population.
How will the framework make a difference?
We know from evidence that risks associated with weight and type 2 diabetes are avoidable. We also understand that there is variation in the provision of weight management services across Scotland. The Scottish Government therefore will support delivery partners in our shared aim of improved weight management services to support better outcomes for people across Scotland.
This framework therefore sets out the pathway which will sit within wider weight management services. NHS Health Scotland is currently leading on work to agree minimum standards of an effective weight management service. This will be based on the principles that an effective weight management service supports the achievement and maintenance of weight loss, is person centred and encourages lifestyle changes.
The pathway for prevention, early intervention and early detection of type 2 diabetes is underpinned by the risk stratification process (see here) which will identify those ‘at risk’ of developing type 2 diabetes as well as those who could potentially reverse their condition. This will help in directing individuals to an appropriate weight management intervention and help individuals achieve and maintain a healthy weight, while possibly reducing their risk of developing type 2 diabetes and for those diagnosed the possibility for reversible or avoidance of complications.
The Scottish Government recognises that historically, specific groups of people have not been engaged in the types of prevention interventions set out below. Therefore, implementation of this framework will require services to be co-produced with people and communities with lived experience particularly to encourage greater participation among those vulnerable to health inequalities.
The framework is also supported by significant investment – £42 million over the next five years (See below).
The Scottish Government also recognises that people who are overweight or obese typically experience stigma and discrimination due to their weight and therefore all services, resources and campaigns must be designed to ensure positive promotion of both emotional and physical health.
How has the framework been developed?
The framework has been produced in collaboration with the prevention sub-committee of the Scottish Diabetes Group ( SDG). The sub-committee has been informed specialists in diabetes, dietetics, maternal health, public health, primary care and obesity.
The subcommittee used responses submitted to the ‘A healthier future: Actions and ambitions on diet, activity and Healthy Weight Consultation’ launched in 2017  to inform the content and presentation of this framework.
Analysis of these responses focused around the following themes:
- Positive reception to the increased investment in weight management services in the context that there is widespread variation in the availability of programmes across Scotland and agreement that a national approach would help.
- The need for a national approach to identifying those ‘at risk’ of and ‘high risk’ of developing type 2 diabetes.
- Concerns raised around the current limited referral route predominately by GPs to the services and a desire to incorporate other health and social care professionals so as to expand opportunities for discussing risk and highlighting the support available as well as facilitating self-referral.
- Differences in the nature and content of what constitutes an effective weight management service and the programmes within these.
How will the framework be funded?
£42 million will be invested to support the delivery of this framework and to provide increased weight management interventions for people at risk of or diagnosed with type 2 diabetes. This funding will be allocated over the next five years and will complement existing funding the Scottish Government allocates to health boards for weight management services for the provision of generic child and adult healthy weight interventions through the prevention bundle.
An initial £1.5 million will be allocated to early adopter boards in 2018/2019. They will begin the implementation of the framework. From year two of implementation, the intention is that all boards will receive funding that will increase annually for five years. All boards will receive a share of the £42 million.