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Identifying People at High Risk of Type 2 Diabetes

Guidelines presents Primary Care Hacks, a series of clinical aide-memoires across a range of topics. Developed by Dr Kevin Fernando, Primary Care Hacks aim to provide a quick and easy resource for primary healthcare professionals and ultimately help improve patients' lives.

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Identifying People at High Risk of Type 2 Diabetes

Early identification of people at high risk of type 2 diabetes is pivotal in primary care to prevent the debilitating complications ofthe condition that impact both quality and quantity of life. This Medscape UK Primary Care Hack outlines who is at high risk of type 2 diabetes and how to identify them, and suggests interventions according to level of risk to reduce the likelihood of developing type 2 diabetes.

Click on the link below for a downloadable PDF of this Primary Care Hack

Identifying People at High Risk of Type 2 Diabetes

What is Prediabetes?
  • Prediabetes refers to raised blood glucose levels above normal but not above the diagnostic threshold for type 2 diabetes (T2D). HbA1c values of 42–47 mmol/mol indicate prediabetes[1] and a single test is sufficient. People living with prediabetes have an increased risk of developing T2D
  • Depending on what test is used, prediabetes can also be referred to as:[2]
    • non-diabetic hyperglycaemia (HbA1c 42–47 mmol/mol[3])
    • impaired fasting glucose (fasting plasma glucose [FPG] ≥6.1 and <6.9 mmol/l[4])
    • impaired glucose tolerance (2-hour oral glucose tolerance test ≥7.8 and <11.1 mmol/l[4])
  • Prediabetes is associated with an increased risk of all-cause mortality and cardiovascular disease (CVD) in the general population and in those with atherosclerotic CVD.[5] This has implications for the screening and management of prediabetes in the primary and secondary prevention of CVD[5]
  • Prediabetes is more than just dysglycaemia. A recent prospective cohort study found that reversion to normoglycaemia in those with prediabetes was only associated with lower risks of death and a longer life expectancy when accompanied by significant lifestyle change such as high levels of physical activity, not smoking, and maintaining a healthy bodyweight.[6]
Identifying Those at High Risk of Diabetes
NICE PH38 recommends a two-stage strategy to identify people at high risk of T2D (and those with unidentified T2D):[4]
  1. A risk assessment should be offered using a validated computer-based risk assessment tool, which can use routinely available data from individuals’ electronic health records such as QDiabetes-2018
  2. For those with high-risk scores for developing T2D (e.g., QDiabetes-2018 score ≥10%), a blood test for HbA1c should be offered
Additionally, if aged ≥25 years and of South Asian or Chinese descent with body mass index (BMI) >23kg/m2, there is no need to use a risk assessment tool and instead directly offer HbA1c blood test.
Special Populations of Note

Gestational Diabetes

  • Women with a history of gestational diabetes mellitus (GDM) are almost 10 times more likely to develop T2D over their lifetime than women without a history of GDM[7]
  • For women previously diagnosed with GDM and whose blood glucose levels return to normal after birth, NICE recommends:[8]
    • lifestyle advice (including weight management, diet, and exercise)
    • offer a FPG 6–13 weeks after delivery to exclude T2D (HbA1c should not be used until 3 months postpartum). Practically, this can be part of the 6-week postnatal check
      • if FPG <6.0 mmol/l, there is a low probability of T2D. Lifestyle advice should be reinforced and ensure under recall for lifelong annual HbA1c to check for progression to T2D
      • if FPG 6.0–6.9 mmol/l, the individual is at high risk of developing T2D and the Matching Interventions to Risk flowchart should be followed
      • if FPG ≥7.0 mmol/l, a diagnosis of T2D is likely, and Matching Interventions to Risk flowchart should be followed.

Polycystic Ovary Syndrome

  • Women living with polycystic ovary syndrome (PCOS) are 1.4 times more likely to develop T2D over their lifetime than women without PCOS[3]
  • This increased risk is independent of baseline bodyweight;[9] NICE recommends assessing glycaemic status with an HbA1c blood test at baseline in all women living with PCOS. Thereafter, glycaemic assessment should take place every 1–3 years lifelong, depending on the presence of other risk factors for developing T2D.[10]

People Living with Severe Mental Illness

  • People living with severe mental illness (SMI) are 1.3 times more likely to develop T2D over their lifetime than people without SMI[3]
  • The Lester UK adaptation: positive cardiometabolic health resource 2023 update gives recommendations relating to monitoring physical health in people living with SMI such as psychosis and schizophrenia.[11] The aim of this resource is to help reduce the health inequality of a 15–20-year mortality gap in people living with SMI[12]
  • For all people in the ‘red zone’ as depicted in the Lester UK adaptation: positive cardiometabolic health resource intervention framework for people experiencing psychosis and schizophrenia, including those with HbA1c ≥42 mmol/mol: don’t just screen, intervene!
  • Care should always be person-centred, tailoring discussion to the needs of the person to enable shared decision-making. Refer for investigation, diagnosis, and treatment as appropriate
  • For those at high risk of T2D (HbA1c 42–47 mmol/mol), offer referral to an evidence-based lifestyle change programme. If ineffective, offer metformin modified release if safe and appropriate. Aim for HbA1c <42 mmol/mol.


  • NICE recommends we use our clinical judgement on whether (and when) to offer metformin to support lifestyle changes in people at risk of T2D with rising HbA1c blood tests. Consider metformin if:[4]
    • HbA1c continues to rise despite participation in an intensive lifestyle change programme
    • the individual is unable to participate in a lifestyle change programme, particularly if BMI is >35 kg/m2
  • If commencing metformin, start low and go slow, e.g. 500 mg once daily and increase gradually as tolerated to 2000 mg daily. If the individual is intolerant of standard-release metformin, consider using modified-release metformin[4]
  • Prescribe metformin for 6–12 months initially. Check HbA1c at 3-month intervals and stop metformin if no benefit is seen.[4]
Managing Prediabetes—Key Interventions
  • By making changes to diet, increasing physical activity and losing weight, around half of cases of T2D can be prevented or delayed[13]
  • Review co-existing risk factors such as blood pressure, lipids, and smoking status.
Useful Resources

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Primary Care Hacks are developed by Dr Kevin Fernando, GP Partner, North Berwick Health Centre; GP with special interest in CVRM and medical education; Content Advisor for WebMD Medscape Global and UK. This Primary Care Hack, co-developed by Dr Eimear Darcy, GP Partner, Grange Family Practice, Omagh, is partly based on the authors' interpretation of relevant summaries of product characteristics. Primary Care Hacks are for information for primary healthcare professionals in the UK only. They bring together currently available recommendations and/or prescribing information and indications for therapeutics licensed within Great Britain. Licensed indications and/or prescribing information for Northern Ireland may differ. You are advised to review local licensed indications before prescribing any therapeutic. Primary Care Hacks are reviewed intermittently to ensure the information is up to date at the time of publication. Primary Care Hacks are independently produced by WebMD, LLC and have not been created in conjunction with any guideline or prescribing body.