Running head: INTEGRATIVE REVIEW PAPER 1

Integrative Review Paper

Charito Ward, RN

Bon Secours Memorial College of Nursing

Nursing Research

NUR 4222

Dr. Christine Turner

November 20, 2016

I PLEDGE.
 Abstract

The purpose of this integrative review is to evaluate studies regarding early education and

health maintenance in preventing Type-2 diabetes in adults by the age of 35. Type-2 diabetes is

an avoidable disease for most Americans. New diagnosis of diabetes occurs at an alarming rate

every year, and is the seventh leading cause of death in America. Early education on health

maintenance and food choices helps patients become aware of a sedentary lifestyle and poor

food choices can lead to type-2 diabetes.

The research design is an integrative review. The main search engine used was Google

Scholar due to ease of use. When a PubMed article was shown on Google Scholar the necessary

login process into PubMed was done. Google Scholar search engine produced 1,230,000

different results, five of which satisfied the components for research criteria. The results of the

five articles being used show evidence of the effectiveness on early education and health

management preventing the development of Type-2 diabetes. Current statistical information was

taken from the American Diabetes Association (ADA) website. The studies showed that early

education on diet and health maintenance had an impact on preventing or delaying the diagnosis

of type-2 diabetes, the articles state that the outcomes based on their study were positive and that

education is necessary. Additional research should study effectiveness of early education in

patients that are younger than 45 on diet and health management in the prevention of developing

Type-2 diabetes as adults.

 Integrated Review Paper

Type-2 diabetes is on the rise it is more relevant now than ever before. Currently 29.1

million people in America have diabetes, another 21 million people have it, but are undiagnosed

or do not know they have it (American Diabetes Association, 2016). The Population,

Intervention, Comparison and Outcome (PICO) question on how to address Americas current

diabetic statistics would be: Would early education and health maintenance reduce or eliminate

the risk of developing type-2 diabetes by the age of 35?

Many Americans who suffer from type-2 diabetes is usually due to poor food choices and

a sedentary lifestyle, possibly due to the neighborhoods they have to live in. This issue is

important because the relevance and cost. Currently 1.4 million American Adults are diagnosed

with diabetes each year; the youth population approximately 1 in 400 children are diagnosed

with diabetes yearly (American Diabetes Association, 2015). In 2012 the total economic burden

was 322 billion with 1 in 10 health care dollars spent on diabetes complications and 1 in 5 health

care dollars spent on treating people with diabetes (American Diabetes Association, 2015). That

means to the working Americans (who may or may not have diabetes) an increase in health care

insurance, higher co-pays, increased medical expenses and higher taxes to pay for treatment of

diabetes and its complications in America.

Design, Search Methods

The research design is an integrative review entailing how the reviewer conducted the

search for the literature pertaining to this study. Computer based search engines such as Google

Scholar, PubMed, Ebsco was used to find articles that had information specifically on education,

health maintenance, and prevention of Type-2 Diabetes.

 The key words used for the search engines included education, health maintenance,

Type-2 diabetes, prevention, and diet. Google Scholar was used more frequently due to

easier access to articles. Google Scholar provided more that 1,000,000 different articles

pertaining to the topic. To streamline the search engine results the word studies was added.

Articles were then included or excluded by titles and dates; articles past 2005 were dismissed.

The articles then had to address the PICO question For the low-income socioeconomic status

community, would early education and health maintenance reduce or eliminate the risk of

developing type-2 diabetes by the age of 35?

The five articles were then selected based on the inclusion criteria for the PICO question:

prevention or delay of type-2 diabetes, preventing type-2 diabetes, diet and nutrition, reducing

risk of development, changing lifestyle and diet. Although other articles had more relevance to

the PICO they had to be eliminated due to the articles being older than 2005 with no current

updated facts. Articles selected for the integrative review were based on having statistics,

methods of study, topics being studied, and patient outcome that was in favor of the PICO

question.

More prevalent studies that were cited in other articles referred to the Diabetes

Prevention Program Study (DPP) that was initially done in 2002; there have been updates to the

article and study since then. The screening produced five intervention/prevention articles, all five

articles were qualitative in nature with one of them predicting amount of Americans who will

develop type-2 diabetes.

Findings/Results

The findings and results of the five reviewed studies are as follows: The Diabetes

Prevention Program (DPP) done by the American Diabetes Association (ADA) in 2002 with
updates as late as 2014. Research design for the DPP was based on stratified randomized clinical

trials. Data collection for the study included frequent contact, ongoing intervention, 16 core

curriculum sessions ranging from 30 minutes to one hour, self-monitoring, supervised activity

sessions, centralized training, toolbox, feedback and support. The subjects in the ADA study

totaled to 3,234 participants with the mean age of 51. Women made up 68 percent of the total

subjects. Out of the total subjects 55 percent were Caucasian, 20 percent were African American,

16 percent Latino, five percent Indian and four percent were Asian. The sampling methods the

ADA used for this study was observation with intervention and annual follow-ups for many

years. The data analysis used for the DPP intervention and risk assessment at each subjects

baseline at the beginning of the study and annually since then, empirical literature was also used

for analysis of the subjects results. The conclusion that the DPP study drew; was through

extensive centralized feedback, training, support and education that the incidence of diabetes had

decreased by 58 percent eluding that the study was very successful.

The second study is The National Diabetes Fact Sheet done by the Center of Disease

Control (CDC) in 2011. The research design for the CDC study was past data from the CDC,

Indian Health Services (HIS), National Information Reporting System (NPIRS), U.S Renal Data

System of the National Institute of Health (NIH), U.S. Census Bureau, and published studies

which falls under a complete sample for their information. Data collection was from data that

was reported under multiple patient reporting systems. Sampling methods to produce prediction

numbers used the behavioral risk factor surveillance system. Data analysis from the CDC study

was taken from the national database, monthly telephone surveys, and state specific surveys. The

conclusion of this article produced the relevance of diabetes in Americans under the age of 20 is

26.6 million or 11.3 percent of this age group. The age group 26 to 65 is 10.9 million or 26.9
percent with type-2 diabetes. Men make up 13 million or 11.8 percent of the 20 and up age

group, with no medication intervention (Center for Disease Control [CDC], 2011).

The Third Article is Different strategies for screening and prevention of type-2 diabetes

in adults: cost effectiveness analysis (Gillies et al., 2008). Research design was based on cost

effective analysis base on development and evaluation of probabilistic, comprehensive economic

decision analytic model, from screening to death (Gillies et al., 2008, para. 2). The research

design was specific to formulate possible future cost versus prevention interventions to decrease

or eliminate diagnosis of type-2 diabetes. Data collection was obtained through previous

published clinical trials, epidemiological studies taken from electronic databases,

supplementary data collected from Department of Health Statistics for England and Wales,

Screening Those At Risk (STAR) survey and the ADDITION study from the Leicester division

(Gillies et al., 2008, para. 2). The sampling method for this article was a hypothetical

population, aged at 45 during the screening with a high risk of diabetes. Data analysis was done

through information received from the STAR survey, QALY survey and screening.

The overall conclusion the study provided was with appropriate intervention for those

who are in above average risk with the population aged 45, seems to be cost effective (Gillies et

al., 2008). The importance of this study for the integrative review is to show that early education

and intervention has financial benefits for patients as well as the American taxpayer by

alleviating preventable cost on a disease that can be avoided by a maintaining a healthy diet and

regular exercise.

The fourth study Reduction in weight and cardiovascular disease risk in individuals with

type-2 diabetes: One-year results of the Look AHEAD trial (Research Group et al., 2007). The

AHEAD acronym of the title is for Action for Health in Diabetes. The research design method in
this study used multi-centered randomized control trial based on stratified randomization. Data

collection was accrued from intensive lifestyle interventions, continuous care, ongoing

assessments, serum measures and statistical measures. 5,145 subjects participated in this study

and had the diagnosis of type-2 diabetes. The age range of the subjects was 45-74 years old and

Body Mass Index (BMI) greater than 25kg/m2. The subject group consisted of equal number of

male and female participants and the racial disparity in the group was 33%. Data collection used

by this study included anthropometry, one-year assessment, 15 category Rated Perceived

Exertion (RPE) scale, and serum measures. Data analysis in this article was preformed through

analyzing the covariance and logistic regression from the subjects baseline to the one-year mark

after interventions. Conclusions from this study found with diabetes support and education alone

there was a decrease in the subjects mean HbA1c but was not as effective as intense lifestyle

intervention with education. The results showed clinically significant weight loss in persons

with type-2 diabetes was associated with improved diabetes control and cardiovascular risk

factors (Research Group et al., 2007, p. 2). The study also showed that broadly achievable

weight loss improved risk for diabetes and cardiovascular risk. There was also a significantly

greater remission of metabolic syndrome in the subjects one-year after the trial started.

The final article for review is Type-2 diabetes prevention in the Real world (Absetz,

2007). Research design for this study was quantitative data through the use of Reach

Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE/AIM) surveys. Data

collection was gathered by using the subjects baseline labs, weight, measurements, and physical

fitness, as well as employment and education status comparing baseline results at three months,

six months, nine months and one year later. The subjects in this study were a total of 352 people,

of that total amount of people 103 were men, and 286 were women. Each of the subjects then
split into 36 different groups based on their home location from the closest participating medical

facility. Data collection was through anthropometric measurements, lab tests, and repeated

measures. Data analysis was done with comparison to the study subjects baseline results; x2

statistics was then applied and placed into the statistical analysis software package (SPSS). The

conclusion of this study was that with education, support, nutrition guides showed favorable

outcomes in risk factors such as decreased BMI, decreased waist circumference, and lower blood

pressure, by those measures alone the study stated that it is arguably unethical not to offer this

treatment to an individual (Absetz, 2007, p. 2468).

Discussion/Implications

The findings of the integrative review address the importance of early education on

nutrition and health management to prevent type-2 diabetes versus control groups in various

clinical outcomes concerning risk for development of type-2 diabetes. Therefore, the article

reviews directly relate to support the researchers PICO question. The PICO question specifically

asked about early education on nutrition and health maintenance in delaying or preventing the

development of type-2 diabetes. All five articles concluded that the diagnosis of type-2 diabetes

can me avoided or delayed by several years if a person makes healthy eating choices and

exercises frequently. Articles from the CDC and by Absetz, et. al, specifically state in their

conclusions that a proper diet alone can make a drastic difference in developing type-2 diabetes,

though diet and exercise together is much more effective.

All five studies focused on prevention of type-2 diabetes but touched on different aspects

of it. Two of the studies were quantitative in nature done by Absetz, et. al, and DPP studied

interventions to prevent the development of type-2 diabetes, primarily focusing on diet and
exercise; both articles came to the same conclusion that diet and exercise would reduce if not

eliminate the risk of developing the disease.

The article by the CDC was predicting in nature, stating the significance of the diagnosis

of type-2 diabetes yearly, that study stressed that nearly 215,000 people go undiagnosed who

currently have the disease and are unaware of it. The CDC study also mentions type-2 diabetes in

the major contributor to other diseases that lead to death and is currently the seventh leading

cause of death in the United States (CDC, 2011). The CDC study also mentioned the DPP studys

conclusion A large prevention study of people at high risk for diabetes, showed that lifestyle

intervention to lose weight and increase physical activity reduce the development of type-2

diabetes by 58% during a 3-year period. The reduction was even greater at 71% among adults

aged 60 years or older (CDC, 2011, para. 31).

The article done by Gilles, et. al, was a cost analysis study on interventions preventing

type-2 diabetes versus management and treatment of diabetes. Gilles, et. al, concluded that long

term compliance with interventions is an important consideration. Sensitivity analysis of

compliance with interventions found that even with compliance rates as low as 50%, the

screening strategies involving either lifestyle or pharmacological interventions were still cost

effective when compared with no screening (Gillies et al., 2008, p. 10). This study states that

lifestyle changes to eliminate the diagnosis of type-2 diabetes is still more cost effective than

doing nothing, backing the researchers PICO question of effectiveness on health maintenance.

The study done by M. Espeland explored the correlation with type-2 diabetes and

cardiovascular disease affected by a nutritious diet and increased physical activity had improved

diabetes control and cardiovascular risk factors reduced (Research Group et al., 2007, p. 9). The

findings again support the researchers PICO question by applying diet and exercise to the study
group showing reduction in metabolic syndrome, improved glycemic control and reduced risk of

acquiring cardiovascular disease. This study not only addressed diabetes they also linked it to

cardiovascular disease, again being reiterated by the article from the CDC stating diabetes causes

cardiovascular disease.

The only portion of the PICO question not addressed was the age set at 35. The

researchers reasoning to picking 35 years old is because of the clinical significance of developing

type-2 diabetes at a later age. The thought is that prevention intervention at a younger age could

possibly eliminate all risk of developing of type-2 diabetes. By 45 years old most people are

considered at risk for the development of type-2 diabetes. Addressing the risk of type-2 diabetes

at an earlier age would prevent diagnosis all together. Introducing a healthier meal plan and

exercise regimen early on can have vastly different outcomes opposed to waiting until patients

start presenting with symptoms and becoming at risk for developing type-2 diabetes.

Limitation

Due to lack of experience in the researchers history of conducting and integrated review

prior to this paper was seen as a limitation. Another limitation is only having five articles that

could be used for the review with particular information that needed to be addressed. The

reviewer had further limitations by isolating the dates of the search engine dating from 2005 to

present; this was done to have the most current and accurate information presented for the

review.

Conclusion

All five articles were extremely useful in assessing the importance of educating patients

on nutrition and exercise. Although each study focused on different topics, they all had the same

interventions applied in each one when obtaining their own data. The answer to the PICO
question: Would early education on nutrition and health maintenance reduce or eliminate the

diagnoses of type-2 diabetes by the age of 35? The answer is yes, it would.

Nurses play an influential role as a health care provider; typically nurses have a majority

of face-to-face contact with patients developing a bond and sense of trust with the patient. The

best implication to help a patient who may be at risk for developing type-2 diabetes is to educate

them on their risk and how important it is for them to make wiser nutritional choices. Nurses are

able to integrate patients culture or religion into meal plans to make the adjustment suited for

their needs and easier to comply with.

Additionally educating each patient on the importance of exercise to reduce weight,

eliminating the risk of diabetes. Nurses can give patients examples of what they can do for

exercise. Depending on the patients health status and capability, some patients may be able to

run, while others may only be able to walk. While nurses may not be able to treat diabetes, they

can help prevent the development of it by relaying crucial information and taking time to tailor

exercise and nutrition to each person.

 References

Absetz, P. (2007, October 10). Type 2 Diabetes prevention in the Real-world: One-year results

of the GOAL implementation trial [Article in journal]. Diabetes Care, 30(10), 2465-2470.

http://dx.doi.org/10.2337/dc07-0171

Center for Disease Control. (2011). National diabetes fact sheet: national estimates and general

information on diabetes and prediabetes in the United States, 2011 [Fact sheet].

Retrieved from Department of Health and Human Services, Centers for Diseas Control :

https://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf

Gillies, C. L., Lambert, P. C., Abrams, K. R., Sutton, A. J., Cooper, N. J., Hsu, R. T., ... Khunti,

K. (2008). Different strategies for screening and prevention of type-2 diabetes in adults:

cost effectiveness analysis (doi:10.1136/bmj.39545.585289.25). Retrieved from BMJ:

http://www.bmj.com/content/bmj/336/7654/1180.full.pdf

Research Group, L., Pi-Sunyer, X., Blackburn, G., Brancati, F. L., Bray, G. A., Bright, R., ...

Curtis, J. M. (2007). Reduction in weight and Cardiovasular disease risk factors in

individuals with Type-2 diabetes: One-year results of the Look AHEAD trial. Retrieved

from American Diabetes Association: https://www.ncbi.nlm.nih.gov/pubmed/17363746

The Diabetes Prevention Program Coordinating Center, Biostatistics Center (Ed.). (2002-2014).

The diabetes prevention program report (PMCID: PMC1282458). Retrieved from U.S.

National Library of Medicine National Institutes of Health:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282458/