Running head: INTEGRATIVE REVIEW 1

Integrative Review

Linda Phan

Bon Secours Memorial College of Nursing

Arlene Holowaychuk EdD, MSN, RN, CNE

Nursing Research NUR 4122

March 10, 2019

Honor Code “I pledge..”

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Abstract

The purpose of this paper is to analyze research articles on the comparison of diet and exercise to

reduce levels of fasting glucose and dieting alone as well as other lifestyle interventions.

Previous studies have shown that impaired fasting glucose also correlates with comorbidities

such as obesity, hypertension and high cholesterol. The PICO question under consideration is: In

impaired fasting glucose patient, what is the effect of diet and exercise on reducing impaired

fasting glucose compare to dieting alone? The design of this research is an integrative review.

Research articles were conducted on databases such as EBSCO host, PubMed and Nursing

research center. The results generated 4,290 articles and five articles met the criterion for this

integrative review. The five articles reveal that individuals who are diagnosed with impaired

fasting glucose are at risk of developing diabetes if interventions such as diet, exercise and

weight loss are not taken into consideration. There are a few obstacles to the review which

include limited experience by the researcher. This could result in the oversight in collection of

critical information and a delay in finalizing the study. Another obstacle encountered was the

amount of time the researcher had available to complete the study. Lastly, there were only 5

articles available for review which provided a limited amount of research to review. However, a

few positive outcomes of the review include the identification that early screenings and

intervention help to improve outcomes and reduce the quantity of people who suffer with

impaired fasting glucose.

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Integrative Review

The purpose of this integrative review is to analyze research articles on the comparison of

diet and exercise to reduce signs and symptoms of impaired fasting glucose to non-dieting and

exercise on individuals at risk for prediabetes. Research studies have indicated that about six to

nine percent of individuals with impaired fasting glucose progress to diabetes worldwide (Liao,

Nishida, Shahbazi & Zhao 2016). Although there are numerous studies on prevention of

prediabetes, the prevalence and risk factors of impaired fasting glucose continues to rise.

Lifestyle modifications such as diet and exercise are the “Gold Standard” for preventing diabetes

yet managing impaired fasting glucose level is still a struggle for primary care providers to

manage (Slentz et al., 2016). Furthermore, some research indicated that comorbidities such as

hypertension and hyperlipidemia are linked to prediabetes which makes it harder to manage by

many primary care providers. Prevention of the development of diabetes is being managed

worldwide because it is a major public health concern and cost billions of dollars (Shahbazi et

al., 2017). The aim of this review is to examine previous research on lifestyle modification to

improving impaired fasting glucose as it relates to the researcher’s PICO question: In impaired

fasting glucose patient, what is the effect of diet and exercise on reducing impaired fasting

glucose compare to dieting alone.

Design and Search Method

The research design is an integrative review. The articles that were researched were

utilized search engines such as EBSCO, PubMed and Nursing Research Center databases. The

search terms included ‘impaired fasting glucose’, ‘prediabetes’, ‘diet and exercise’, ‘prevention

of diabetes’, ‘glucose intolerance’, ‘comorbidities’, ‘lifestyle modification’. The results initially

yielded 26,784 articles from the Nursing Reference Center and 16 articles from EBSCO. To
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narrow the search, the search criteria was narrow down to scholarly peer-reviewed, qualitative

and quantitative nursing research articles published in English and written between 2015 and

2019.

The articles had to relate to the researcher’s PICO question, “In impaired fasting glucose

patient, what is the effect of diet and exercise on reducing fasting glucose compare to dieting

alone?” The articles were then chosen based on relevance and how it applies to the PICO

question. Any research articles that did not meet the criterion of the research information of

impaired fasting glucose, diet and exercise or lifestyle modification to prevent diabetes were

eliminated from the review. Limiting the search criteria produced five articles that are

quantitative.

Findings and Results

The findings and results of the five reviewed studies indicate that individuals with

impaired fasting glucose who do not participant in preventative measures such as diet and

exercise will progress to diabetes (Herman et al., 2017, Hong et al., 2016, Shahbazi et al., 2018,

Slentz et al., Zhao et al.). A synopsis of the research articles is included in the Appendix 1. This

review is structured based on the following themes found among impaired fasting glucose

individuals: impaired fasting glucose, prediabetes, and diet and exercise to improve impaired

fasting glucose.

Impaired Fasting Glucose

Three of the five research articles applied quantitative studies to examine the relationship

between impaired fasting glucose and diet and exercise (Hong et al., 2016, Nishida et al., 2018 &

Zhao et al., 2018). In a study conducted by Hong et al. (2018), the authors researched a cross

sectional study among adults in Northeast China and the prevalence of impaired fasting and the
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relationship on impact of diet and exercise. This detailed study sampled 15, 540 subjects in Jilin

Province of China. The methods of research conducted in this study by collecting questionnaires

from individuals and face to face interviews. The questionnaires included demographics, lifestyle

factors, and health status. The data was collected then analyzed using IBM SPSS 21.0 for

Windows and Kolmogorov-Smirnov testing. Participants were asked to fast for 12 hours and a

finger stick was performed on a blood glucose monitor. A logistic regression model was

analyzed to evaluate the relation of improving impaired fasting glucose to diet and exercise.

The results pointed out that the health status of the individuals with impaired fasting glucose who

did not diet, and exercise was 45% higher in their test. A P<.05 was considered statistically

significant.

In the second quantitative study, conducted by Nishida et al. (2018), the researchers wanted

to investigate Japanese adults who are at risk of impaired glucose level participate in a 12 month

diet and exercise intervention. This randomized controlled study was comprised of 5067

participants ages 40-69 of males and females. In order to meet the criteria of the study, all the

participants had to have health check-ups and those with HbA1c greater than 5.9% were selected.

Subjects were mailed invitation to participate in this study, out of this, 322 participants

responded that they want to be in the study. Subjects were separated into intervention group and

controlled group. Upon completion of the study, 180 participants actually participated. The data

was collected and analyzed using Fisher chi square tests and Student’s t test. A comparison test

was done using the analysis of covariance (ANCOVA) to compare the intervention group and the

controlled group. The result of the study indicated the intervention group had a decreased in

HbA1c to 5.4 while the controlled group measured at 5.5. Results of the research pointed out no

significant differences between the two groups. This study was consisted with other studies
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revealing the benefit of diet and exercise with weight loss to improving fasting glucose. Lastly,

in the cross-sectional study by Zhao et al. (2018), the researchers pointed out that impaired

fasting glucose puts individuals at risk for developing type two diabetes mellitus. Comorbidities

such as overweight and hypertension will put the individual with impaired fasting glucose at a

higher risk. Having these comorbidities in the long run can progress to type two diabetes

mellitus.

Prediabetes

Two of the five research articles integrated outcomes linking a prediabetes diagnosis

progressing to type 2 diabetes (Shahbazi et al., 2018 & Zhao et al., 2018). The experimental,

randomized clinical trial study by Shahbazi et al., (2018) examined the prevalence of individuals

with prediabetes integrating diet alone. The study consisted of a comparison between high

monounsaturated fat diet to normal fat diet without a weight loss program. The research

involved a sample of 322 adults with prediabetes. The first phase of the study was cross-

sectional and the second phase was a parallel randomized controlled clinical trial. Both study

was done on adults ages 20 and above in the small city of Sarableh, Iran in 2012.

The subjects were assessed by a trained dietician using block randomization to collect data.

Weight, height were measured and fasting blood glucose obtained after subjects ingested 75g of

glucose. Subjects were unaware of their results. These were measured at 12 months and 24

month. Subjects were asked to write down their dietary intake for three consecutive day. Self-

reported physical activity was collected using a Modifiable Activity Questionnaire. The data

was analyzed using Paired t test for group comparison. The Cox regression analysis was used to

estimate the relative risk of diabetes with 95% cumulative incidence and the P ≤ 0.05 was

considered statistically significant. The results revealed that the sample size was inadequate in
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measuring diabetes because there were only 336 subjects with prediabetes. Although the sample

size was inadequate, subjects with impaired fasting glucose who consume high-monounsaturated

fat and engaged in weight loss program revealed a slow progression to diabetes. This

combination and strategy is better seen in larger studies.

Lastly, a randomized controlled trial study by cohort researchers Zhao et al., (2018), reveal

that individuals with impaired fasting glucose are overweight or obese and at a greater risk of

progressing to type 2 diabetes. While there is evidence to explain that prediabetes can progress

to type 2 diabetes, lifestyle modifications such as diet and exercise can decrease this incidence.

Clearly, the findings designate that individuals with prediabetes are significantly at greater risk

of developing type 2 diabetes if not managed in a timely manner.

Diet and Exercise

Two of the five articles revealed a connection between moderate exercise compared to

moderate exercise with lifestyle modification to improving impaired fasting glucose in

individuals at risk for diabetes (Liao et al., 2015, & Slentz et al., 2016). The longitudinal, cross-

sectional study by Liao et al. (2015) examined the effects of moderate aerobic exercise to

improved impaired fasting glucose. The research included 120 participants diagnosed with IFG

were assigned to active group and controlled group in the city of Guangzhou, China. The active

group were recommended 30 minutes of moderate aerobic exercise such as jogging or brisk

walking five days a week. The controlled group were recommended with similar task but not

mandatory. After three months follow up, data was collected to compare the two groups. Data

was collected utilizing the laboratory from the hospital to collect blood samples of subjects for

glycated hemoglobin level (HbA1c) at baseline and three months follow up. Data was analyzed

using the multivariate regression analysis to analyze the relationship between exercise and other
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variables and a p value of <0.05 was statistically significant. The results from the study

suggested increased moderate exercise was beneficial in IFG.

In the quantitative research completed by cohort Slentz et al., (2016), the study examines

moderate-intensity exercise and diet versus vigorous intensity exercise alone could be beneficial

to manage impaired glucose fasting. This research was a randomized control trial that consisted

of 237 participants with impaired fasting glucose in Durham, NC and surrounding area from

2009 to 2012. The study included variables such as participants with pre-diabetes, sedentary

lifestyle and gender. Data was collected using a statistician, it was collected on the two-

controlled group, collected on active group and not inactive group, four computers and a

Beckman-Coulter DxC600 clinical analyzer. The data was analyzed using a two-tailed paired

(pre-intervention vs post-intervention) t test and the analysis were performed ‘per protocol’. The

result suggested that high amount of moderate-intensity exercise and lifestyle modification may

slow the progression to diabetes in individuals with impaired fasting glucose.

Discussion and Implications

The research articles selected for this integrative review suggested awareness of prediabetes

and how lifestyle modifications such as diet and exercise can prevent or slow the progression to

diabetes. The PICO question, in impaired fasting glucose patient, what is the effect of diet and

exercise on reducing fasting glucose compare to dieting alone, was explained based on the

research findings. The research convey the prevalence of individuals who have impaired fasting

glucose or glucose intolerance are at an increased risk of progressing to diabetes. The risk of

progression to diabetes is higher in individuals who have comorbidities such as obesity,

hypertension and high cholesterol as well. The quantitative studies conducted by Liao et al.

(2015), Nishida et al. (2018), Shahbazi et al. (2018), Slentz et al. (2016) and Slentz et al. (2016)
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points out the importance of preventing diabetes by incorporating diet, exercise and lifestyle

modification into reducing impaired fasting glucose.

The implications of these findings suggest that individuals with impaired fasting glucose

should take actions such as lifestyle modifications and manage their symptoms early in order to

prevent the progression to diabetes. Managing this problem should start early on and include

health care providers and prevention programs in early diagnose of prediabetes. When a person

has impaired fasting glucose, it is imperative that the individual takes measures to prevent further

progression because it is very costly further down the road to manage the diagnoses of diabetes.

Future research should integrate individuals with impaired fasting glucose taking actions to

reduce their risk of developing type two diabetes mellitus over several months and how their

actions improved.

Limitations

As in most cases, this study had its own hindrances and limitations. For one, the researcher

was limited in their experience which can have negative side effects on a research study. Also,

the five articles used for review were not in abundance. Also, the articles used were all written

within five years of each other, thus reducing the longevity of the collected information. The

research by Nishida et al. (2018) was limited to participants at one health check-up only and

cannot be generalized to other populations, and the research conducted by Zhao et al. (2018), the

research was cross-sectional needed follow up to validate their results.

In the research conducted by Shahbazi et al. (2018), the sample size was inadequate to assess

the significance of their findings. The study by Liao et al. (2015) needs further investigation

because genetic factors played a role in their research. Lastly, the research by Slentz et al. (2016)
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indicated that it was difficult for their participants to engage in moderate-intensity exercise when

these participants had a low fitness lifestyle.

Conclusion

The findings in this integrative review points out the relationship between impaired fasting

glucose and how lifestyle modification such as diet and exercise can reduce the prevalence of

prediabetes. Results in the five articles relates to the PICO question. The findings suggest that

individuals with impaired fasting glucose who do not engage or participate in lifestyle

modification such as diet, exercise and losing weight are at risk for the progression to diabetes.

Without early detection and management of prediabetes, in the long run, it can be costly and

detrimental to an individual’s life.

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References

Liao, H-C., Z., Si-gan., Peng, L., Chen, Wei-ben., Cheng, C., Wang, Yue-gang., Wu, Ping-Seng

& Xiao, C. (2015). Effects and mechanism of moderate aerobic exercise on impaired

fasting glucose improvement. Lipids in Health and Diesease 14(157), 1-6.

doi:10.1186/s12944-015-0117-z

Nishida, T., Shimaoka, K., Tsuzuku, S., Kazumasa, I., Sakakibara, H. (2018). Prolonged

intervention in Japanese adults at risk of impaired glucose or lipid metabolism. Asia

Pacific Journal of Clinical Nutrition 27(5), 1010-1017. doi:10.6133/apjcn.052018.06

Shahbazi, S., & Shariatpanahi, Z.V., (2017). Prevention of type 2 diabetes mellitus by changes in

diet among subjects with abnormal glucose metabolism: a randomized clinical trial.

International Journal of Diabetes in Developing Countries. 38(1), 69-74.

doi:10.1007/s13410-017-0548-3

Slentz, C.A., Bateman, L.A., Willis, L.H., Granville, E.O., Piner, L.W., Samsa, G.P., &… Kraus,

W.E. (2016). Effects of exercise training alone vs a combined exercise and nutritional

lifestyle intervention on glucose homeostasis in prediabetic individuals: A randomised

controlled trial. Diabetologia 7(59), 2088-2098. doi:10.1007/s00125-016-4051-z

Zhao, Q., Zhen, Q., Yong, L., Ruogu, L., Zhang, K., Qiao, Y., Kou., & Liu, Y. (2018). Prevelance

and risk factors of impaired fasting glucose among adults in northeast china: a cross-

sectional study. Endocrine Practice 24(7) 677-684. doi:10.4158/EP-2018-0046