Running head: CRITICAL APPRAISAL 1

Critical Appraisal

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Critical Appraisal

Introduction

Diabetes, a worldwide pandemic, continues to present huge health burdens for most

countries (Albright et al., 2000). Diabetes is considered a major risk factor for cardiovascular

disease development. In the United States alone, over 10 million diagnosed and 5 million

undiagnosed diabetes cases have been estimated in the general population (Albright et al., 2000).

However, a large portion of this disease burden falls upon the older adults and minority

populations (Castaneda et al., 2002). In particular, aging, coupled with unbalanced diets and

physical inactivity are some factors indicated to exacerbate the problem and/or induce insulin

sensitivity reduction. Globally, appropriate care of diabetes is largely essential at the primary

care, where individuals with type 2 diabetes are treated, and the best practice for disease

management is vital for success. The rise in the prevalence of type 2 diabetes, with associated

complications have called upon researchers (Albright et al., 2000; Castaneda et al., 2002; Conn

et al., 2007; Estacio et al., 1998; Michishita, Shono, Kasahara, & Tsuruta, 2008) to increasingly

investigate therapeutic measures proposed to enhance quality of life and improve health

outcomes.

Despite various studies documenting metabolic and/or glycemic control importance as

well as pharmacological advances in this area, diabetic adults often fail to reach the required

metabolic control levels, and this is found to be correlated with increased risks of medical

problems associated with type 2 diabetes mellitus (Conn et al., 2007). The great variety of T2D

complications and the limited time required to solve these problems make it difficult for nurses

to personalize care for patients, considering individual barriers and needs. It is even more

difficult when one has to choose from the various and increasing number of new standardized
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medications which may be beneficial, but also pose detrimental effects and risks. This problem

area of study is important to enhance evidence-based practice in nursing as it calls for non-

pharmacologic interventions, such as exercise to be an effective T2D self-management modality.

The present analysis is, therefore, conducted to integrate, review and synthesize research

findings examining therapeutic modalities for type 2 diabetes.

Aside from type 2 diabetes, a chronic disease proved to be among the leading causes of

mortality and morbidity in the adult population worldwide, other concepts studied in literature

are therapeutic measures likely to improve the disease outcomes (Albright et al., 2000;

Castaneda et al., 2002; Conn et al., 2007). In this regard, exercise, described as the physical

activity required to lower microvascular and macrovascular complications specific for diabetes is

the emerging theme. Glycemic and/or metabolic control are determined by literature as the

changes and outcomes in glucose tolerance, which show the role of physical activity on

metabolic reactions in individuals with type 2 diabetes (Albright et al., 2000; Castaneda et al.,

2002; Conn et al., 2007; Estacio et al., 1998). Maximal oxygen consumption is also a concept

studied to reflect individual’s oxygen endurance capacity following prolonged exercise. The

current scholarly works have explored the impact of behavior-change interventions on type 2

diabetes control and related risks. The PICOT question is: In adults with type 2 diabetes, does the

use of exercise programs change the risk of cardiovascular disease when compared to the use of

standard care within 6 months?

Major Concepts/Themes

The emerging concepts in the 5 studies include the effect of exercise on type 2 diabetes

with regards to metabolic and glycemic control and/or oxygen consumption levels of individuals

with T2D. From the articles, there is accumulating findings that cardiovascular disease is a
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resulting effect and a leading cause of mortality and morbidity in diabetic patients, but regular

moderate and high-intensity exercises are effective in T2D management. These physical

activities are associated with significantly improved glycemic and metabolic control, but such

improvement may be affected by increased years of diabetes or insulin insensitivity. The

rationale is that individuals with greater diabetic complications levels often have lower peak

oxygen consumption (Estacio et al., 1998), which affects exercise capacity. Nonetheless, acute

physical activity bouts can favorably change insulin resistance and abnormal blood glucose.

What was found similar in the studies is that frequent physical activities are beneficial in

the management of type 2 diabetes; appropriate physical activities enhance glycemic control and

increase insulin sensitivity. However, exercise capacity of the diabetic individual is important

(Estacio et al., 1998). The diminished exercise performance due to diabetic macrovascular

complications has negative implications for the ability of T2D individual to perform normal

activities, which may augment cardiac morbidity and mortality risks. In line with these findings,

Castaneda et al. (2002) demonstrated that resistance training significantly improved glycemic

and metabolic control, increased fat-free mass, reduced systolic blood pressure and abdominal

adiposity, and largely reduced the diabetes medication requirements. Therefore, subjects

undergoing resistance training are more likely to reduce many of T2D-related abnormalities

associated with the metabolic syndrome, including glucose intolerance, hypertension, and

hypertriglyceridemia. Similarly, other researchers (Michishita et al., 2008; Albright et al., 2000)

have found regular physical activity to have glucose-lowering effects and promote insulin

sensitivity. According to Michishita et al. (2008), such improvements in insulinogenic index

suggest better beta cell functioning after exercise therapy. Most importantly, all studies showed

an adverse effect of less-favorable glycemic status on mortality; increased fitness was shown to
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promote glycemic control and metabolic outcomes (Conn et al., 2007), and reduce mortality risks

associated with hyperglycemia.

However, there were mixed findings in literature on how exercise would be an effective

modality in the management of type 2 diabetes, especially following diagnosis; hence the

association between the capacity to exercise and cardiovascular disease. Some authors (Albright

et al., 2000; Estacio et al., 1998) pointed out that certain microvascular and macrovascular

complications associated with T2D impair exercise capacity. The rationale is that those with type

2 diabetes can adapt less to physical training as they have low maximal oxygen uptake (Estacio

et al., 1998), yet modest increases in maximum oxygen consumption is essential in major

reductions in cardiovascular risks and mortality rates (Albright et al., 2000). Thus, the findings in

NIDDM population without a coronary artery disease indicated a potential pathogenic

correlation between microvascular complications and exercise capacity (Estacio et al., 1998).

While some authors (Castaneda et al., 2002) emphasized high-intensity, progressive

resistance training to be effective in improving glycemic control and reducing defects associated

with metabolic syndrome, Michishita et al. (2007) found the insulinogenic index in T2D patients

to have improved even after a low intensity exercise therapy. Other researchers identified the

combination of exercise and medical nutrition therapy as essential for the initial T2D treatment

to the extent even when drug therapy is required, such measures of weight loss/maintenance are

necessary for maintaining drug therapy efficacy (Albright et al., 2000). As indicated by Albright

et al. (200), while a low-intensity level exercise is adequate to aid metabolic changes, in some

patients it may fail to meet the required minimum threshold of exercise capacity for improving

cardiorespiratory endurance.
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Critique of Research

The current studies, collectively, were designed to investigate diverse interventions for

improving self-management behaviors in T2D individuals, including increasing physical activity.

Overall, as far as cardiac benefits are concerned, the data from these studies support the efficacy

of non-pharmacological interventions to increase physical activity with or without emphasis on

other self-care improvements. Although recommendations to commence exercise may not be

appropriate for some populations with diabetic complications (Albright et al., 2000; Estacio et

al., 1998), the most promising of the current studies, however, is the potential well-being and

health gains of exercise therapy as outlined in the research. Most of the studies (Castaneda et al.,

2002; Conn et al., 2007; Estacio et al., 1998) incorporated controlled experiments to test

variations in the components and delivery of interventions. Such studies advance our

understanding of appropriate strategies for assessing and enhancing cardiac functioning in adults

with type 2 diabetes.

However, few limitations exist in the current studies. Some, by design, control subjects

would receive standard care only, thereby lacking the same contact period as exercisers

(Castaneda et al., 2002). These researchers also ignored the observed chest pains of participants

during training, yet this underscores the importance of proper medical screening, prescription of

the exercise, and supervision prior to implementing an exercise program. Consequently,

questions regarding the feasibility of employing exercise as the treatment for type 2 diabetes

present a number of potential pitfalls in the current type of studies. The 5 studies synthesized

and/or used a small/large number of male/female subjects of the total samples used, posing

unclear cardiovascular outcomes on whether women or men improve their behaviors less than

their counterparts. On one hand, the 5 studies benefit from a cohort of motivated subjects, who
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are particularly interested in their health and will most likely engage in follow-up. However, in

the real world, individuals with diabetes may lack the motivation, and if the non-

pharmacological intervention is interrupted, efficacy results from exercise programs are difficult

to achieve. In this regard, the current studies suffer from verifiability issues due to limitations

emanating from lack of tools to assess adherence to the interventions, reproducibility, and

fidelity.

With regards to the evaluation criteria of the 5 studies, it is important to note that the

problem, purpose, question and/or hypothesis development of the current studies have been

identified. These studies (Castaneda et al., 2002; Conn et al., 2007; Estacio et al., 1998) have

clearly stated their purposes, problem, question and/or hypothesis development, and are

congruent with the information articulated in the literature or references used. However, some

descriptive studies (Albright et al., 2000) have not specifically identified these items; some have

basically referred to them in the analysis (Michishita et al., 2008). The sample sizes used in these

studies (if any) are adequate to produce generalizability of results and reduce the threat of

sampling errors. The target populations have been clearly identified; the samples selected, and/or

inclusion/exclusion criteria explained.

Support for Innovation or Concept of Interest

In this research, the concept of interest is whether exercise can change the risk of

cardiovascular disease in patients with T2D when compared to the use of standard care within six

months. From the research findings, there is enough evidence to show that exercise is an adjunct

to standard care in individuals with type 2 diabetes (Castaneda et al., 2002), and is more effective

than pharmacological therapies as it can change the risk of cardiovascular disease in this

population. In line with this evidence, these studies exploring the correlation between exercise
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and T2D have revealed resistance training to be a potential modality for muscle strength and

endurance, improved body composition and flexibility (Albright et al., 2000), increased insulin

sensitivity and glucose tolerance (Castaneda et al., 2002; Michishita et al., 2008), while

decreasing risk factors for cardiovascular illnesses.

Why it would be emphasized that these studies focus on and support the fact that

exercise, compared to standard care, change the risk of cardiovascular disease, is that most

researchers incorporated quantified mechanisms comparing treatment and control groups. They

either focused on interventions that would only emphasize exercise therapy or those targeting

multiple health behaviors. These diverse studies (Albright et al., 2000; Castaneda et al., 2002;

Conn et al., 2007; Estacio et al., 1998; Michishita et al., 2008) analyzing wide-ranging

interventions to change diabetes behaviors presented important data to support our study

concept.

In a large part, the intervention being recommended here is a non-pharmacological one,

and the recommendations from the 5 studies are similar, though diverse. Of course, individuals

with type 2 diabetes are prone to various cardiovascular risk factors such as dyslipidemia and

hypertension (Albright et al., 2000). Therefore, behavioral interventions that incorporate

physically active lifestyles are recommended as they help in the effective control of blood sugar

levels and reduction of long-term complications of the disease. According to Albright et al.

(2000), exercise, coupled with medical nutrition therapy is recommended for the initial treatment

of T2D and lowering cardiovascular risk factors. Moderate weight loss has been found to aid

sufficient metabolic goals, and regular exercise and nutrition therapy combined are even more

effective in achieving quicker results unlike either alone of these strategies are used (Conn et al.,

2007). For instance, exercise is recommended as it results in the preferential upper body fat
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mobilization. When exercise is combined with proper balanced diets, loss of visceral fats could

be the resultant benefit leading to the reduction of obesity and substantial improvement in

metabolic indices. In particular, abdominal obesity is deemed a major cardiovascular risk factor

and aids the development of T2D (Albright et al. 2000). Exercise is, thus, a valuable adjunct

modality along with changes in food intake when it comes to long-term management of weight.

Besides, patients who indulge in regular exercises can observe better nutritional advice as

physical activity enhances self-esteem and mood, and consequently contribute to improved

control of food intake.

It is also stated that the psychosocial adjustments to T2D in later life may have significant

consequences on the patient’s perceived stress, psychological health (Albright et al., 2000) and

glucose control. Diabetic complications become more prevalent in individuals with long-

standing T2D and who require psychosocial adjustments (Estacio et al., 1998). Therefore, given

that the management of T2D is emotionally stressful, yet this stress can negatively affect

glycemic control, unlike clinical interventions, regular physical activities can be a vital step in

reducing stress while promoting psychological well-being and reducing cardiovascular risk

factors. The goal of T2D treatment is to achieve or maintain near-normal, if not normal blood

sugar levels (Michishita et al., 2008), but optimal lipid levels should also be achieved in order to

delay or prevent macrovascular and microvascular complications. Aside from improving insulin

sensitivity (Michishita et al., 2008), exercise, unlike many anti-diabetic medications, modifies

lipid abnormalities and changes hypertensive levels to prevent cardiovascular diseases (Albright

et al., 2000).

Nonetheless, exercise programs for adults with T2D and those without significant

diabetic limitations or complications should demonstrate appropriate exercise endurance and

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resistance for ensuring cardiorespiratory fitness (Estacio et al., 1998), appropriate body

composition, muscular endurance and strength (Albright et al., 2000). For that matter, the

research has recommended well-rounded resistance training program to help in maintaining or

increasing fat-free weight (Castaneda et al., 2002). In addition, appropriate intensity, frequency,

modes and duration of the exercise program should be identified for adults with type 2 diabetes.

In order to improve cardiovascular outcomes and secure successful results among adults with

T2D, interventions designed to encourage exercise regimen adoption should be responsive to the

current state of readiness of the patient and focus efforts on helping the individual move through

the various levels of behavioral change. Probably, for most exercise interventions, continuous

monitoring and positive reinforcement are crucial, and this can be made possible through a

variety of tools that deliver education, automated reminders, and counseling.

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References

Albright, A., Franz, M., Hornsby, G., Kriska, A., Marrero, D., Ullrich, I., & Verity, L. S. (2000).

American College of Sports Medicine position stand. Exercise and type 2 diabetes.

Medicine and Science in Sports and Exercise, 32(7), 1345-1360.

Castaneda, C., Layne, J. E., Munoz-Orians, L., Gordon, P. L., Walsmith, J., Foldvari, M., ... &

Nelson, M. E. (2002). A randomized controlled trial of resistance exercise training to

improve glycemic control in older adults with type 2 diabetes. Diabetes care, 25(12),

2335-2341.

Conn, V. S., Hafdahl, A. R., Mehr, D. R., LeMaster, J. W., Brown, S. A., & Nielsen, P. J. (2007).

Metabolic effects of interventions to increase exercise in adults with type 2 diabetes.

Diabetologia, 50, 913-921.

Estacio, R. O., Regensteiner, J. G., Wolfel, E. E., Jeffers, B., Dickenson, M., & Schrier, R. W.

(1998). The association between diabetic complications and exercise capacity in NIDDM

patients. Diabetes care, 21(2), 291-295.

Michishita, R., Shono, N., Kasahara, T., & Tsuruta, T. (2008). Effects of low intensity exercise

therapy on early phase insulin secretion in overweight subjects with impaired glucose

tolerance and type 2 diabetes mellitus. Diabetes Research and Clinical Practice, 82(3),

291-297.