1

Evidence-Based Practice Paper

Caroline Manrubia, Mariafernanda Osornio, Ashley Peña, and David Valdez

University of Arizona
 2

Evidence-Based Practice Paper

The topic of this evidence-based practice paper is to evaluate the effect of prediabetes

status on an individual’s overall health. To promote overall health for a patient with prediabetes,

nurses can utilize Integrative Nursing Principles (INPs). INPs are based on the ideology that

people are whole systems, and their health and well-being depend on factors including their

environment, connectedness with nature, and relationships. As nursing professionals, each nurse

plays a critical role in a patient’s experience, and by connecting INPs with a patient’s diagnosis

and care, nurses can optimize patient outcomes. Regarding a patient’s overall health with

prediabetes, we recognized the importance of INP #4, which states that integrative nursing is

person-centered and relationship-based. Nurses can use this principle to establish trusting

relationships with their patients and evaluate how a diagnosis like prediabetes may affect other

aspects of a person’s life and health. We also determined that INP #5, which states that

integrative nursing is evidence-based, is relevant to this topic. Nurses who know and utilize the

evidence behind correlations to prediabetes status and overall health can better educate patients

and help them succeed (University of Minnesota, 2021). According to the Centers for Disease

Control and Prevention, approximately 88 million adults in the United States are prediabetic and

more than 80% are unaware of their prediabetic status (Centers for Disease Control and

Prevention [CDC], 2021). Due to these staggering numbers, health care professionals must

educate their patients on prediabetes status and learn and anticipate the health outcomes for these

patients. As nurses, a large part of our commitment to patients is education. By establishing

relationships with their patients, understanding common themes in changes to overall health with

prediabetes, and offering evidence-based education, nurses can help prediabetic patients navigate

their diagnosis.
 3

Background and Purpose

The term diabetes mellitus stems from Greek and Latin terms meaning to siphon or filter

something sweet. A history of diabetes treatment included prescribing dietary changes such as

consuming wine, promoting starvation, and purposefully overeating to compensate for excess

fluid loss. (Mandal, 2019). Modern health sciences have made leaps and bounds since the days of

wine and starvation prescriptions. We now understand that diabetes is the manifestation of low or

inhibited insulin production, resulting in elevated blood glucose. Pharmaceutical scientists have

developed many medications to regulate insulin production for diabetic patients. While medicine

allows us to manage this condition, the number of individuals affected by diabetes continues to

grow. Researchers estimate that approximately one-third of adults in the United States have

prediabetes, but only 11% are thought to be aware of their prediabetic status (Li et al., 2021).

Knowledge of prediabetes and patient intervention, including changes in diet and exercise, has

been correlated with a decreased risk for developing diabetes (Li et al., 2021). One study found

that prediabetic status awareness was correlated with the perception of being overweight and a

desire to change weight and diet (Owei et al., 2019). Nurses can help patients navigate the health

changes that accompany a prediabetic diagnosis if we can anticipate what changes are likely to

occur. The purpose of this paper is to explore what health perceptions and health outcomes are

correlated with a prediabetic diagnosis so that we may better serve patients who have this

diagnosis.

PICOT Question
 4

We have sought to answer the question: “Does awareness of pre-diabetes status influence

overall health status in adult patients?” This question is classified as a prognosis/prediction

question as it addresses the anticipation of the course of a disease. (Northern Arizona University,

2021). The goal of asking this particular question is to understand the common themes in

changes in health status after a patient has received a prediabetes diagnosis. As nursing students,

we are also interested in understanding the correlation between nursing interventions and the

health and wellbeing of prediabetic patients. To research this topic, group members searched for

relevant studies using the PubMed and CINAHL databases. Students selected search limitations

for article publication dates between 2017-current, and limitations to only include articles with

the full-text available. The PubMed and CINAHL searches included terms such as prediabetic

status, nursing + prediabetes, and health + outcomes + prediabetes.

Critical Appraisal of the Articles

Article One 

This nurse-intervention study sought to examine the efficacy of a nurse-led

self-management education program on glycosylated hemoglobin in adults with type 2 diabetes

mellitus (Azami et al., 2018). This quantitative, randomized control trial used 142 adults with

type 2 diabetes chosen at random to receive standard diabetes care or standard diabetes care

accompanied by nurse-led self-management education (Azami et al., 2018). The study was

conducted inside endocrine labs in Iran with adults over 18 years of age diagnosed with type 2

diabetes for a minimum of 6 months. Patients in the control group received standard diabetes

care. The intervention group received the standard care for diabetes and 24 weeks of nurse-led

diabetes self-management education (DSME). Researchers examined samples of 10 cc of

venous blood obtained from participants after an 8-10 hour fast. One laboratory examined all
 5

blood samples and derived values for blood levels of HbA1c, total triglyceride, total cholesterol,

and high-density lipoprotein. The results obtained revealed an HbA1C level of <7% in

participants of the intervention group. The control group showed no difference in HbA1C levels.

This study supports our PICOT question by examining integrative therapies that nurses or other

interdisciplinary professions could implement to aid patients experiencing type 2 diabetes

mellitus.

Article Two

This quantitative study sought to understand the association of prediabetes awareness

with behaviors and perception of health (Li et al., 2021). The study was correlational and

reviewed two prior studies from 2015 and 2016. Of 9,971 participants (over the age of 18 and

non-pregnant), 413 were pre-diabetes aware, 1,041 were pre-diabetes unaware, and the

remaining were excluded for various reasons. Participants were interviewed in their homes, with

testing completed in a mobile laboratory. They were propensity-score matched for Body Mass

Index, A1c, race, and education and analyzed for feelings about their risk of diabetes, general

health, weight, diet, and activity. Data was analyzed using chi-square and t-tests to determine the

correlation between pre-diabetes awareness and perception of health. Participants aware of

prediabetes were more likely to report feeling at risk of diabetes at 67.1% and considered

themselves overweight at 69.3% compared to those unaware of prediabetes status at 24.9% and

51.4%, respectively. Strengths in this study include a large sample size and numerical data

values. Limitations for this study include individuals in the prediabetes “unaware” category who

had been told of their prediabetes status but then forgot. This study relates to perceptions of

health with prediabetes as it compares how perceptions differ based on awareness of prediabetes

status.
 6

Article Three

Researchers in New Zealand studied a quantitative and qualitative evaluation of a

primary-care, nurse-led dietary intervention for individuals with prediabetes compared to

standard practice (Copell et al., 2011). The study took place in standard clinical settings in New

Zealand, among 157 indigenous Maori individuals recently diagnosed with pre-diabetes (HbA1c

= 41-49 mmol/mol), at least 70 years old, not pregnant, or being treated with metformin. Data

was collected by measuring baseline values and 6-month values for HbA1c levels, weight, waist

circumference, body mass index, blood pressure, and lipids. Data for each group was analyzed

using Chi-squared and Fisher’s Exact tests at baseline and follow-up with a linear regression

model. Quantitative results included a mean loss of 1.3 kg more, decreases in BMI and waist

circumference, and HbA1c in the intervention group, while each factor increased for the control

group. Qualitative themes included high acceptance of the intervention by participants. Strengths

for this study were high-quality quantitative data analysis and no signs of researcher bias, and

limitations were small sample size and limited variation. This study reinforces the link between

prediabetes health status and perception because differing care for prediabetic patients correlated

to altered health and perception of health.

Article Four

This prospective cohort study focused on the pathobiology of prediabetes by following

normoglycemic African American and European American offspring of parents with type 2

diabetes mellitus for incident prediabetes and study the impact of passive notification of

prediabetes status on glucose tolerance, glycemia, adiposity, and lifestyle modifications in a

research center setting (Owei et al., 2019). Sampling and data collection included an initial

screening and enrollment. Of the 343 offspring between 18-65 years with good health and no
 7

evidence of diabetes, 101 subjects developed prediabetes, were informed of status with no

interventions, and separated from the control “normoglycemia” group. Data was analyzed using

statistical analysis via mean and linear regression models to determine the relationship between

changes in anthropometric and metabolic variables. Results of the study include: improved

dietary and exercise habits in the prediabetic group and higher BMI, waist circumference, and

fasting plasma glucose in incident diabetics compared to control (r=0.2, P=.01). A strength of

this study is the effectiveness of behavioral alterations to explain glycemic and weight benefits in

the prediabetic group. A limitation of this study is variability due to possible discussion of status

with providers and subsequent counseling outside of the study. This study relates to the current

problem of undiagnosed prediabetes and the need for diagnosis and management as early

awareness may instill lifestyle modifications to improve glucose tolerance, glycemia, and

adiposity.

Summary

The four appraised articles cover similar themes where populations were either aware

or unaware of prediabetic diagnosis and individuals to evaluate future health outcomes.

Additionally, some studies utilized nursing interventions to educate patients and examined

baseline and post-study measurements and blood samples to determine if BMI, HbA1c, or waist

circumference changed. Each article supports either the importance of awareness of prediabetes

status or nursing interventions, as these factors correlate to significant impacts on overall patient

health. As nurses, we could benefit from education, guidelines, and standardized screenings to

identify prediabetes. Nurses could also use education on expected outcomes for patients after
 8

receiving a prediabetes diagnosis. To further help patients, nurses could also benefit from

education to promote healthy diet and exercise changes for prediabetic patients.

Implications for Nursing Education, Research, and Practice

Our findings stress the importance of nurses to educate patients on their prediabetes

status, their expected health changes, and how to navigate this diagnosis. We, as nurses, can

provide these tools to promote better health outcomes and reduce the development of diabetes.

We must remember that education and screening for diseases are continuous and prevalent in

various settings like the community, primary care settings, and hospitals (Funnell, 2018).

In terms of education, nursing students must be aware of the physiological changes

associated with prediabetes status and be mindful of the psychological changes to help their

patients be more proactive in their health. Educated nurses can also provide patients with

resources to better their self-perception, improve their diet, and monitor progress. Finally, nurses

must learn to put aside their preconceptions about this disease to provide the best care, advocacy,

and support for their patients (Funnell, 2018).

Further investigation is needed to understand the correlation between nurse knowledge of

patients’ psychological burden of prediabetes status and patient outcomes. Researchers can use

surveys to evaluate patients’ outlooks and acquire suggestions from patients to improve their

care. Another approach to nursing research on this topic could be assessing the effectiveness of

community support for lifestyle interventions and the success rates. Having a support group

could improve motivation and self-perception, with some benefits including improved quality of

life through shared experiences, online convenience, and shared valuable tips (Wood, 2021).
 9

In the clinical environment, nurses must obtain baseline values and evaluate patients’

understanding of their conditions and health risks. By doing this, nurses gain the information that

allows them to plan patient care. Additionally, it is vital to document what education was

provided by the nurse and the patient’s comprehension and need for further teaching. Completing

these steps facilitates consistent care between providers and reinforces education as necessary,

leading to improved patient outcomes.

Conclusion

The research that we evaluated has emphasized the importance of patient education and

nursing care to improve the health outcomes for individuals with a prediabetic status. We have

identified common themes of positive outcomes for patients notified of their prediabetes status

and those with nurses who can provide them with guidance and education. Patients aware of their

prediabetic status have better control over their dietary and exercise habits and more success in

lowering their BMI and blood glucose levels. Patients who are given education and guidance

from nurses on their prediabetic status also have better health outcomes. Each research article

helped clarify how the patient perceives their health, what changes they made or did not make

based on their awareness of their prediabetic status, and how nurses helped lower the risk for

developing diabetes. As diabetes is an increasingly prominent diagnosis in the United States and

worldwide, nurses and other healthcare professionals must understand the importance of relaying

prediabetic status information to their patients; doing so could be the difference in becoming

diabetic.
 10

References

Azami, G., Soh, K., Sazlina, S., Salmiah, M., Aazami, S., Mozafari, M., & Taghinejad, H.

(2018). Effect of a nurse-led diabetes self-management education program on

glycosylated hemoglobin among adults with type 2 diabetes. Journal of Diabetes

Research, 2018, 1–12. https://doi.org/10.1155/2018/4930157

Centers for Disease Control and Prevention. (2021, February 12). A snapshot: Diabetes in the

united states | diabetes | cdc.

https://www.cdc.gov/diabetes/library/socialmedia/infographics/diabetes.html

Coppell, K. J., Abel, S. L., Freer, T., Gray, A., Sharp, K., Norton, J. K., Spedding, T., Ward, L., &

Whitehead, L. C. (2017). The effectiveness of a primary care nursing-led dietary

intervention for prediabetes: A mixed methods pilot study. BMC Family Practice, 18(1),

106. https://doi.org/10.1186/s12875-017-0671-8

​Funnell, M. & Freehill, K. (2018). Keeping up-to-date with diabetes care and education. Nursing,

48(10), 22-29. https://doi.org/10.1097/01.NURSE.0000545015.98790.27

Li, E., Silverio, A., Cunningham, A., LaNoue, M. D., & Mills, G. (2021). Association of

prediabetes status awareness with behaviors and perception of health. The Journal of the

American Board of Family Medicine, 34(1), 224–230.

https://doi.org/10.3122/jabfm.2021.01.200146

Mandal, A. (June 4, 2019). History of diabetes. News Medical Life Sciences.

https://www.news-medical.net/health/History-of-Diabetes.aspx

Melnyk, B. M., & Fineout-Overholt, E. (Eds.). (2011). Evidence-based practice in nursing &

healthcare: A guide to best practice. Lippincott Williams & Wilkins.

 11

News Medical Life Sciences. (2009, December 2). History of diabetes. News-Medical.net.

https://www.news-medical.net/health/History-of-Diabetes.aspx

Northern Arizona University. (2021). Evidence Based Practice. Cine Library.

https://libraryguides.nau.edu/c.php?g=665927&p=4682772

Owei, I., Umekwe, N., Ceesay, F., & Dagogo-Jack, S. (2019). Awareness of prediabetes status

and subsequent health behavior, body weight, and blood glucose levels. The Journal of

the American Board of Family Medicine, 32(1), 20–27.

https://doi.org/10.3122/jabfm.2019.01.180242

University of Arizona, Wilson, H., Valente, E., & da Silva, V. (2019, May 29). The impact of

diabetes in Arizona. Cooperative Extension | The University of Arizona.

https://extension.arizona.edu/pubs/impact-diabetes-arizona

University of Minnesota. (2021). Principles of integrative nursing. Center for Spirituality and

Healing - University of Minnesota.

https://www.csh.umn.edu/education/focus-areas/integrative-nursing/principles-integrative

-nursing

Wood, K. (March 2, 2021). Staying connected: How to find online support for type 2 diabetes.

Healthline.

https://www.healthline.com/health/type-2-diabetes/online-support-for-type-2-diabetes
 12

Table 1
Table of Evidence
Author(s) & Date Questions and/or Design, Sample, Setting Results Findings Level of Evidence
Variables and/or (Melnyk &
Objectives and/or Fineout-Overholt,
Hypothesis(es) 2011)
G. Azami, K. Lam What is the effect of a Design: Quantitative, Results found that the Level II
Soh, S. Ghazali nurse-led diabetes two-arm, randomized trial. group exposed to the
Sazlina, Md. Said self-management nurse-led diabetes
Salmiah, S. Aazami, education program on Sample: Adults over 18 education program had a
M. Mozafari, and H. glycosylated hemoglobin years of age that were decrease in their HbA1C
Taghinejad among adults with type diagnosed with type II levels. The control group
(July 8th, 2018) II diabetes? diabetes for a minimum of 6 did not have decreased
months. levels.

Setting: Endocrine clinic in

Illam City, Iran.
E. Li, A. Silverio, A. What is the association Design: Cross-sectional Participants aware of Level VI
Cunningham, M. of the awareness of secondary analysis. prediabetes were more
LaNouem and G. prediabetes with Individuals were interviewed likely to report feeling at
Mills behaviors and perception and scored based on Body risk of diabetes and
of health? Mass Index (BMI), A1c, consider themselves
January/February race, and education. overweight.
2021
Perceptions for feeling at Prediabetes aware feeling
risk for developing diabetes, at risk for diabetes: 67.1%
 13

general health status,

perception of weight, desire
to lose weight, dietary
behaviors, and physical
activity behaviors were
evaluated.
Sample: Civilian,
noninstitutionalized United
States population
Prediabetes unaware
feeling at risk for diabetes:
24.9%
Prediabetes aware feeling
overweight: 69.3%
Prediabetes unaware
feeling overweight: 51.4%

Setting: Participants home Those unaware of

prediabetes risk had no
association w/ any
difference in dietary or
activity behaviors.
K.J. Coppell, What is the effect of a Design: Mixed Methods, Primary outcome Level III
S.L. Abel, primary-care nurse-led Pragmatic, Non-Randomized measures were weight and
T. Freer, intervention for a patient pilot study with a qualitative HbA1c.
A. Gray, diagnosed with process evaluation
K.Sharp, pre-diabetes on weight Intervention group lost a
J.K. Norton, and HbA1c? Sample: 157 indigenous mean 1.3 kg more than the
T. Spedding, Maori individuals in New control group.
L. Ward & Zealand, aged ≥ 70 years
L.C. Whitehead diagnosed with prediabetes 65% of intervention group
(December 21st, indicated by HbA1c levels: lost some weight, 18%
2017) 41-49 mmol/mol and a BMI achieved at least 5%
≥ 25 weight loss compared with

Setting: General practices
and community setting
I. Owei, N. How does awareness of Design: Prospective cohort
Umekwe, F. Ceesay prediabetes status affect study that followed African
and S. Dagogo-Jack subsequent health American and European
(May 29th, 2019) behavior, body weight, American offspring of
and blood glucose parents with type 2 diabetes
levels? mellitus for incident
prediabetes. During 5.5
years of follow-up (mean,
2.62 years), 101 of 343
subjects developed
prediabetes and were
notified, without any
interventions. Participants
were recalled 18 months
post study.
14
32% and 5%, respectively
for control group
Mean HbA1c, BMI and
waist circumference
decreased in the
intervention group and
increased in the control
group, but differences
were not statistically
significant.
Knowledge of prediabetes Level IV
status is associated with
improvements in glucose
tolerance, glycemia, and
adiposity, likely due to
lifestyle changes.
 15

Sample: Normoglycemic
African American (AA) and
European American (EA)
offspring of parents with
type 2 diabetes mellitus for
incident prediabetes.

Setting: visits to University

of Tennessee general
Clinical Research Center