Exercise as Intervention for Diabetes

This literature review explores the effectiveness of exercise therapy as a non-pharmacological intervention for managing diabetes in a population of 18 to 60 years old. It discusses the benefits of exercise, challenges in adherence, and strategies to improve adherence. The review also includes a critical appraisal of eight research articles on the topic.

Running head: EXERCISE AS INTERVENTION OF DIABETES
Exercise as intervention of diabetes
Name of the student:
Name of the university
Author note:

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EXERCISE AS INTERVENTION OF DIABETES
Introduction:
With the growing prevalence of chronic disease, diabetes type II has become a public health concern that contributed to the
global burden of the disease and premature death. A study by Roze et al. (2016 ), suggested that in united kingdom approximately 24
millions of individuals are suffering from this chronic disease which affected their quality of life . A significant number of individuals
have above normal blood glucose level. Therefore, populations who are at higher risk of developing diabetes type II can also develop
other chronic diseases such as kidney and liver disease and cardiovascular. The issue is prevalent in the Asia Pacific region due to the
specific race and ethnicity but United Kingdom also identified one of the countries for higher prevalence (Patel et al. 2017). Ntuk et
al . (2014), suggested that a considerate number of individuals were refuse to seek clinical help due to high expenditure of the
pharmacological interventions. A study Scheen (2015), suggested that the implementation of physical activity as a component of
lifestyle interventions is useful for reducing the global burden of the disease. However, the lack of clinical applications of this
intervention and low patient adherence are huge barriers for improving patient outcome (Campbell et al. 2014). This paper will
illustrate a literature review of diabetes in the first part and critical appraisal of a paper in second part in the following paragraphs.
Background of the study:
According to Punthakee et al. (2017), approximately 24 million of the individuals in the United Kingdom are affected by this
chronic disease which increased their risk of premature death. A study by Shah et al. (2015), suggested that diabetes mellitus causes
production of insulin impaired. As discussed by Green et al. (2015), that because of this health condition, type II diabetes patient
experience physically weakness and therefore, physical activity is crucial for improving the blood glucose level in individuals.

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Molecular biologist suggested that intensive physical activity is effective in enhancing the metabolism such as mitochondrial
biogenesis and beta-oxidation and molecular biogenesis. Li et al. (2017), argued that physical exercise proved to reduce 58% risk of
developing diabetes mellitus in pre-diabetic individuals and improved the quality of life in the patient with diabetes mellitus. Low et
al. (2014) suggested that only 40 % of the population engage in exercise as lifestyle interventions and 28.4% of them are able to
achieve a positive outcome. Accumulated evidence suggested that poor knowledge of individuals about lifestyle modification through
exercise and rare clinical practice of it are identified as a huge barrier for the management of the disease (Guest et al., 2015).
Therefore, literature reviews need to conduct for reducing the gap.
Research question:
In the United Kingdom can exercise therapy as non-pharmacological interventions be effective in the management of diabetes in a
population of 18 to 60 years old?
The rationale behind this question is that diabetes is public health concern that not only affected health but also affected the
psychological wellbeing. Therefore, the purpose of the research question is to identify whether exercise is effective for the
management of diabetes.
Strategy:
For constructing research question, the SPICE model was beneficial for identifying the type of search concept in the (appendix
A), it help in obtaining qualitative research articles. To find the research question, a specific research tool SPICE model which
evaluated the specific outcome and thus formulated research question was used for this literature review.

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Aim and objectives:
The purpose of the literature review is to evaluate the effectiveness of exercise therapy as non-pharmacological interventions in the
management of diabetes in a population of 18 to 60 years old through collecting evidence.
Objective:
• To explore the effectiveness of to exercise therapy in population between 18 to 60 years.
• To explore the reason behind lack of adherence
• To recommend strategies to adhere to the non-pharmacological interventions.
Design and Methodology
Because of the type the research question most appropriate nature of the study is the qualitative methodology as it provided a
relevant and possible result which further assists researchers in gaining details of the effectiveness of exercise therapy for management
of diabetes mellitus (Berger et al. 2015). The research was conducted using library where various articles were searched in order to
assess the effectiveness of physical activity for diabetic patient and adherence of it in the study. It is important to gather all of the
important information and critically analyses those articles in the realistic time frame for addressing the research question.

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Search for article and data extracting:
:
Once the research question had been formulated using specific research tool, it was possible to gather information and analyze articles
which were obtained after filtering range of evidence (Lewis 2015). There are specific inclusions and exclusion criteria for the articles
which was an roadmap for evaluation of the effect of exercise that further helped in obtaining the relevant article for research. The
research term that was used for the study including “type II diabetes mellitus”,” lifestyle intervention” “exercise’, “exercise-induced
metabolic changes”, “glucose metabolism”. To access articles, electronic databases were used such as CINAHL, Social Science
Citation index, Medline, in order to identify the accurate result of research question which would improve patient outcome.
The inclusion and exclusion criteria for the literature review are the following:
The inclusion and exclusion criteria for the literature review are following:
Inclusion criteria Exclusion criteria
 All relevant journals included
were published within last 5
 All relevant journal than 5
years were excluded
 All non reviewed articles were

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EXERCISE AS INTERVENTION OF DIABETES
years
 All relevant paper that were
included in the study were peer
review journal
 All relevant articles that were
included in the study were
published in English language.
 All relevant paper that were
included in the study worked on
human subject.
 All relevant paper which
discussed about the theories,
specific concepts was included.
 all relevant paper that fit into
the check list of CASP tool
were included in the study
 All relevant paper that
excluded
 All articles published in other
than English article were
excluded.
 All articles that published the
data work on other than human
subject will be eliminated.
 All paper which discussed
other then theories, specific
concepts were excluded
 all relevant paper that does not
fit into the check list of CASP
tool were included in the study
 . All relevant paper that was
undertaken studies other than

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EXERCISE AS INTERVENTION OF DIABETES
undertaken primary studies
were included.
primary studies were excluded.
Once all the articles had been filtered, 5423 articles which were further filtered for eliminating duplicates. After elimination of all
irreverent articles, 8 articles were selected from 63 articles corresponding with the inclusion criteria. In order to gain theme with the
help of prisma flowchart, different range of the study was evaluated and ultimately 8 journals were selected for best comprehensive
study (Moher et al. 2015). After obtaining these eight articles, these articles assisted researchers to categorize as well as analyze
different themes of the research.
Results Synthesis and Quality Appraisal of 8:
In order to identify the strength and limitation of each article, it is crucial to analyze and appraise each article which relate to
the research question for addressing the current issue (Lockwood et al. 2014). All of the articles were analyzed by using different
parameters such as methodology. Articles were assessed for different theme generation such as the effect of exercise on diabetes, the
effect of exercise on weight reduction and effect of exercise on metabolism.
Using data extraction table found in appendix C, the researcher was able to assess what is important for the study. The aim of
this is to provide clarity regarding extracted paper without re-examining the original articles. The extracted articles were assessed in

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order to identify it was fit for the purpose or not (Alvesson and Sköldberg 2017). Once all of the articles were methodically read
through for generating logical themes, the literature synthesis was done.
Miller et al. (2018) suggested that in order obtain accurate literature review, it is crucial to identify the studies which are
appropriate for the synthesis of the result. The articles were that was mostly randomized trail control and using meta-synthesis
approach, each articles were assessed thoroughly. Few cohort studies are also included for gaining appropriate result in order to
address the research question. Qualitative meta-synthesis is defined as a coherent and international approach of literature for analyzing
the data of qualitative studies (Herber et al. 2015). This process is useful in assisting researchers in identifying a research question and
select, appraise and summarize the combination of different qualitative studies for addressing the research question (Brundisini et al.
2015). Therefore, Meta-synthesis is extremely crucial for the successful accomplishment of the study. However, the limitation of
these eight articles also identified after assessing these paper thoroughly. The limitations of these eight articles are that these articles
although researchers were tried to address the issue and use exercise as a lifestyle interventions for managing diabetes, These studies
failed to answer each part of the question. Moreover, the majority of the studies were conducted in the United Kingdom and thereby,
level of cultural homogeneity is a potential bias of these studies which might not be applicable for the patients who are living in other
countries.
These articles were filtered again using a specific tool for the diagnosis tool ( critical appraisal skill program ) produced by
Kitchenham (2007), which was intended to appraise specific papers by subjecting each paper in specific scales of questions such as

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whether the aims are clear or not , whether study able to achieve the aim and data was adequate to conduct literature or not. These
articles were ranked on the basis of the variable answer such as ‘Yes’, ‘No’ and ‘Inconclusive’(see Appendix D).
The ranking of these eight articles was based on the highest level of evidence observed i (appendix c). and grading was done
by Cardwell’’s appraisal tool before selecting the highest level of the articles which were critically appraised (Pitt et al. 2015). it was
observed during the study that only one out of 63 articles were able to give conscious information of the study which was included in
the appendix B. Details calculation were used for gaining the sample size and no missing inclusion criteria were not observed that was
observed in other articles and immediately excluded from the research. Ultimately, these articles were selected for conducting an
appropriate study which met all of the inclusion criteria that is present in the methodology section. Moreover, these articles were
successful in avoiding any potential bias that would otherwise impact the evidence of the research.
Reviewing each of the eight articles, each article considered diabetes type two is a public health problem that is not only
affecting the quality of life but also enhancing the premature rate. Each of the eight articles highlighted that due to high expenditure of
the health care, majority of the individuals do not seek clinical help. One of the articles such as Bhopal et al. (2014) Implementation
of nonpharmacological intervention such as physical activity is effective in reducing the prevalence in reducing the high risk of
diabetes and obesity. Dixit et al. (2014) and Cassidy et al. (2016), also highlighted the positive effect of exercise on individuals with
diabetic and it is able to enhance the metabolic activity of the individuals. Cassidy et al. (2016) showed that intense aerobic exercise
is effective in shaping cardiac muscles and reduce the fat in the patient who is suffering from type II diabetes. Ngandu et al. (2015),

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highlighted that exercise with other psychological therapies are crucial for reducing the premature death amongst elderly patient who
is at higher risk of developing a disease like a type II diabetes. On a different note, Vlaar et al. (2017), highlighted that the culturally
targeted lifestyle interventions such as physical activity are not always effective because the high rate of unemployment, high drop out
and other psychological disorders also affected the adherence to the physical activity.
Other articles such as Palakodeti et al. (2015), Otten et al. (2015) and Karjalainen et al. ( 2015) are successfully conducted
research and highlighted that proper diet such as Palaeolithic diet as well as intensive physical activity is crucial for reducing the fat
mass and increasing insulin sensitivity. Karjalainen et al. ( 2015) also highlighted that physical activity not only help in insulin
sensitivity also assist in controlling glucose production. Therefore, this research evidence are highly useful for identifying the
effectiveness of the non-pharmacological interventions such as exercise and implementing it in the clinical practice for reducing
premature death in the vulnerable population. This research evidence are accurate compared to other 63 journals in terms of research
method which help in theoretical understanding the diabetes type ii in patients and who are at higher risk of at it. This evidence also
effective in identifying the effects of physical activity in reducing the risk factor of diabetes, cardiovascular disease and managing
other chronic diseases. These eight articles addressed the potential ethical issues such as confidentiality data after data collection and
patient’s information. Patient’s safety is crucial ethical that usually arise in the research field while conducting any primary studies. In
the last stage of appraising articles for obtaining best evidence of research, each 8 articles were ranked on the basis of hierarchical
study and individually graded based on the scientific publication published by Kitchenhams (2007) and one out of eight articles were
selected for the critical appraisal which would be conducted in the second part of the study. Each of the eight studies that were

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included in addressing the research question provided excellent evidence of the exercise therapy as a lifestyle intervention which is
effective in reducing diabetes.
Summary and synthesis of the paper:
Assessment of Quality of Evidence and Overview of Themes:
After assessment of study using critical appraisal skill program for qualitative study, each article was thoroughly scrutinized
for ensuring that each of them addresses the issue written in the research question, as well as each study, is compatible with the current
study for sound contribution in the findings of the study. Therefore, the understanding the cost-effectiveness of the exercise in a
patient with type II diabetes and individuals with pre-diabetes assisted the researcher to select common themes that are prevalent in
these eight journals. Through identifications of the themes, researchers were able to assess the common research process and the
methodology and sample tool used for the study.
The theme was generated on the basis of three crucial components such as:
Abstracts:
Abstract was clearly produced in each of the eight articles and therefore, it provided a concise idea of the study indicating
prime aim of the study. It also assisted researchers to generate effective and logical theme for the research topic with the help of
databases which is useful for the study.

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EXERCISE AS INTERVENTION OF DIABETES
Methodology:
Eight articles that are included in the study were chosen qualitative methodology; that further helped in scrutinizing on
participants in details on the prospective study (Baumann, Schröder and Fink 2015). Majority of the study conducted a randomized
control trial for the research. Only in Palakodeti et al. (2015) and Karjalainen et al. (2015), the researcher conducted a cohort study for
obtaining accurate evidence. However, the assessment questions limit the further exploration of the study. All eight evidence was used
for assessing the effectiveness of exercise including the effect of it in metabolic activity, fat reduction, weight reduction which would
further useful for implementing it in the clinical practice; Therefore, few of the studies also highlighted the reason behind lack of
adherence through gaining feedback from the participants. Qualitative methodology is also an effective procedure since it helps
researchers to gain personal narrative in each study (Zulfiqar et al. 2017). However, potential biases also exist in the qualitative
research method during the data collection since it is highly subjective. The study also depends on the point of view of others which is
also a potential bias for the study.
Sample tool:
Sample tool for the majority of the article systematic for assessing the qualitative of evidence found in the research article. The
prime reason behind choosing this study is that it enables researchers to collect data efficiently and give an opportunity to gain an idea
of the individuals suffering. However, the potential bias is that cultural homogeneity in the study. Few studies also highlighted the
broader sampling and data collection need to be done.
Broader themes form the study:

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Effect on weight:
Diabetes type II is a group of metabolic disorder in which the insulin production is impaired and consequently, the blood
contains a high amount of glucose that contributed to the premature death. Bhopal et al. (2014), Vlaar et deal. ( 2017) and Cassidy et
al. ( 2016) highlighted that after 1 year of contestant adherence to the exercise or daily exercise for at least 30 minutes is effective in
reducing the weight within 1 year. Therefore, targeting physical activity as a self-management option for the vulnerable population
would be the optimal approach who consumes high-fat diet and it also provides confidence to the population who are feeling less
confident because of obesity.
Effect of it on diabetes:
From the assessment of the eight articles, it was identified that those individuals who have impaired fasting of glucose and
insulin resistant are able to achieve the positive outcome of the diabetes.all of the articles (Ngandu et al. 2014, Dixit, Maiya, and
Shastry 2014, Palakodeti et al. 2015, Bhopal et al. 2014, Vlaar et al .2017, Otten et al. 2017, Karjalainen et al. 2015 and Cassidy et
al. 2016), highlighted that exercise lower HbA1c potentially and delays onset diabetes in individuals who are at higher rate of
developing diabetes. The physical activity is effective for young population who has higher risk of diabetes but also for the older
individuals.

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EXERCISE AS INTERVENTION OF DIABETES
Effect of it on metabolic activity:
Accumulated evidence suggested that insulin resistant is related to high visceral adiposity. six studies out of eights studies
(Ngandu et al. 2014, Dixit, Maiya, and Shastry 2014, Palakodeti et al. 2015, Bhopal et al. 2014, Vlaar et al .2017, Otten et al. 2017)
highlighted that it effectively shape metabolism which involves beta-oxidation, glycolysis, and improvement of cardiac activity.
Closing discussion:
The present study was developed for addressing the research question through gathering information on the primary studies
conducted by different researchers and find out any gaps using systematic methods and filter each potential source of evidence
(Workneh, Bjune, and Yimer 2016). The proposed method of research reflects the difficulty of original studies while collecting data. It
also reflects the obstacles of the gathering information from different databases and filtering each study on the basis of different
criteria and ultimately obtaining eight high pieces of evidence according to the hierarchy studies. From the eight journals, it was
observed that diabetes is a common public health concern in the united kingdom and highly prevalent in South Asian origin of united
kingdom due to the ethnicity. Therefore, physical activity and exercise training proved to have health benefits for a patient who is
obese and suffering from coronary artery disease and diabetes type II. These pieces of evidence also suggested that intensive physical
activity improves nerve activity. However, due to the lack of clinical practice, personal beliefs, the adherence is lower to the activity
and only a few individuals are able to achieve a positive outcome (McSharry et al. 2016). Therefore, including exercise therapy in
different rehabilitation program of hospital and in the home setting can reduce the risk of developing diabetes type II. Physical activity

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is proved to elevate mood and self-confidence of individuals by inducing serotonin secretion in the patient. In order to gain the
understanding of the patient for measuring the outcome of exercise further exploration of the study would require irrespective of
culture race and population (Barber et al. 2016). For more concrete research, mixed method study can be used.
In Depth Single review Appraisal
Using the critical appraisal skilled program , researchers identified that Bhopal et al. (2014) was the highest ranked evidence
which clearly stated the each hypothesis and provide a concise idea of physical activity in diabetic patient as well as suffering from
the cardiac disease.
Bhopal et al. (2014), researchers provided a concise analysis and abstract that was well formulated. The study clearly stated the
purpose of the research which also reflected in the result obtained by the researcher. The aim of the study is to evaluate the role of
physical activity and home based exercise in patient with diabetes type II so that it can further implemented in the clinical practice. In
order to obtain the effectiveness of the exercise in diabetic patient is crucial to evaluate the research work and summarize the key finds
of the paper for comparing it with other part of the study for understanding the contribution of researcherS. Researchers used
qualitative methodology for the study which is crucial since it helped researchers to understand the actual health conditions and effect
of intensity training in 1319 people through family based interventions. It also helped in gaining deeper understanding of the patients
as well as family members need for the management of diabetes in order to prevent diabetes. The research clearly stated the
hypothesis that obesity is another reason behind premature death in patient with type II diabetes. The Study identified that 78 families

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with 86 participants were allocated for the exercise interventions. The importance of the exercise in family was reflected by
researchers through the research findings. The potential biases were addressed by the researchers but since the most of the research
work were conducted in UK, cultural homogeneity is also a potential bias. Ethical standards were maintained by researcher for
conducting successful research and agreed to publish the study. The themes such as effect on the diabetes and weight were highlighted
throughout the study. By the end of the study researchers highlighted that intensive exercise in the family setting is effective for
weight loss in 28% of patient and reduce the high glucose level. It is also effective in preventing adiposity related diseases in patient
suffering from type II diabetes. Therefore, the research is a valuable piece of evidence which assisted researcher to gain the
information of non- pharmacological interventions such as exercise which help in implementing in clinical practice and it also assisted
to reduce the health care cost.

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Conclusion:
This part of the paper will give a summative overview of the study that was conducted by the researcher. It was found out that
physical activity is effective for not only younger population but also older population. The qualitative approach was undertaken
where different databases were used and evidence was filtered n the basis of different articles. Different range of papers was found in
the researcher's selection of articles and ultimately, an article which is the high piece of evidence was found from the literature search.
Eight articles were obtained through CASP skilled program, to identify the highest quality of evidence. One journal that was ranked as
highest evidence was identified after critical appraisal. The theme generation was conducted by the researcher by assessing the eight
journals. Identified themes suggested that physical activity and exercise therapy as an effective intervention for reducing obesity,
controlling glucose level, lower HbA1c, improve nerve activity. However, the adherence is lowered due to lack of knowledge and
beliefs. Therefore, physical activities should rehabilitation program of hospital, and in-home setting for increasing adherence of the
exercise and achieve the appropriate outcome

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A. and Hemingway, H., 2015. Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1· 9 million people. The
lancet Diabetes & endocrinology, 3(2), pp.105-113
Vlaar, E.M., Nierkens, V., Nicolaou, M., Middelkoop, B.J., Busschers, W.B., Stronks, K. and van Valkengoed, I.G., 2017.
Effectiveness of a targeted lifestyle intervention in primary care on diet and physical activity among South Asians at risk for
diabetes: 2-year results of a randomised controlled trial in the Netherlands. BMJ open, 7(6), p.e012221
Workneh, M.H., Bjune, G.A. and Yimer, S.A., 2016. Assessment of health system challenges and opportunities for possible
integration of diabetes mellitus and tuberculosis services in South-Eastern Amhara Region, Ethiopia: a qualitative study. BMC
health services research, 16(1), p.135.
Zulfiqar, T., Lithander, F.E., Banwell, C., Young, R., Boisseau, L., Ingle, M. and Nolan, C.J., 2017. Barriers to a healthy lifestyle
post gestational-diabetes: An Australian qualitative study. Women and Birth, 30(4), pp.319-324.

23
EXERCISE AS INTERVENTION OF DIABETES
Appendix: 1
S SETTING WHERE?
IN
WHATCONTEXT?
E.G. HOSPITAL
OR
COMMUNITY
P PERSPECTIVE FOR WHO? E.G. ADULTS
HAVING DIABETES
I INTERVENTION PHENOMENON OF
INTEREST-WHAT?
E.G. EXERCISE
( PHYSIACL
ACTIVITY)
C E.G. NON OR

24
EXERCISE AS INTERVENTION OF DIABETES
COMPARISON WHAT ELSE? PHARMACOLOGICAL
E EVALUATION HOW WELL?
WHAT RESULT?
E.G. NUMBER
OF
SUCCESSFUL
ADAHRANCE AND
EFFECT ON
DIABETIC PATIENT
APPENDIX 2:

25
EXERCISE AS INTERVENTION OF DIABETES
RECORD IDENTIFIED THROUGH DATABASES
5423 journals AFTER DUPLICATION REMOVED
3756 journals
AFTER SCREENING
789 journals
RECORD EXCLUDED
504 journals
FULL TEXT ACCESSED
109 journals
FULL TEXT WITH REASON EXCLUDED
46 journals
STUDIES INCLUDED IN THE QUALITATIVE SYNTHESIS 63STUDIES EXCLUDE FOR NOT MEETING INCLUSION
55 journals
8 journals were included in the study

26
EXERCISE AS INTERVENTION OF DIABETES
Appendix c:
Author
and year
Journal Type of
study
Purpose Sample Design Data
collection
Ethical issues Key findings
1.
Cassidy et
al. 2016
Diabetologia,
59(1),
Qualitative
research
To evaluate high
intensity
intermittent
exercise improves
cardiac structure
and function and
reduction of fat in
diabetic patients
random
allocation
sequence,
28patients
with type2
diabetes
Randomised
Controlled
Trial
Questionnair
e and Cardiac
structure mea
surement
Informed consent
taken from
participants. Consent
taken from general
practitioner and
specialist
an exercise interventi
in type 2 diabet
effectively reduce
liver fat and impro
cardio metabolic risk
2. Ngandu
et al. 2015
The
Lancet, 385(9
984),
Qualitative
research
To evaluate
multidomain
interventions such
as, exercise and
other activities in
patient who are at
higher risk
Participants
were 2654
respondents
Randomized
Controlled
Trial
Comparison
between two
groups
Informed consent
taken from
participants. Consent
taken from general
practitioner and
specialist
The key findings of t
study multidoma
intervention cou
improve the cogniti
function of individua
who are at higher rs
of diabetes
3. Bhopal
et al. 2013
Research
was
conducted
in UK
The lancet
Diabetes &
endocrinolog
y,
Qualitative
research
Effect of lifestyle
intervention on
weight change in
south Asian
individuals in the
UK
1319 people
were
screened
and 156
were
families
family-
cluster
randomized
controlled
trial
each
extended
family was
mapped and
randomized
list were
produced
Informed consent
taken from
participants. Consent
taken from general
practitioner and
specialist
Medium-term chang
in weight a
achievable through t
life style interventio
and life sty
interventions a
effective in preventi

27
EXERCISE AS INTERVENTION OF DIABETES
data collected
according to
the outcome
adipose mediat
disease.
4. Dixit,
Maiya and
Shastry et
al. 2014
Journal of
Diabetes and
its
Complication
s,
Qualitative
research
Effect of aerobic
exercise on
peripheral nerve
functions of
population with
diabetic peripheral
neuropathy in type
2 diabetes: a single
blind, parallel
group randomized
controlled trial
87 patients
with DPN
were
evaluated in
the study
Randomized
Controlled
Trial
Comparison
were done
through
RANOVA
Informed consent
taken from
participants. Consent
taken from general
practitioner and
specialist
intensity aerob
exercises plays
crucial role
disruption of norm
progression of DPN
type two diabe
patient
5.
Palakodeti
et al. 2015
Diabetic
Medicine
Diabetic
Medicine
To evaluate
changes due to
exercise in diabetes
patients
6853
individuals
were
participated
for
December
2011 and
November
2012
Longitudal
cohort study
Through self-
report of
patient
Informed consent
taken from
participants. Consent
taken from general
practitioner and
specialist
physically activ
patient with diabet
lost weight after 1 ye
6. Vlaar et
al. 2017
Study was
conducted
in
Netherlan
ds
BMJ open Qualitative
research
Effectiveness of a
targeted lifestyle
intervention in
primary care on
diet and physical
activity among
South Asians at
A total of
536 18- to
60-year-old
South
Asians at
risk for
diabetes
Randomized
Controlled
Trial
2-year
follow-up
with
independent-
sample t-
tests, chi-
square test
Informed consent
taken from
participants. Consent
taken from general
practitioner and
specialist
Culturally targeted l
style is not effective f
south Asian populatio
Researchers suggest
to use new strategies f
effective outcome.

28
EXERCISE AS INTERVENTION OF DIABETES
risk for diabetes: 2-
year results of a
randomised
controlled trial in
the Netherlands.
were
participated
and data
was
analyzed for
314
participants
7. Otten et
al. 2017
Diabetes/
metabolism
research and
reviews, 33(1
),
Qualitative
research
To evaluate
benefits of a
Paleolithic diet
with and without
supervised exercise
on fat mass, insulin
sensitivity, and
glycemic control
32 patients
were
participated
who
followed
Palaeolithic
diet for 12
weeks
Randomized
Controlled
Trial
Through
evaluation of
mass
decrease
Informed consent
taken from
participants. Consent
taken from general
practitioner and
specialist
Paleolithic di
improves the fat ma
and exercise improv
lean mass in men a
improves cardiac fitnes
8.
Karjalaine
n et al.
2015
Diabetes
Care
Qualitative
research
To evaluate effects
of physical activity
and exercise
training on
cardiovascular risk
in coronary artery
disease patients
with and without
type 2 diabetes.
539
individuals
were
participated
for 2 years
of follow up
Randomized
Controlled
Trial
Through
evaluation of
effect of diet
and home
based
exercise
Informed consent
taken from
participants. Consent
taken from general
practitioner and
specialist
home-based exercis
has minor effect
cardiac patient and hu
effect on diabetic patie

29
EXERCISE AS INTERVENTION OF DIABETES
Appendix D Critical Appraisal Forms: Critical Appraisal Skill Programme-Cardwell’s Questions Marking scheme:
NO=1 YES=2 PARTIALLY=1
Questions Article
1
Article
2
Article
3
Article
4
Article
5
Article
6
Article
7
Article
8
Does title reflect
the content?
Y Y Y Y Y Y Y Y
Are the Authors
Credible?
Y Y Y Y Y Y Y Y
Does the
abstract
summarise the
key
components
Y Y Y Y Y Y Y Y
Is the rationale
for
Y Y Y Y Y Y Y Y

30
EXERCISE AS INTERVENTION OF DIABETES
understanding
the research
clearly
outlined?
Is literature
review
comprehensive
and current?
Y Y Y P Y Y P Y
Is the aim of
the research
clearly stated?
Y Y Y Y Y Y Y Y
Are all ethical
issues identified
and addressed?
P P Y P P Y Y Y
Is
methodology
identified and
Y P Y P Y Y Y Y

31
EXERCISE AS INTERVENTION OF DIABETES
justified?
Is the design
clearly
identified and
rationale
provided
Y Y Y Y P Y Y Y
Is there an
experimental
hypothesis
clearly stated
and are the key
variables
identified?
Y N Y P P N Y N
Is the
population
identified?
Y P Y Y P Y Y P
Is the sample Y P Y P P Y P Y

32
EXERCISE AS INTERVENTION OF DIABETES
adequately
described and
reflective of
the
population?
Is the method of
data analysis
valid and
reliable?
Y Y Y P Y Y P P
Are the results
presented in a
way that is
appropriate
and clear?
Y P Y Y Y Y P P
Is the
discussion
p P Y Y Y P Y Y

33
EXERCISE AS INTERVENTION OF DIABETES
comprehensive?
Is the
conclusion
comprehensive?
Y Y Y Y Y P P Y
Total: 30 26 29 26 27 28 26 28

34
EXERCISE AS INTERVENTION OF DIABETES
APPENDIX E:
CASP (Critical Appraisal Skills Programme) Check List: 10 Questions
Q1. Was there a clear statement of the aims of the research?
Yes/No
Q2. Is a qualitative methodology appropriate?
Yes/No
Q3. Was the research design appropriate to address the aims of the research?
Yes/No
Q4. Was the recruitment strategy appropriate to the aims of the research?
Yes/No
Q5. Were the data collected in a way that addressed the research issue?

35
EXERCISE AS INTERVENTION OF DIABETES
Yes/No
Q6. Has the relationship between researcher and participants been adequately considered?
Yes/No
Q7. Have ethical issues been taken into consideration?
Yes/No
Q8. Was the data analysis sufficiently rigorous?
Yes/No
Q9. Is there a clear statement of findings?
Yes/ No
Q10. is the research valuable ?

36
EXERCISE AS INTERVENTION OF DIABETES
Yes/No