University of Wollongong: Diabetes Prevention Literature Review

This report is a structured literature review on preventing diabetes, addressing the clinical question of the effectiveness of lifestyle modification interventions in adults over 18. The author conducted a literature search using CINAHL and MedLine, focusing on articles published between 2008 and 2018. The review examines the impact of physical activity interventions, multi-component lifestyle interventions (combining diet, exercise, and other factors), and dietary interventions in preventing diabetes. The findings suggest that multi-component interventions are more effective than single interventions. The report highlights the significance of motivational elements and peer support in achieving long-term success. The review includes critical appraisals of various studies, including randomized controlled trials, and identifies gaps, such as the influence of self-report and lack of residual bias, which need to be considered in future research. The author concludes that lifestyle modification is an effective step in controlling and preventing diabetes and related healthcare costs.

Running head: PREVENTING DIABETES
Preventing diabetes
Name of the student:
Name of the University:
Author’s note

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Role of lifestyle interventions like diet and physical activity in preventing obesity: A
literature review:
Significance of the study:
Diabetes is one of the major public health burden in Australia as it increases risk of other
chronic disease in people and increase the health care cost associated with management of the
condition. The significance of the issue is understood from the fact that about 1 million
hospitalization took place due to diabetes in 2015-2016 in Australia. The diabetes related
mortality was found to be higher in remote and very remote areas. Another vital element of the
Australians statistics is that the prevalence of diabetes increases up to the rate of 75 years
(AIHW, 2018). Hence, considering these statistics, it is necessary to identify the risk factor
behind such high rate of diabetes cases and hospitalization in Australia. Evidence suggest poor
lifestyle like unhealthy eating patterns and high involvement in sedentary behavior such as lack
of physical activity, prolonged screen time as one of the major risk factor of diabetes. Hence,
avoiding risk factors and lifestyle modification can play a significant role in preventing diabetes
in Australia. This paper aims to critically evaluate research evidence to understand how far
lifestyle modification is effective in preventing diabetes.
Research question:
How effective is lifestyle modification intervention in preventing diabetes in adults above
18 years old?

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Search strategy:
To get answer to the research questions, articles for the literature review were retrieved
from databases like CINAHL and MedLine. The main rationale behind using these databases for
the review is that they are globally recognized database known for publishing peer reviewed
journal articles from the field of health care, biomedical and nursing. Hence, the two chosen
database is likely to yield lot of evidence regarding for research work done for the prevention of
diabetes. The keywords that were used for the search process was extracted from the research
question and the main primary key terms included ‘lifestyle modification’, ‘lifestyle
intervention’ and ‘diabetes prevention’. These key terms were the primary search terms used for
the search process. However, the search process was widened by the use of Boolean operators
use of synonyms and thesaurus for the primary search terms and using advanced search filters in
CINAHL database. The use of thesaurus helped to identify synonyms for the primary search
terms. In this way, other additional key words like ‘physical activity intervention’, ‘dietary
intervention’, ‘exercise intervention’ and ‘lifestyle intervention was selected’. These search
terms were combined with ‘AND’ and ‘OR’ to get the desired research papers. For example,
some of the search phrases that were used conduct advanced searching included ‘dietary
intervention and diabetes prevention’, ‘lifestyle intervention and diabetes prevention’ and ‘
physical activity and diabetes prevention’.
The search process was also guided by set of inclusion and exclusion criteria. The main
eligibility criteria for the selection of research papers included inclusion of only those papers
which has been published within 2008 to 2018 and analysis of any type lifestyle modification as
the main intervention for the study. Qualitative research papers, cohort study, systematic review
and randomized control trial (RCT) were included for critical review.

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Summary of evidence:
Based on the review of the 10 articles selected for this research study, it has been found that
three types of intervention has been incorporated in health promotion program for the prevention
of diabetes. These interventions include the following:
1. Physical activity intervention:
Out of 10 articles, there were at least two papers which investigated about the efficacy of
physical activity intervention alone in preventing diabetes. Thomas et al. (2009) examined the
association between physical activity and glucose tolerance among adolescents. Physical activity
of participants was assessed using the acceloremtry over 8 days and study revealed that physical
activity was associated with improvement in glucose tolerance. The strength of the study is that
impact of both moderate and vigorous physical activity level was assessed. Hence, it gave
answer to the research question. However, the transferability of the work was affected by small
sample size. Another randomized controlled trial gave evidence regarding the use of physical
activity promotion for improving health of patients with pre and type 2 diabetes. The
significance of this paper is that it used randomized controlled trial as the study design which
comes under top heirarchy of research evidence. Physical activity intervention in this study was
provided to two groups. The first included the multi-component group who had to follow
physical activity prescription, motivational interviewing and group consultation. The second
group included people received pedometers to track their steps (Rossen et al., 2015). The
significance of this research is that it used motivation aspects in the physical activity intervention
too and helped to eliminate barriers such as discontinuation of physical activity intervention for

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people with diabetes. The benefits of this approach is also understood from the fact that multi-
compont approach using motivational interviewing was more effective in improving physical
activity and promoting health of diabetes patients. Evidence supports the fact that motivational
aspect is important in promoting physical activity in people at risk of diabetes (Mori et al., 2011).
The importance of physical activity as a lifestyle modification intervention was also
shown by Mui et al. (2018) which also considered cultural aspect to promote physical activity
among people living in China. A telephone counselor was used to promote physical activity in
research participants and the system was used for six-month period. The significance of this
intervention is that it focused on behavioral informatics to change mindset of people and increase
their interest in physical activity. Hence, the research article can be applied in health promotion
initiatives to understand strategies that can be used to encourage people to become physically
active. This approach would enhance the success of any lifestyle intervention initiative in
Australia too. A systematic review also proved the efficacy of structured physical activity on
glycaemic control thus guiding implementation of more number of evidence based prevention
programmes in target setting (Edwards & Hosseinzadeh, 2017).
2. Lifestyle intervention using multiple approach:
Another significant finding of this critical review is that the critical appraisal of the papers
revealed that multi-component lifestyle intervention is more beneficial in preventing diabetes
and risk of complication compared to single intervention. There were at least four papers that
reported about the effectiveness of multi-component lifestyle intervention. For example, the
follow-up study used lifestyle intervention such as weight reduction program such as healthy diet
and moderate level of physical activity, room with treadmills and indoor physical activity

5PREVENTING DIABETES
facilities to promote behavioral change in research participant (Fianu et al., 2016). Another study
used web-based system to implement lifestyle intervention for individuals at risk of diabetes and
the main significance of this intervention was it considered all risk factors that lead to diabetes.
For example, weight loss, increase in physical activity, healthy eating, cessation of smoking and
stress management was incorporated in the web-based program to promote health of research
participants. The significance of this research paper is that it guides regarding the necessary
component that can be included in screening program for the successful prevention of diabetes
(Cha et al., 2017). The delivery of the intervention using web-based system has the advantage of
being cost-effective and reachable too. The paper by Thankappan et al. (2018) also revealed that
peer support group can play an important role in successful delivery of the lifestyle intervention
for patients at risk of diabetes.
Dietary intervention:
There was only one paper that used dietary intervention alone to prevent. This included the
paper by Du et al. (2017) which revealed that fresh fruit consumption is associated with lower
risk of diabetes and lower risk of death. However, the gap in the paper was that as it used
observation study design, it could not eliminate the effect of residual confounding factors.
Critical review of evidence:
The significance of this critical review is that maximum of the research papers included
RCT as the main research design. Although Thomas et al. (2009) was a poor quality paper as it
used only single component and small sample size to confirm the efficacy of physical activity
intervention, however many high quality research papers were also retrieved. The paper by
Thomas et al. (2009) had limitations as it had little benefit in application of the evidence in real

6PREVENTING DIABETES
practice. However, there were some papers which were very explicit and revealed the pros and
cons of both multi-component lifestyle modification intervention as well as single component
lifestyle modification intervention. The overall critical appraisal revealed the superiority of
multi-component intervention compared to single intervention in preventing diabetes. For
example, the multi-component intervention considered multiple risk factors that lead to diabetes
and focused on using different strategies to encourage people to avoid those risk behavior. In
addition, the study not only gave idea about innovative resources such as web-based tool and
telecounselling to motivate individuals to change their behavior; instead papers also gave idea
regarding important stakeholders who can play a role in enhancing the efficacy of the
intervention. For example, Thankappan et al. (2018) revealed the potential of peer support group
in preventing diabetes. However, one rationale behind the lack of generalizability of this study
was that the author did not adjust for multiple comparison and biases that could affect the study
result.
Despite limitations of some papers in having small sample size and little research rigour,
maximum papers were RCT trial and they used multi-component to enhance the efficacy of the
program. For example, the review of the paper by Cha et al. (2017) and Block et al. (2016)
suggested the importance of online mode as a cost effective strategy to prevent diabetes. For
example, Block et al. (2016) revealed the efficacy of online diabetes program in promoting
improvement in weight and gylcemic markers by considering eating habits, physical activity and
wellness factors for target group.
Gaps and implications of the findings

7PREVENTING DIABETES
The study gives implication to incorporate motivational elements like motivational
interviewing and peer support to achieve long-term success of the lifestyle modification
intervention. However, some gaps left behind in the research is that certain confounding factors
like influence of self-report and lack of residual bias has not been considered. This needs to
considered in future research.
Conclusion:
From the critical review of research papers, it can be said that lifestyle modification is an
effective step to control and prevent health care cost associated with diabetes. The critical
review of the 10 papers revealed that multi-component lifestyle intervention are more effective
in glucose control and reducing risk of complications compared to single component
intervention. The research paper can have implications in adding elements that can enhance the
success of the preventive program

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Australian Institute of Health and Welfare (AIHW) (2018). Diabetes snapshot. Retrieved from:
https://www.aihw.gov.au/reports/diabetes/diabetes-snapshot/contents/how-many-
australians-have-diabetes
Block, G., Azar, K. M. J., Romanelli, R. J., Block, T. J., Palaniappan, L. P., Dolginsky, M., &
Block, C. H. (2016). Improving diet, activity and wellness in adults at risk of diabetes:
randomized controlled trial. Nutrition & diabetes, 6(9), e231.
Cha, S. A., Lim, S. Y., Kim, K. R., Lee, E. Y., Kang, B., Choi, Y. H., ... & Ko, S. H. (2017).
Community-based randomized controlled trial of diabetes prevention study for high-risk
individuals of type 2 diabetes: lifestyle intervention using web-based system. BMC public
health, 17(1), 387.
Du, H., Li, L., Bennett, D., Guo, Y., Turnbull, I., Yang, L., ... & Millwood, I. Y. (2017). Fresh
fruit consumption in relation to incident diabetes and diabetic vascular complications: a
7-y prospective study of 0.5 million Chinese adults. PLoS medicine, 14(4), e1002279.
Duijzer, G., Haveman-Nies, A., Jansen, S. C., Ter Beek, J., van Bruggen, R., Willink, M. G.
J., ... & Feskens, E. J. M. (2017). Effect and maintenance of the SLIMMER diabetes
prevention lifestyle intervention in Dutch primary healthcare: a randomised controlled
trial. Nutrition & diabetes, 7(5), e268.
Edwards, J., & Hosseinzadeh, H. (2017). The impact of structured physical activity on glycaemic
control in diabetes prevention programmes: A systematic review. Proceedings of
Singapore Healthcare, 2010105817739924.

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Fianu, A., Bourse, L., Naty, N., Le Moullec, N., Lepage, B., Lang, T., & Favier, F. (2016). Long-
Term Effectiveness of a Lifestyle Intervention for the Primary Prevention of Type 2
Diabetes in a Low Socio-Economic Community–An Intervention Follow-Up Study on
Reunion Island. PloS one, 11(1), e0146095.
Mori, D. L., Silberbogen, A. K., Collins, A. E., Ulloa, E. W., Brown, K. L., & Niles, B. L.
(2011). Promoting physical activity in individuals with diabetes: telehealth
approaches. Diabetes Spectrum, 24(3), 127-135.
Mui, L. W., Friedman, R. H., Lau, J. T., Peng, J., & Abdullah, A. S. (2018). A RCT to evaluate a
totally automated, culturally-adapted telephone counselor for increasing physical activity
among physically inactive individuals in China. BMC public health, 18(1), 785.
Rossen, J., Yngve, A., Hagströmer, M., Brismar, K., Ainsworth, B. E., Iskull, C., ... &
Johansson, U. B. (2015). Physical activity promotion in the primary care setting in pre-
and type 2 diabetes-the Sophia step study, an RCT. BMC public health, 15(1), 647.
Thankappan, K. R., Sathish, T., Tapp, R. J., Shaw, J. E., Lotfaliany, M., Wolfe, R., ... & Fisher,
E. B. (2018). A peer-support lifestyle intervention for preventing type 2 diabetes in India:
A cluster-randomized controlled trial of the Kerala Diabetes Prevention Program. PLoS
medicine, 15(6), e1002575.
Thomas, A. S., Greene, L. F., Ard, J. D., Oster, R. A., Darnell, B. E., & Gower, B. A. (2009).
Physical activity may facilitate diabetes prevention in adolescents. Diabetes Care, 32(1),
9-13.

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Appendix :
Description Research
design
outcomes Your
judg
ment
s
Reference
details
Researc
h Aims/
objectiv
es
Nat
ure
of
inter
vent
ion
Stud
y
popu
latio
n
Rese
arch
desig
n
type
Data
coll
ecti
on
Findin
gs/
results
Concl
usion
s
As
su
mp
t
ion
s
Limitatitio
ns
Usef
ulnes
s as
infor
matio
n
sourc
e for
your
topic
1st
articl
e:
Phys
ical
Acti
vity
May
Facil
itate
Diab
etes
Prev
Author
names :
Amy S.
Thomas,
Lori F.
Greene,
Jamy D.
Ard,
Robert A.
Oster,Bett
The
aim of
this
study
was to
examin
e the
associa
tion of
Tota
l
popu
latio
n of
32
male
and
fema
le.
long
itudi
nal
pare
nt
stud
y,
Pri
mar
y
All of
the
data
were
colle
cted
durin
g one
inpati
In the
study
,
physi
cal
activi
ty
was
assoc
iated
The study
only
includes
the
adolescenc
e
population
. They did
not
consider
Usef
ul for
under
stand
ing
that
physi
cal
activi
ty

11PREVENTING DIABETES
entio
n in
Adol
esce
nts
Jour
nal
name
:
Diab
etes
care.
vol.
32(1)
y E.
Darnell,
and
Barbara
A.
Gower.
Year of
publicatio
n : 2009
Country :
Number
of
participan
ts : 32
physic
al
activit
y with
glucos
e
toleran
ce and
resting
energy
expend
iture
(REE)
among
adoles
cents.
ent
visit
to the
Gene
ral
Clini
cal
Rese
arch
Cente
r
with
carbo
hydra
te
meta
bolis
m. It
sugge
sted
that
physi
cal
activi
ty
reduc
es the
risk
of
obesit
y,
gluco
se
intole
rance
of the
popul
the effect
in older
population
reduc
es
the
risk
of
obesi
ty