Effectiveness of Lifestyle Interventions in the Prevention of Type 2

Question: Discuss about the Effectiveness of Lifestyle Interventions in the Prevention of Type 2 Diabetes Among Adults: A Systematic Review. Answer: Literature Review The rise of noncommunicable diseases in recent decades has stood out as a significant public health problem for both developed and developing countries. This rise is primarily attributed to both an ageing population, and also the shift to nutrition and dietary habits of the western world and the sedentary lifestyles. This shift, especially and dietary habits is influence by both development (socioeconomic and technological), urbanisation and globalisation (Alouki, Delisle, Bermdez-Tamayo, Johri, 2016). Diabetes stands out as one of the major noncommunicable disease attributable to nutrition. Its worldwide prevalence increases rapidly and especially in the developing nations. As per the most recent statistics, 400 million people worldwide, 29.1 million people in the US, 3.8 million people in the UK, and 1.2 million people in Australia suffer from diabetes, with 90% of which present with type II diabetes (T2D) (International Diabetes Federation, 2016; CDC, 2016; Australian Institute of Health and Welfare (AIHW), 2018; Public Health England, 2016). Type 2 diabetes is a lifestyle disease which can be prevented by lifestyle changes, in terms of changes in dietary habits and also increased physical activity. A number of studies have reported success in the reduction of T2D prevalence through the of lifestyle interventions (Gong, et al., 2011; Diabetes Prevention Program Outcomes Study Research Group, 2013). Weight control is central to the prevention and management of T2D independent of the dietary factor. Owing to the fact that obesity is a major risk factor for T2D, lifestyle interventions aimed at weight management are central to its prevention. Except for some Asian countries (China and India in particular), minimal research has been conducted so far on diabetes prevention programs in developing countries. A number of systematic reviews on this topic have been conducted so far, and they do not all reach the conclusion that there is enough data to recommend the use of lifestyle interventions as advocated for by diabetes prevention programmes currently. As such, this systematic review aims at addressing some questions: Among high risk groups, does combined diet and physical activity interventions have an impact on glycaemic control and the incidence of T2D? Does the patients age, sex or ethnicity affect their participation in combined diet and physical interventions and the resulting incidence of T2D? Does the nature of the trial (explanatory or pragmatic trial) influence the effect of combined diet and physical activity interventions on the participants? Aims of this review The questions outlined above spell the aim of this systematic review, which simply put, aims at synthesizing recent evidence from the past ten years on the effectiveness of lifestyle interventions in the management of weight in glycaemic control and eventually on the incidence of type II diabetes among adults. Search Strategy In order to identify all relevant studies on the effectiveness of lifestyle interventions in the management of weight in glycaemic control and eventually on the incidence of type II diabetes, a search will be conducted on the following electronic databases: CINAHL, MEDLINE, and Academic Search Complete. The search terms shown table 1 below will be used. The alternative keywords and phrases as identified using thesaurus, a search on Google Scholar followed by scanning of the results for alternative words and phrases, and lastly, the use of the US National Library of Medicines Medical Subject Headings (MeSH) search are shown in the third row and will be used accordingly. Patient or Population or Problem Intervention (or Exposure) Comparison Outcomes Type II Diabetes Diet Physical activity N/A Weight management Glycaemic control Incidence of type II diabetes Diabetes Mellitus Noninsulin-Dependent Diabetes Mellitus Type 2 Diabetes Type 2 Diabetes Mellitus Dietary Management Nutritional Management Diet Therapy Diet Habits Feeding Behaviour Nutritional Therapy - Exercise - Physical Education and Training N/A HBA1c blood sugar Weight reduction plan Diabetes mellitus incidence Incidence of diabetes mellitus Type II diabetes incidence Incidence of Noninsulin-Dependent Diabetes Mellitus The MeSH and other relevant terms as identified above will then be combined with Boolean operators AND and OR and used appropriately. This will lead to combinations such as (i) Type II Diabetes (title) OR Diabetes Mellitus (MeSH) OR Noninsulin-Dependent Diabetes Mellitus (MeSH) OR Type 2 Diabetes (MeSH) OR Type 2 Diabetes Mellitus (MeSH) AND (ii) Diet (title) OR Dietary management (MeSH) OR Nutritional management (MeSH) OR diet therapy (MeSH) OR diet habits (title) OR Feeding Behaviour (MeSH) OR Nutritional therapy (MeSH) OR physical activity (title) OR exercise (MeSH) OR Physical Education and Training (MeSH) AND (iii) glyc##mic control (title) OR HBA1c or blood sugar OR weight management (title) OR weight reduction plan (MeSH) OR incidence of type II diabetes (title) OR diabetes mellitus incidence (MeSH) OR incidence of diabetes mellitus (MeSH) OR type II diabetes incidence (MeSH) OR incidence of Noninsulin-Dependent Diabetes Mellitus (MeSH) OR Maturity-Onset Diabetes Mellitus (MeS H). Truncation and wildcards will be used sparingly, with the following terms adult*, Diabet####, gly##mic. The search will be limited to studies that involved adults as participants. Additional searching will also be done on the reference lists from the identified relevant systematic reviews The results from the search will be imported to Endnote X7 to be assesses of relevance to the current review, duplicates and those not in English language will be removed. The remainder will be assessed by title alone, and the irrelevant ones will be removed. The abstracts of the remaining studies will then be assessed. The full texts of those that will remain will be examined against the following inclusion and exclusion criteria: Original research articles published in peer-reviewed journals. The study participants were adults (18 years and above), and classified to be at a high risk of developing the disease attributable to aggregation of risk factors such as obesity, impaired fasting glycaemia, gestational diabetes, or impaired glucose intolerance. The study will include the interventions of dietary modifications or physical activity or both for the prevention of the condition or weight management and control of obesity. Studies whose outcomes are weight management, glycaemic control, incidence of type II diabetes and other relevant outcomes. Studies published between January 2012 and December 2017. Studies that were only published in English and not translated from any language. The articles full text has to be accessible. Studies conducted both in the clinical and in an academic environment. The following will be the exclusion criteria: Duplicate copies of the same study Studies published in a language other than English Student thesis reports and studies published on company websites. Books or book chapters. Those studies that will have met the above inclusion and exclusion criteria for the review will be tabulated. Study quality assessment The quality of the identified documents will be then analysed. The quality will be based on three factors: internal validity, external validity, and bias. Study quality assessment will be conducted for the purposes of evaluating the validity of the identified studies. As reiterated by Staples and Niazi, (2007), it is quite challenging to determine the extent to which threats of validity have been addressed by the researchers. Therefore, the quality assessment has to be based on research paper structure criteria. For the current study, the assessment will be evaluated on structure: Introduction, Research Method, Results, Research Conduct and Ethical Concerns, and Conclusion. The researcher will evaluate whether each potential study answers the following questions. Does the papers introduction section provide an overview of diabetes, and lifestyle modifications? Does the study clearly describe the research methodology adopted? Are the study results defined in the paper? Are they helpful in answering the search questions developed for the current study? With regard to research conduct and ethical conduct, does the researcher uphold the research code of conduct in the region which the study was undertaken? Generally, the paper should outline how the research upheld the principles of; (a) honesty in communicating the research goals, methods and procedures, (b) reliability in performing the research and also communicating the results, (c) objectivity in interpretation and concluding on the facts and data arrived at, (d) impartiality and independence from interested parties or economic or financial interests, (e) openness and accessibility of the study and its materials, (f) duty of care for the study participants, (g) fairness in proper referencing and giving due credit to the work of others, (h) responsibility for future science generations (European Science Foundation:, 2017). On the conclusion section, does the paper report the findings (both positive and negative properly) And does it address the studys limitations? Search Results A search on MEDLINE with Full Text, CINAHL, and Academic Search Complete identified 372 results. A total of 90 duplicates were removed. Upon assessment of the titles and abstracts of the 282 remaining studies, another 27 studies were excluded, leaving 255 full-text articles for further review (figure 1 below). One (1) paper was further excluded as it had originally been published in Spanish, and even though it was re-published in English, it was excluded as per the current reviews inclusion and exclusion criteria. Out of the 254 remaining full-text articles, 158 were excluded. One article was excluded on the basis of just being a study protocol for a study in the future, 5 articles were excluded for not specifying the type of diabetes that was studied, another 8 studies had included subjects who had not made the cut-off age for the current study (18 years). Further, another 11 studies were not accessible, 45 were not peer-reviewed, 37 did not adopt a lifestyle-based intervention (die t or physical activity), another 26 did not meet this systematic reviews criteria, and the abstracts of another 25 studies did not contain adequate information to determine the inclusion criteria had been met. The 96 remaining studies recruited adult samples of 30 to 7,467 participants. The reported mean age was on average, 45 years (37 to 50 years). Female participants made up about 60%. the studies had adopted either diet or physical activity as the lifestyle interventions, and they measured the outcomes in terms of weight management, glycaemic control and incidence of type II diabetes mellitus. Risk of bias within studies The methodological aspect of the first ten included studies were assessed for risk of bias. The assessment was carried out as per the Cochrane collaborations tool for assessing risk of bias (Higgins, et al., 2011). As per the tool, the studies are assessed on 7 parts where there is the likelihood of bias. On the 7 domains, one is to respond with either a yes to indicate low risk, no to indicate significant risk, or unclear to indicate that there was not enough information to come up with the decision on the risk of bias. The median score was 7 (minimum -1, maximum 9); only three studies (Frank et al., 2014; Jacobs et al., 2015; Liubaoerjijin, Terada, Fletcher, Boul, 2016) were regarded as having a low risk of bias , five (Mandalazi, Drake, Wirflt, Orho-Melander, Sonestedt, 2016; Parajuli, Saleh, Thapa, Ali, 2014; Sangeetha et al., 2013; Shu, Chan, Huang, 2017; Yom-Tov et al., 2017) had moderate risk , while two (Grntved et al., 2014; Mikus, Oberlin, Libla, Boyle, Thyfault, 2012) were regarded as having high risk . References Alouki, K., Delisle, H., Bermdez-Tamayo, C., Johri, M. (2016). Lifestyle Interventions to Prevent Type 2 Diabetes: A Systematic Review of Economic Evaluation Studies. J Diabetes Res., 2159890. Australian Institute of Health and Welfare (AIHW). (2018, January 18). Diabetes. Retrieved from Australian Institute of Health and Welfare: https://www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/diabetes/overview CDC. (2016, July 25). Working to Reverse the US Epidemic: At A Glance 2016. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm Diabetes Prevention Program Outcomes Study Research Group. (2013). Long-term effects of the Diabetes Prevention Program interventions on cardiovascular risk factors: a report from the DPP Outcomes Study. Diabet Med, 46-55. European Science Foundation: (2017). European Code of Conduct. Berlin: All European Academies. Frank, L. K., Krger, J., Schulze, M. B., Bedu-Addo, G., Mockenhaupt, F. P., Danquah, I. (2014). Dietary patterns in urban Ghana and risk of type 2 diabetes. The British Journal Of Nutrition, 112(1), 89-98. doi:10.1017/s000711451400052x Gong, Q., Gregg, E., Wang, J., An, Y., Zhang, P., Yang, W., . . . Bennett, P. (2011). Long-term effects of a randomised trial of a 6-year lifestyle intervention in impaired glucose tolerance on diabetes-related microvascular complications: The China Da Qing Diabetes Prevention Outcome Study. Diabetologia, 300-7. Grntved, A., Pan, A., Mekary, R. A., Stampfer, M., Willett, W. C., Manson, J. E., Hu, F. B. (2014). Muscle-strengthening and conditioning activities and risk of type 2 diabetes: a prospective study in two cohorts of US women. Plos Medicine, 11(1), e1001587-e1001587. doi:10.1371/journal.pmed.1001587 Higgins, J. P., D. G., Gtzsche, P. C., Jni, P., Moher, D., Oxman, A. D. (2011). The Cochrane Collaborations tool for assessing risk of bias in randomised trials. BMJ, d5928. International Diabetes Federation. (2016). Facts and Figures. Retrieved from International Diabetes Federation: https://www.idf.org/WDD15-guide/facts-and-figures.html Jacobs, S., Harmon, B. E., Boushey, C. J., Morimoto, Y., Wilkens, L. R., Le Marchand, L., . . . Maskarinec, G. (2015). A priori-defined diet quality indexes and risk of type 2 diabetes: the Multiethnic Cohort. Diabetologia, 58(1), 98-112. doi:10.1007/s00125-014-3404-8 Liubaoerjijin, Y., Terada, T., Fletcher, K., Boul, N. G. (2016). Effect of aerobic exercise intensity on glycemic control in type 2 diabetes: a meta-analysis of head-to-head randomized trials. Acta Diabetologica, 53(5), 769-781. doi:10.1007/s00592-016-0870-0 Mandalazi, E., Drake, I., Wirflt, E., Orho-Melander, M., Sonestedt, E. (2016). A High Diet Quality Based on Dietary Recommendations Is Not Associated with Lower Incidence of Type 2 Diabetes in the Malm Diet and Cancer Cohort. International Journal Of Molecular Sciences, 17(6). doi:10.3390/ijms17060901 Mikus, C. R., Oberlin, D. J., Libla, J., Boyle, L. J., Thyfault, J. P. (2012). Glycaemic control is improved by 7 days of aerobic exercise training in patients with type 2 diabetes. Diabetologia, 55(5), 1417-1423. doi:10.1007/s00125-012-2490-8 Parajuli, J., Saleh, F., Thapa, N., Ali, L. (2014). Factors associated with nonadherence to diet and physical activity among Nepalese type 2 diabetes patients; a cross sectional study. BMC Research Notes, 7, 758-758. doi:10.1186/1756-0500-7-758 Public Health England. (2016, September 13). 3.8 million people in England now have diabetes. Retrieved from Gov.uk: https://www.gov.uk/government/news/38-million-people-in-england-now-have-diabetes Sangeetha, S., Fatimah, A., Rohana, A. G., Norasyikin, A. W., Karuthan, C., Nik, S. S., . . . Nor, A. K. (2013). Lowering dietary glycaemic index through nutrition education among Malaysian women with a history of gestational diabetes mellitus. Malaysian Journal Of Nutrition, 19(1), 9-23. Shu, P. S., Chan, Y. M., Huang, S. L. (2017). Higher body mass index and lower intake of dairy products predict poor glycaemic control among Type 2 Diabetes patients in Malaysia. Plos One, 12(2), e0172231-e0172231. doi:10.1371/journal.pone.0172231 Staples, M., Niazi, M. (2007). Experiences using systematic review guidelines. Journal of Systems and Software, 1425-1437. Yom-Tov, E., Feraru, G., Kozdoba, M., Mannor, S., Tennenholtz, M., Hochberg, I. (2017). Encouraging Physical Activity in Patients with Diabetes: Intervention Using a Reinforcement Learning System. Journal of Medical Internet Research, 19(10), e338-e338. doi:10.2196/jmir.7994