Running Head: Integrative Review Paper 1
Running Head: Integrative Review Paper 1
Running Head: Integrative Review Paper 1
Charito Ward, RN
Nursing Research
NUR 4222
I PLEDGE.
Abstract
The purpose of this integrative review is to evaluate studies regarding early education and
health maintenance in preventing Type-2 diabetes in adults by the age of 35. Type-2 diabetes is
an avoidable disease for most Americans. New diagnosis of diabetes occurs at an alarming rate
every year, and is the seventh leading cause of death in America. Early education on health
maintenance and food choices helps patients become aware of a sedentary lifestyle and poor
The research design is an integrative review. The main search engine used was Google
Scholar due to ease of use. When a PubMed article was shown on Google Scholar the necessary
login process into PubMed was done. Google Scholar search engine produced 1,230,000
different results, five of which satisfied the components for research criteria. The results of the
five articles being used show evidence of the effectiveness on early education and health
management preventing the development of Type-2 diabetes. Current statistical information was
taken from the American Diabetes Association (ADA) website. The studies showed that early
education on diet and health maintenance had an impact on preventing or delaying the diagnosis
of type-2 diabetes, the articles state that the outcomes based on their study were positive and that
patients that are younger than 45 on diet and health management in the prevention of developing
Type-2 diabetes is on the rise it is more relevant now than ever before. Currently 29.1
million people in America have diabetes, another 21 million people have it, but are undiagnosed
or do not know they have it (American Diabetes Association, 2016). The Population,
Intervention, Comparison and Outcome (PICO) question on how to address Americas current
diabetic statistics would be: Would early education and health maintenance reduce or eliminate
Many Americans who suffer from type-2 diabetes is usually due to poor food choices and
a sedentary lifestyle, possibly due to the neighborhoods they have to live in. This issue is
important because the relevance and cost. Currently 1.4 million American Adults are diagnosed
with diabetes each year; the youth population approximately 1 in 400 children are diagnosed
with diabetes yearly (American Diabetes Association, 2015). In 2012 the total economic burden
was 322 billion with 1 in 10 health care dollars spent on diabetes complications and 1 in 5 health
care dollars spent on treating people with diabetes (American Diabetes Association, 2015). That
means to the working Americans (who may or may not have diabetes) an increase in health care
insurance, higher co-pays, increased medical expenses and higher taxes to pay for treatment of
The research design is an integrative review entailing how the reviewer conducted the
search for the literature pertaining to this study. Computer based search engines such as Google
Scholar, PubMed, Ebsco was used to find articles that had information specifically on education,
Type-2 diabetes, prevention, and diet. Google Scholar was used more frequently due to
easier access to articles. Google Scholar provided more that 1,000,000 different articles
pertaining to the topic. To streamline the search engine results the word studies was added.
Articles were then included or excluded by titles and dates; articles past 2005 were dismissed.
The articles then had to address the PICO question For the low-income socioeconomic status
community, would early education and health maintenance reduce or eliminate the risk of
The five articles were then selected based on the inclusion criteria for the PICO question:
prevention or delay of type-2 diabetes, preventing type-2 diabetes, diet and nutrition, reducing
risk of development, changing lifestyle and diet. Although other articles had more relevance to
the PICO they had to be eliminated due to the articles being older than 2005 with no current
updated facts. Articles selected for the integrative review were based on having statistics,
methods of study, topics being studied, and patient outcome that was in favor of the PICO
question.
More prevalent studies that were cited in other articles referred to the Diabetes
Prevention Program Study (DPP) that was initially done in 2002; there have been updates to the
article and study since then. The screening produced five intervention/prevention articles, all five
articles were qualitative in nature with one of them predicting amount of Americans who will
Findings/Results
The findings and results of the five reviewed studies are as follows: The Diabetes
Prevention Program (DPP) done by the American Diabetes Association (ADA) in 2002 with
updates as late as 2014. Research design for the DPP was based on stratified randomized clinical
trials. Data collection for the study included frequent contact, ongoing intervention, 16 core
curriculum sessions ranging from 30 minutes to one hour, self-monitoring, supervised activity
sessions, centralized training, toolbox, feedback and support. The subjects in the ADA study
totaled to 3,234 participants with the mean age of 51. Women made up 68 percent of the total
subjects. Out of the total subjects 55 percent were Caucasian, 20 percent were African American,
16 percent Latino, five percent Indian and four percent were Asian. The sampling methods the
ADA used for this study was observation with intervention and annual follow-ups for many
years. The data analysis used for the DPP intervention and risk assessment at each subjects
baseline at the beginning of the study and annually since then, empirical literature was also used
for analysis of the subjects results. The conclusion that the DPP study drew; was through
extensive centralized feedback, training, support and education that the incidence of diabetes had
The second study is The National Diabetes Fact Sheet done by the Center of Disease
Control (CDC) in 2011. The research design for the CDC study was past data from the CDC,
Indian Health Services (HIS), National Information Reporting System (NPIRS), U.S Renal Data
System of the National Institute of Health (NIH), U.S. Census Bureau, and published studies
which falls under a complete sample for their information. Data collection was from data that
was reported under multiple patient reporting systems. Sampling methods to produce prediction
numbers used the behavioral risk factor surveillance system. Data analysis from the CDC study
was taken from the national database, monthly telephone surveys, and state specific surveys. The
conclusion of this article produced the relevance of diabetes in Americans under the age of 20 is
26.6 million or 11.3 percent of this age group. The age group 26 to 65 is 10.9 million or 26.9
percent with type-2 diabetes. Men make up 13 million or 11.8 percent of the 20 and up age
group, with no medication intervention (Center for Disease Control [CDC], 2011).
The Third Article is Different strategies for screening and prevention of type-2 diabetes
in adults: cost effectiveness analysis (Gillies et al., 2008). Research design was based on cost
decision analytic model, from screening to death (Gillies et al., 2008, para. 2). The research
design was specific to formulate possible future cost versus prevention interventions to decrease
or eliminate diagnosis of type-2 diabetes. Data collection was obtained through previous
supplementary data collected from Department of Health Statistics for England and Wales,
Screening Those At Risk (STAR) survey and the ADDITION study from the Leicester division
(Gillies et al., 2008, para. 2). The sampling method for this article was a hypothetical
population, aged at 45 during the screening with a high risk of diabetes. Data analysis was done
through information received from the STAR survey, QALY survey and screening.
The overall conclusion the study provided was with appropriate intervention for those
who are in above average risk with the population aged 45, seems to be cost effective (Gillies et
al., 2008). The importance of this study for the integrative review is to show that early education
and intervention has financial benefits for patients as well as the American taxpayer by
alleviating preventable cost on a disease that can be avoided by a maintaining a healthy diet and
regular exercise.
The fourth study Reduction in weight and cardiovascular disease risk in individuals with
type-2 diabetes: One-year results of the Look AHEAD trial (Research Group et al., 2007). The
AHEAD acronym of the title is for Action for Health in Diabetes. The research design method in
this study used multi-centered randomized control trial based on stratified randomization. Data
collection was accrued from intensive lifestyle interventions, continuous care, ongoing
assessments, serum measures and statistical measures. 5,145 subjects participated in this study
and had the diagnosis of type-2 diabetes. The age range of the subjects was 45-74 years old and
Body Mass Index (BMI) greater than 25kg/m2. The subject group consisted of equal number of
male and female participants and the racial disparity in the group was 33%. Data collection used
Exertion (RPE) scale, and serum measures. Data analysis in this article was preformed through
analyzing the covariance and logistic regression from the subjects baseline to the one-year mark
after interventions. Conclusions from this study found with diabetes support and education alone
there was a decrease in the subjects mean HbA1c but was not as effective as intense lifestyle
intervention with education. The results showed clinically significant weight loss in persons
with type-2 diabetes was associated with improved diabetes control and cardiovascular risk
factors (Research Group et al., 2007, p. 2). The study also showed that broadly achievable
weight loss improved risk for diabetes and cardiovascular risk. There was also a significantly
greater remission of metabolic syndrome in the subjects one-year after the trial started.
The final article for review is Type-2 diabetes prevention in the Real world (Absetz,
2007). Research design for this study was quantitative data through the use of Reach
collection was gathered by using the subjects baseline labs, weight, measurements, and physical
fitness, as well as employment and education status comparing baseline results at three months,
six months, nine months and one year later. The subjects in this study were a total of 352 people,
of that total amount of people 103 were men, and 286 were women. Each of the subjects then
split into 36 different groups based on their home location from the closest participating medical
facility. Data collection was through anthropometric measurements, lab tests, and repeated
measures. Data analysis was done with comparison to the study subjects baseline results; x2
statistics was then applied and placed into the statistical analysis software package (SPSS). The
conclusion of this study was that with education, support, nutrition guides showed favorable
outcomes in risk factors such as decreased BMI, decreased waist circumference, and lower blood
pressure, by those measures alone the study stated that it is arguably unethical not to offer this
Discussion/Implications
The findings of the integrative review address the importance of early education on
nutrition and health management to prevent type-2 diabetes versus control groups in various
clinical outcomes concerning risk for development of type-2 diabetes. Therefore, the article
reviews directly relate to support the researchers PICO question. The PICO question specifically
asked about early education on nutrition and health maintenance in delaying or preventing the
development of type-2 diabetes. All five articles concluded that the diagnosis of type-2 diabetes
can me avoided or delayed by several years if a person makes healthy eating choices and
exercises frequently. Articles from the CDC and by Absetz, et. al, specifically state in their
conclusions that a proper diet alone can make a drastic difference in developing type-2 diabetes,
All five studies focused on prevention of type-2 diabetes but touched on different aspects
of it. Two of the studies were quantitative in nature done by Absetz, et. al, and DPP studied
interventions to prevent the development of type-2 diabetes, primarily focusing on diet and
exercise; both articles came to the same conclusion that diet and exercise would reduce if not
The article by the CDC was predicting in nature, stating the significance of the diagnosis
of type-2 diabetes yearly, that study stressed that nearly 215,000 people go undiagnosed who
currently have the disease and are unaware of it. The CDC study also mentions type-2 diabetes in
the major contributor to other diseases that lead to death and is currently the seventh leading
cause of death in the United States (CDC, 2011). The CDC study also mentioned the DPP studys
conclusion A large prevention study of people at high risk for diabetes, showed that lifestyle
intervention to lose weight and increase physical activity reduce the development of type-2
diabetes by 58% during a 3-year period. The reduction was even greater at 71% among adults
The article done by Gilles, et. al, was a cost analysis study on interventions preventing
type-2 diabetes versus management and treatment of diabetes. Gilles, et. al, concluded that long
compliance with interventions found that even with compliance rates as low as 50%, the
screening strategies involving either lifestyle or pharmacological interventions were still cost
effective when compared with no screening (Gillies et al., 2008, p. 10). This study states that
lifestyle changes to eliminate the diagnosis of type-2 diabetes is still more cost effective than
doing nothing, backing the researchers PICO question of effectiveness on health maintenance.
The study done by M. Espeland explored the correlation with type-2 diabetes and
cardiovascular disease affected by a nutritious diet and increased physical activity had improved
diabetes control and cardiovascular risk factors reduced (Research Group et al., 2007, p. 9). The
findings again support the researchers PICO question by applying diet and exercise to the study
group showing reduction in metabolic syndrome, improved glycemic control and reduced risk of
acquiring cardiovascular disease. This study not only addressed diabetes they also linked it to
cardiovascular disease, again being reiterated by the article from the CDC stating diabetes causes
cardiovascular disease.
The only portion of the PICO question not addressed was the age set at 35. The
researchers reasoning to picking 35 years old is because of the clinical significance of developing
type-2 diabetes at a later age. The thought is that prevention intervention at a younger age could
possibly eliminate all risk of developing of type-2 diabetes. By 45 years old most people are
considered at risk for the development of type-2 diabetes. Addressing the risk of type-2 diabetes
at an earlier age would prevent diagnosis all together. Introducing a healthier meal plan and
exercise regimen early on can have vastly different outcomes opposed to waiting until patients
start presenting with symptoms and becoming at risk for developing type-2 diabetes.
Limitation
Due to lack of experience in the researchers history of conducting and integrated review
prior to this paper was seen as a limitation. Another limitation is only having five articles that
could be used for the review with particular information that needed to be addressed. The
reviewer had further limitations by isolating the dates of the search engine dating from 2005 to
present; this was done to have the most current and accurate information presented for the
review.
Conclusion
All five articles were extremely useful in assessing the importance of educating patients
on nutrition and exercise. Although each study focused on different topics, they all had the same
interventions applied in each one when obtaining their own data. The answer to the PICO
question: Would early education on nutrition and health maintenance reduce or eliminate the
diagnoses of type-2 diabetes by the age of 35? The answer is yes, it would.
Nurses play an influential role as a health care provider; typically nurses have a majority
of face-to-face contact with patients developing a bond and sense of trust with the patient. The
best implication to help a patient who may be at risk for developing type-2 diabetes is to educate
them on their risk and how important it is for them to make wiser nutritional choices. Nurses are
able to integrate patients culture or religion into meal plans to make the adjustment suited for
eliminating the risk of diabetes. Nurses can give patients examples of what they can do for
exercise. Depending on the patients health status and capability, some patients may be able to
run, while others may only be able to walk. While nurses may not be able to treat diabetes, they
can help prevent the development of it by relaying crucial information and taking time to tailor
Absetz, P. (2007, October 10). Type 2 Diabetes prevention in the Real-world: One-year results
of the GOAL implementation trial [Article in journal]. Diabetes Care, 30(10), 2465-2470.
http://dx.doi.org/10.2337/dc07-0171
Center for Disease Control. (2011). National diabetes fact sheet: national estimates and general
information on diabetes and prediabetes in the United States, 2011 [Fact sheet].
Retrieved from Department of Health and Human Services, Centers for Diseas Control :
https://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
Gillies, C. L., Lambert, P. C., Abrams, K. R., Sutton, A. J., Cooper, N. J., Hsu, R. T., ... Khunti,
K. (2008). Different strategies for screening and prevention of type-2 diabetes in adults:
http://www.bmj.com/content/bmj/336/7654/1180.full.pdf
Research Group, L., Pi-Sunyer, X., Blackburn, G., Brancati, F. L., Bray, G. A., Bright, R., ...
individuals with Type-2 diabetes: One-year results of the Look AHEAD trial. Retrieved
The Diabetes Prevention Program Coordinating Center, Biostatistics Center (Ed.). (2002-2014).
The diabetes prevention program report (PMCID: PMC1282458). Retrieved from U.S.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1282458/