SNPG917 Evidence Into Practice

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?

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. 

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 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 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 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

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

References

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.

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.