Diabetes is a global problem which leads to premature death and causes complications such as blindness, amputation, renal disease and cardiovascular disease. Lack of physical activity and improper diet are the well-known risk factors for diabetes which, can be possibly reversed by making a minor modification in lifestyle. The prevalence of type 2 diabetes has increased dramatically in western countries decreasing the life expectancy by 15 years. Nearly 5 % of NHS resources and 10 % of health care facilities resources are utilized for caring patients with diabetes. Interventions which help to prevent and delay the onset of type 2 diabetes have significantly reduced the burden of health care cost ((Hu, 2011).
Individuals with impaired glucose tolerance have a greater risk of developing type 2 diabetes. Therefore, many clinical trials have focused on the interventions which help to prevent type 2 diabetes in individuals with impaired glucose tolerance ((Hu, 2011). These interventions include pharmacological, lifestyle modification and herbal remedies. Several reviews have been carried on prevention of type 2 diabetes which focused on the pharmacological and lifestyle interventions ((Hu, 2011). Therefore, in order to consolidate the pieces of evidence of all the researchers a systematic review is carried by us.
A systematic review helps to summarize the results of the different studies and trials conducted on the health interventions for a given disease. A systematic review is being carried out on the studies published on the pharmacological and lifestyle modification interventions to control type 2 diabetes in patients with impaired glucose tolerance. The studies were searched in PubMed and Embase by custom ranging the search result since 2007 to 2017. The Medical Subject Heading Terms was used while searching the articles in PubMed. The search terms included type 2 diabetes and prevention, and impaired glucose tolerance. We also explored the Cochrane central register of controlled trials and a Conchrane library of systematic reviews to get an expert opinion.
The selection criteria include – the studies must be experimental, must have a lifestyle interventions or pharmacological interventions, must have patients with impaired glucose tolerance, must have patients with type 2 diabetes or focus on preventing type 2 diabetes, must have measurable outcomes related to diabetes and must be in English. The studies which qualified all the four selections criteria were screened, and randomized controlled trials with high quality of evidence were selected. A total of 1,207 citations were retrieved of these 128 full test articles were accessed. Three studies met the inclusion criteria. Ime randomized controlled trials with measurable outcomes.
Nearly 21 clinical studies met the inclusion criteria, and severe studies were considered for the systematic review as mentioned in table 1. These trials were heterogeneous as they focused on different interventions and included participants of different age group and ethnicity. The inclusion criteria for the participants in all trials were similar. Patients with fasting blood glucose level of ≥ 7.8 mmol/l and plasma glucose level more than or equal to 11.1mmol/l 2 hours of after receiving 75 g glucose load are considered to have type 2 diabetes. Individuals having plasma glucose level 7.8 to 11.1mmol/L, two hours after receiving a glucose load are considered to have impaired glucose tolerance (Centres for Disease Control and Prevention,2011).
The interventions ranged from 6 to 48 months with a follow-up of 6 to 9 months. All the studies included diet modification and physical exercise along with an additional component. In three studies the participants were given group and individual counselling and in two studies medication was one of the interventions for reducing the risk of diabetes.
The systematic review of these clinical trials suggests that lifestyle interventions are as effective as pharmacological interventions in reducing the risk of type 2 diabetes in individuals with impaired glucose tolerance. Lack of physical activity and obesity are highly linked with the greater prevalence of diabetes in westernized societies. The main aim of lifestyle intervention is to increase physical activity and reduce obesity which directly helps to reduce the risk of type 2 diabetes (Hu, 2011).
The clinical studies which focused on increasing the physical activity investigated the effectiveness of aerobic exercise, progressive resistance, yoga, breathing and mixed aerobic exercise program. The results of these structured exercise studies suggested that the relaxation and aerobic exercises decreased the HbA1c levels in the participants who followed it regularly (Yavari, Hajiyev, & Naghizadeh, 2010).
The diabetes prevention program reported that withdrawal of medications such as metformin and troglitazone resulted in the progression of type 2 diabetes. The results from clinical trials suggest that the effect of pharmacological interventions did not sustain after the discontinuing the treatment. Some clinical trials reported that participants had experienced minor adverse events such as gastrointestinal problems (Tabák, Herder, Rathmann, Brunner, & Kivimäki, 2012). Therefore, it is essential for a long term follow-up to ensure patient compliance and adherence to the treatment. We anticipate that lifestyle interventions cause less critical side effects than medications. However, their impact may not be everlasting as that of the pharmacological interventions. Recommendation on weight-reduction plan and workout should be strengthened on an average basis. Moreover, despite the fact that compliance of the participants towards the lifestyle intervention was high in these trials, we nevertheless know whether compliance will be maintained after the completion of the study.
The systematic review proves the clinical effectiveness of the pharmacological and lifestyle interventions in decreasing the risk of type 2 diabetes in individuals with impaired glucose tolerance. Hence, the primary health care providers and nurses can follow the lifestyle interventions while caring for patients with impaired glucose tolerance to reduce the risk of type 2 diabetes. However, numerous problems remain unanswered. Determining an efficient method to intervention, either pharmacological or lifestyle, relies not just on their overall performance in trial settings but also on the problems that may occur after the trial. In the case of pharmacological interventions, the adverse effects of medications need to be understood to prevent potential harms and maximize the advantages of the treatment. Therefore, long term follow-up should be conducted to assess the participants. Also, researchers should identify- Whether lifestyle problem is dealt with a lifelong course of drugs? As compliance is the important thing for the achievement of positive outcomes of lifestyle interventions, techniques to help compliance need to be cautiously thought to the participants and must be implemented.
Table 1: Review of Literature
|
Author, year |
Study duration/ Follow-up |
Diet |
Exercise |
Counselling |
Control Group |
|
Bo et al, 2007 |
12 months to 3 years |
Set individual goals, followed NIG guidelines, Recommended daily calorie distribution |
150 min. week moderate PA. Individualized |
Individual and group counselling in lifestyle modification |
Usual or standard care provided |
|
Oh et al, 2010 |
6 months |
Low calorie and low carbohydrate diet |
Yoga, stretching, aerobic dance and warm-up |
Nurse researcher provided 20 min counselling on food dairy and exercise adherence |
A booklet with basic education for the metabolic syndrome was provided |
|
Lu et al. 2011 |
2 years |
Face to face lecture on diet modification |
Face to face lecture in exercise |
Medications- Acarbose (50 mg thrice a day) metformin (0.25h three times a day) |
Diabetes education once |
|
Wing et al., 2010 |
4 years to 11.5 years |
Caloric restriction, meals replacement, increased fruit and vegetable intake and low fat intake |
Started with 50 min/week moderate PA increased to >175 min/week by 6 months Strength training exercise was provided |
Group and individual behavioural program was provided by lifestyle counsellor Orlistat was given to the patient who did not lose >10% weight initially |
Three group education or social support annually |
|
Toobert et al, 2011 |
6 mon/12 mon |
Mediterranean diet adapted for latin American subculctures |
30 min/d physical exercise |
Stress management techniques were taught |
Usual care |
|
Christian et al, 2008 |
12 months |
Decreased calorie intake |
Motivated participations to increase physical activity (PA) |
3 months of diabetes education |
Usual standard care |
|
Samuel-Hodge et al, 2009 |
8 month to 4 month |
General healthy eating |
Increase in PA. 15 mins of chair exercise |
Individual and group counselling |
Received 2 pamphlets in the mail published by ADA and 3 bimonthly newsletter regarding general health information |
Reference:
Bo, S., Ciccone, G., Baldi, C., Benini, L., Dusio, F., Forastiere, G., … & Gentile, L. (2007). Effectiveness of a lifestyle intervention on metabolic syndrome. A randomized controlled trial. Journal of general internal medicine, 22(12), 1695-1703. DOI: 10.1007/s11606-007-0399-6
Centers for Disease Control and Prevention.(2011). Diabetes: Successes and Opportunities for Population-Based Prevention and Control—At a Glance 2011. Atlanta: Centers for Disease Control and Prevention. Accessed at www.cdc.gov/chronicdisease/resources/publications/AAG/ddt.htm on 20 July 2017.
Christian, J. G., Bessesen, D. H., Byers, T. E., Christian, K. K., Goldstein, M. G., & Bock, B. C. (2008). Clinic-based support to help overweight patients with type 2 diabetes increase physical activity and lose weight. Archives of Internal Medicine, 168(2), 141-146. DOI: 10.1001/archinternmed.2007.13
Hu, F. B. (2011). Globalization of Diabetes: The role of diet, lifestyle, and genes. Diabetes Care, 34(6), 1249–1257. Doi:10.2337/dc11-0442
Lu, Y. H., Lu, J. M., Wang, S. Y., Li, C. L., Zheng, R. P., Tian, H., & Wang, X. L. (2011). Outcome of intensive integrated intervention in participants with impaired glucose regulation in China. Advances in therapy, 28(6), 511-519. DOI: 10.1007/s12325-011-0022-4
Oh, E. G., Bang, S. Y., Hyun, S. S., Kim, S. H., Chu, S. H., Jeon, J. Y., … & Lee, J. E. (2010). Effects of a 6-month lifestyle modification intervention on the cardiometabolic risk factors and health-related qualities of life in women with metabolic syndrome. Metabolism, 59(7), 1035-1043. DOI: 10.1016/j.metabol.2009.10.027
Tabák, A. G., Herder, C., Rathmann, W., Brunner, E. J., & Kivimäki, M. (2012). Prediabetes: A high-risk state for developing diabetes. Lancet, 379(9833), 2279–2290. Doi: 10.1016/S0140-6736(12)60283-9
Toobert, D. J., Glasgow, R. E., Strycker, L. A., Barrera, M., Radcliffe, J. L., Wander, R. C., & Bagdade, J. D. (2003). Biologic and quality-of-life outcomes from the Mediterranean lifestyle program. Diabetes Care, 26(8), 2288-2293. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/12882850
Samuel-Hodge, C. D., Keyserling, T. C., Park, S., Johnston, L. F., Gizlice, Z., & Bangdiwala, S. I. (2009). A randomized trial of a church-based diabetes self-management program for African Americans with type 2 diabetes. The Diabetes Educator, 35(3), 439-454. DOI: 10.1177/0145721709333270
Wing,R.R, Look AHEAD Research Group. (2010). Long term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes: four year results of the Look AHEAD trial. Archives of internal medicine, 170(17), 1566. DOI: 10.1001/archinternmed.2010.334
Yavari, A., Hajiyev, A. M., & Naghizadeh, F. (2010). The effect of aerobic exercise on glycosylated hemoglobin values in type 2 diabetes patients. The Journal of sports medicine and physical fitness, 50(4), 501-505. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/21178937
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