The Clinical Issue and Research Questions Developed Using PICOT

EVIDENCE- BASED CARE SHEET

ICD-10 E11

Authors Helle Heering, RN, CRRN

Cinahl Information Systems, Glendale, CA

Jeanne Parks-Chapman, RN, BSN Cinahl Information Systems, Glendale, CA

Reviewers Teresa-Lynn Spears, RN, MSN

Cinahl Information Systems, Glendale, CA

Alysia Gilreath-Osoff, RN, MSN Cinahl Information Systems, Glendale, CA

Nursing Practice Council Glendale Adventist Medical Center,

Glendale, CA

Editor Diane Hanson, MM, BSN, RN, FNAP

July 16, 2021

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2021, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Diabetes Mellitus, Type 2: Prevention

What We Know › Diabetes mellitus, type 2 (DM2; formerly called non-insulin dependent diabetes and

adult-onset diabetes) is a chronic, multisystem metabolic syndrome of gradual onset characterized by hyperglycemia caused by insufficient body tissue response to insulin (i.e., insulin resistance) and impaired pancreatic production of insulin. Microvascular disease is commonly present at diagnosis, and serious complications (e.g., cardiovascular and renal disease) occur even in patients with DM2 who receive intensive treatment for DM2. (1,5,12) (For more information, see Quick Lesson About … Diabetes Mellitus, Type 2 ) • The rapidly increasing prevalence of DM2 is believed to be a result of lifestyle-related

changes in diet and physical activity(21)

–The World Health Organization reports an estimated 422 million adults living with diabetes in 2014 which is 8.5% of the adult population(21)

- In 2018, an estimated 34.5% of adults, or 88 million individuals, in the United States had “prediabetes,” (5) which is defined as impaired fasting glucose (IFG; i.e., fasting plasma glucose of 100–125 mg/dL), impaired glucose tolerance (IGT; i.e., 2-hour plasma glucose value after a 75-gramoral glucose tolerance test [OGTT] of 140–199mg/dL); and/or elevated glycosylated hemoglobin (HbA1c; 5.7–6.4%)(1)

- Persons with prediabetes are at relatively high risk for developing DM2(15)

› The American Diabetes Association (ADA) recommends screening for DM2 and prediabetes beginning at age 45 or earlier in patients who are overweight or obese (i.e., body mass index [BMI] ≥ 25 kg/m2) and have one or more additional risk factors for DM2.(1)The U.S. Preventive Services Task Force (USPSTF) recommends screening of overweight and obese adults aged 40–70 years for abnormal blood glucose as part of cardiovascular risk assessment (9)

• Risk factors include having a first-degree relative with DM2, low high-density lipoprotein (HDL) cholesterol, elevated triglycerides, elevated BP, cigarette smoking, physical inactivity, polycystic ovary syndrome (PCOS), history of gestational diabetes, having given birth to a baby weighing > 9 lb, and being a member of certain ethnic or racial groups (e.g., Black, Hispanic, Native American, Pacific Islander)(1,12,15)

› Researchers in several studies have demonstrated that onset of DM2 can be prevented or delayed in patients with prediabetes by instituting lifestyle changes and/or using pharmacologic agents or surgery(2)

• There is a lack of evidence, however, demonstrating that delaying onset of DM2 delays onset of DM2 complications, compared with treatment once DM2 is diagnosed

› Primary DM2 prevention strategies focus on achieving and maintaining normal weight, BP, and blood lipid levels through lifestyle modification that includes eating a healthy diet and regular participation in physical exercise(2,15)

• The ADA recommends that patients with prediabetes participate in a program with the goal of weight loss of 7% of body weight and an increase in physical activity to at least 150 minutes per week of moderate activity (e.g., walking).(2)The USPSTF recommends

that overweight and obese adults ages 35-70years, with additional cardiovascular risk factors—such as prediabetes—receive effective preventive interventions(19)

- In the Diabetes Prevention Program (DPP), which enrolled overweight patients with prediabetes, weight loss and increased physical activity reduced risk for new-onset DM2 by 58% at 3 years and was more effective in reducing risk for progression to DM2 than the antidiabetic drug metFORMIN(16)

- In DPP, each kilogram of weight loss was associated with a 16% reduction in DM2 risk(16)

• Adherence to lifestyle modification requires substantial patient motivation promoted through education and consistent clinician follow-up (6)

–Technology-assisted tools can assist patients in making effective lifestyle modifications(1,20)

- Researchers of a meta-analysis evaluating technology-mediated diabetes prevention interventions targeting diet and exercise report an average of 3.76 kg of lost weight and significant glycemic improvement in participants(4)

- A systematic review of 19 studies reported that behavior change techniques in technology-driven DM2 prevention interventions led to significant outcomes including at least 3% loss of baseline body weight at one year, improvements in HbA1C and fasting glucose levels, and a lower 5-year incidence rate of DM2 (20)

› Dietary changes associated with lowered DM2 risk include consuming low-fatdairy products, adhering to the Mediterranean diet, and avoiding sugar-sweetened beverages (13,18)

• The authors of a systematic review and meta-analysis of 60 studies reported a significant inverse correlation between intake of low-fatdairy products and risk for developing DM2 (18)

• The authors of a systematic review and meta-analysis of 9 studies including more than 100,000 subjects found that those with the highest adherence to the Mediterranean diet—which entails frequent consumption of a variety of fruits, vegetables, grains, and fish; consuming heart-healthy fats, including olive oil; and consuming limited amounts of dairy products and red meat—were 19% less likely to develop DM2 than those with the lowest adherence (13)

• The authors of a nationwide cohort study reported that light intake of alcohol was associated with a decreased risk of DM2 when compared with no consumption and heavy alcohol consumption (10)

• The authors of a systematic review and meta-analysis of 60 studies reported that consumption of sugar-sweetened beverages was associated with an increased risk of DM2. Conversely, coffee consumption was associated with a 35% reduced risk of DM2 (18)

–Replacing sugar-sweetened drinks with artificially-sweeteneddrinks has not been shown to lower the risk of DM2 and may actually increase the risk (18)

› Group-based lifestyle intervention programmes (LIPs) involving DM2 prevention might promote long term behavior change through methods that include participant relatedness and emotional support of peers (3)

› A number of pharmacologic agents have been studied to determine their efficacy in reducing the risk for new-onset DM2(2,15)

• Researchers have demonstrated that several oral antidiabetic drugs are effective in reducing DM2 risk(2,15)

–In patients with prediabetes, metformin reduces the risk of developing DM2 by 31% at three years(14)

–In patients with prediabetes, pioglitazone reduced the risk for developing diabetes by 85% in patients over 61 years old and 69% in patients under 61 years old at two years(7)

–The α-glucosidase inhibitor acarbose reduces DM2 risk by 20%(14)

• The ADA does not recommend the routine use of pharmacologic agents as a substitute for lifestyle changes, but suggests that metformin therapy can be considered in patients with prediabetes, particularly in those with BMI > 35 kg/m2, age < 60, and women with prior gestational diabetes(2)

› Bariatric surgery is associated with complete remission of DM2 in 58-72% of cases 2 years after surgery in patients with obesity (11)

What We Can Do › Learn about prevention interventions for DM2 so you can accurately assess your patients’ personal characteristics and health

education needs; share this information with your colleagues

› Review the ADA recommendations for information on evidence-based diet and exercise strategies available at http://www.diabetes.org/are-you-at-risk/

› Increase awareness of the role culture plays in disease development and patient adherence to medical advice/ recommendations to promote the provision of patient education that is both relevant and culturally sensitive (8)

› Be cognizant of variations in perceptions of self-care behavior by nurses and patients (i.e., nurses’ perception of the need for more health education for patients compared to patients’ beliefs that they are successfully managing their health needs) and the impact of this on patient attitudes and motivation regarding patient education (17)

› Because risk factors for DM2 commonly develop before adulthood; educate parents on strategies and actions to reduce the development of risk factors in their children (e.g., breastfeeding infants, encouraging an active lifestyle, healthy dietary choices)

› Discuss the availability of local service providers with the diabetes nurse specialist and/or the medical social worker so you can coordinate your patients’ use of a range of services, including community programs, health department resources, specialty outpatient clinics, hospital specialty departments, screening services, and knowledgeable clinicians in primary care and specialty private practices • Local services can include walking groups, cooking demonstrations, nutritional classes, and media campaigns

› Educate all community clinicians—whether or not they provide direct DM2 services—regarding risk, screening, prevention, and treatment for DM2 and the coordination of local DM2 resources

› Encourage your patients to ask their primary clinician for screening and/or a referral to a diabetes specialist service provider if they suspect they are at high risk for DM2(15)

› Advocate for patient participation in decision-making related to DM2 treatment regimens that require lifestyle changes › Encourage and model behavior changes that promote a healthy lifestyle

Coding Matrix References are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentations or other such materials

CP Conference proceedings, abstracts, presentation

References 1. American Diabetes Association. (2019). 2. Classification and diagnosis of diabetes: Standards of medical care in diabetes-2019. Diabetes Care, 42(Suppl 1), S13-S28.

doi:10.2337/dc-18-S002 (RV)

2. American Diabetes Association. (2019). 3. Prevention or delay of type 2 diabetes: Standards of medical care in diabetes-2019. Diabetes Care, 42(Suppl 1), S51-54. doi:10.2337/dc19-S003 (G)

3. Begum, S., Povey, R., Ellis, N., & Gidlow, C. (2020). A systematic review of recruitment strategies and behaviour change techniques in group-based diabetes prevention programmes focusing on uptake and retention. Diabetes Res Clin Pract, 166, 1-13. doi:10.1016/j.diabres.2020.108273 (SR)

4. Bian, R. R., Piatt, G. A., Sen, A., Plegue, M. A., De Michele, M. L., Hafez, D., ... Richardson, C. R. (2017). The effect of technology-medicated diabetes prevention interventions on weight: A meta-analysis. Journal of Medical Internet Research, 19(3), 1. doi:10.2196/jmir.4709 (M)

5. Centers for Disease Control and Prevention. (2020). National Diabetes Statistics Report, 2020: Estimates of diabetes and its burden in the United States. Retrieved January 27, 2021, from https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf (PFR)

6. Degefa, G., Wubshet, K., Tesfaye, S., & Hirigo, A.T. (2020). Predictors of adherence toward specific domains of diabetic self-care among type-2 diabetes patients. Clin Med Insights Endocrinol Diabetes, 13, 1-12. doi:10.1177/1179551420981909 (R)

7. Espinoza, S. E., Wang, C. P., Tripathy, D., Clement, S. C., Schwenke, D. C., Banerji, M. A., ... Musi, N. (2016). Pioglitazone is equally effective for diabetes prevention in older versus younger adults with impaired glucose tolerance. Age, 38(5-6), 485-493. doi:10.1007/s11357-016-9946-6 (RCT)

8. Gonzalez, M.B., Herman, K.A., & Walls, M.L. (2020). Culture, social support, and diabetes empowerment among American Indian adults living with type 2 diabetes. Diabetes Spectrum, 33(2), 156-164. doi:10.2337/ds19-0036 (R)

9. Greiner, B., Mercer, H., Raymond, C., Sonstein, L., & Hartwell, M. (2020). A recommendation for earlier screening of type 2 diabetes mellitus within the US population: A cross-sectional analysis of NHIS data. Diabetes Res Clin Pract, 168, 104. doi:10.1016/j.diabres.2020.108376 (RU)

10. Lai, Y., Hu, H., Lee, Y., Ko, M., Ku, P., Yen, Y., & Chu, D. (2018). Frequency of alcohol consumption and risk of type 2 diabetes mellitus: A nationwide cohort study. Clin Nutr, 38, 1368-1372. doi:10.1016/j.clnu.2018.06.930 (C)

11. Magkos, F., Hjorth, M.F., & Astrup, A. (2020). Diet and exercise in the prevention and treatment of type 2 diabetes mellitus. Nat. Rev. Endocrinol, 16, 545-555. doi:10.1038/s41574-020-0381-5 (RV)

12. Malkani, S., & Ayyoub, S. (2021). Diabetes mellitus, type 2. F.J. Domino (Ed.), The 5-minute clinical consult 2021 (29th ed.). Philadelphia, PA: Wolters Kluwer. (GI)

13. Matin-Pelaez, S., Fito, M., & Castaner, O. (2020). Mediterranean diet effects on type 2 diabetes prevention, disease progression, and related mechanisms. A review. Nutrients, 12(8), 1-15. doi:10.3390/nu12082236 (RV)

14. Moelands, S. V. L., Lucassen, P. L. B. J., Akkermans, R. P., De Grauw, W. J. C., & Van de Laar, F. A. (2018). Alpha-glucosidase inhibitors for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus. Retrieved January 14, 2019, from http;// cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005061.pub3/full (SR)

15. National Institute for Health and Care Excellence. (2017). Type 2 diabetes: Prevention in people at high risk. Retrieved January 14, 2019, from http://www.nice.org.uk/guidance/ PH38 (G)

16. National Institute of Diabetes and Digestive and Kidney Diseases. (n.d.). Diabetes prevention program (DPP). Retrieved January 14, 2019, from https://www.niddk.nih.gov/about-niddk/research-areas/diabetes/diabetes-prevention-program-dpp (PFR)

17. O'Brien, C., van Rooyen, D., & Ricks, E. (2020). Self-management of persons living with diabetes mellitus type 2: Experiences of diabetes nurse educators. Health SA Gesondheid: Journal of Interdisciplinary Health Sciences, 25, 1-11. doi:10.4102/hsag.v25i0.1381 (R)

18. Toi, P.L., Anothaisintawee, T., Chaikledkaew, U., Briones, J.R., Reutrakul, S., & Thakkinstian, A. (2020). Preventive role of diet interventions and dietary factors in type 2 diabetes mellitus: An umbrella review. Nutrients, 12(9), 1-17. doi:10.3390/nu12092722 (SR)

19. United States Preventive Services Task Force. (2021). Screening for abnormal blood glucose and type 2 diabetes mellitus: Draft recommendation statement. Retrieved March 16, 2021, from https://www.uspreventiveservicestaskforce.org (G)

20. Van Rhoon, L., Byrne, M., Morrissey, E., Murphy, J., & McSharry, J. (2020). A systematic review of the behaviour change techniques and digital features in technology- driven type 2 diabetes prevention interventions. Digit. Health, 6, 1-27. doi:10.1177/2055207620914427 (SR)

21. World Health Organization. (2016). Global report on diabetes. World Health Organization. Retrieved January 14, 2019, from http://apps.who.int/iris/bitstream/ handle/10665/204871/9789241565257_eng.pdf.jsessionid=35A6696E65E5D56A06572C60A3F61DDE0?sequence=1 (PFR)