literature review

LITERATURE REVIEW 1

Literature Review

Student Name School of Nursing, College of Health & Human Services,

Northern Kentucky University

Authors Note

Student Name completed this paper as part of an assignment for MSN 602. The student name has no conflict of interest to disclose.

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Abstract

Diabetes is a worldwide disease, often classified as a global epidemic (Lade et al., 2016). An

enormous issue with diabetes is the fact that it is typically a precursor to additional

comorbidities in many individuals, and will definitely be prevalent in clinical practice. Type 2

Diabetes is a preventable and manageable disease if an individual is given the proper resources

and education. By educating women on how to lower their hemoglobin A1C with resistance and

aerobic training, it is plausible that many other chronic conditions could also be eliminated.

Middle age women have the opportunity to implement strength and aerobic training into their

daily lives in efforts to reduce their hemoglobin A1C. Consistently implementing these exercises

for more than three months can reduce hemoglobin A1C and prevent other chronic diseases from

developing.

Keywords: pre-diabetes, strength training, aerobic training, middle-aged women, hemoglobin

A1C

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Literature Review

According to the Centers for Disease Control and Prevention (2017), “Nearly 1 in 4

adults living with diabetes – 7.2 million Americans – didn’t know they had the condition. Only

11.6 percent of adults with prediabetes knew they had it.” The World Health Organization stated

the number of individuals with diabetes mellitus increased to 422 million in 2014, which is

quadruple the amount since 1980 (Sawada et al., 2018). It is expected if appropriate measures are

not taken, and primary providers do not implement a positive change, the number of individuals

with diabetes will reach 700 million in the world by 2025 (Sawada et al., 2018).

Introduction and Question

This issue contributes to nursing practice and education because there are millions of

Americans living with Type 2 diabetes, a disease that can be managed extremely well and/or

prevented. Diabetes can lead to many other chronic conditions such as hypertension, neuropathy,

glaucoma, kidney disease, and stroke (Centers for Disease Control and Prevention, 2017). The

focus is to prevent diabetes and chronic conditions before they develop. Advanced practice

registered nurses (APRNs) have the unique opportunity to educate patients on how to lower a

patient’s risk of getting diabetes. However, most of the time the patient will come to a clinic with

underlying diabetes, and these articles suggest specific interventions on how to reduce and

manage the prevalence of Type 2 diabetes, resulting in lower Hemoglobin A1C. It is important to

note hemoglobin A1C is a blood test that measures average glucose levels over three months. By

educating women on how to lower their hemoglobin A1C with resistance and aerobic training,

many other chronic conditions could also be eliminated. With diabetes, eating a healthy diet

seems to be the main focus in research on how to prevent and manage diabetes. Diet is extremely

important, but the question at hand is if adding resistance and aerobic training to a weekly

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routine will lower hemoglobin A1C in comparison to those that are not active. Do middle aged-

women, ages 40-64, with type 2 diabetes who use resistant/aerobic training have lower

hemoglobin A1C compared to those who were sedentary over three months? The independent

variable in this review is strength and aerobic training and the dependent variable is hemoglobin

A1C.

Population and Setting

Middle-aged women have many things going on in their lives such as menopause and

busy lifestyles, but another issue is diabetes. Having diabetes puts women at risk for many other

health-related complications, and the goal is to keep their Hemoglobin A1C within a normal

range, below 5.7%. In particular, women aged 40-64, also do not workout or make it to the gym

as often as they probably should. Many middle-aged women are not taking the time to implement

physical activity into their weekly routines. The focus is to implement strength and aerobic

training into their daily lives. Women can implement aerobic and strength training in gyms or

within their homes.

Review of Literature

While searching for related literature, I used Northern Kentucky University’s Steely

Library to locate peer-reviewed and academic journals. CINAHL, EBSCOhost, and Academic

Search Complete are the main databases used, along with PubMed. A few keywords such as

“pre-diabetes, strength training, aerobic training, middle-aged women, and hemoglobin A1C”

were used to strengthen results. Quite a few results were located, the search is narrowed by date,

using only the last 5-6 years. The search is narrowed down further by eliminating and excluding

studies that did not include women and those that used different types of training such as

heavyweight training. The studies retrieved are classified as mixed-method research, however, a

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focus on randomized controlled trials is the main method used amongst the various studies

included in this review.

Strength and Aerobic Training

Various implementations of strength and aerobic training are using amongst the studies.

Aerobic training is a type of exercise used to enhance cardiovascular and respiratory functional

capacity (Sawada et al., 2018). Resistance training is used to enhance muscle strength (Sawada et

al., 2018). In a study completed by Dai et al., (2019), resistance training involved major muscle

group exercises such as leg presses and extensions, chest presses, pull-downs, and shoulder

presses. Dancing was used for a warm-up aerobic exercise (Dai et al., 2019). The participants

implemented these exercises for 60-minutes, 3 times a week for 24 months resulting in the

decreased progression towards type 2 diabetes (Dai et al., 2019). Another study implemented 5

to 6 weekly aerobic training sessions along with resistant training 3 times a week, and after 12

months, there is a decrease in hemoglobin A1C by 0.4% (Johansen et al., 2017). A randomized

clinical trial with sedentary and obese participants implemented a supervised 3-month strength

training with outstanding results of 34% of the participants no longer being pre-diabetic (Davy et

al., 2017). According to Sawarda et al., (2018), “Aerobic exercise can delay and/or prevent the

development of type 2 diabetes by improving insulin resistance through modification of muscle

quality, including reduction of adiposity and increase of glucose transported in muscle

cells.” Resistance training has been linked to an increase in muscle mass, improved insulin

sensitivity, and increase glucose transport (Shiroma et al., 2017). Overall, these studies suggest

that a higher frequency of combined aerobic and resistance training is related to lowering the

prevalence of developing type 2 diabetes, including hemoglobin A1C. Implementing resistance

and aerobic training into an individual's life can be challenging. An additional study with a

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discrepant finding suggested that implementing high-intensity interval training (HIIT) is more

suitable in comparison to strength and resistance training because it is a time-efficient exercise

modality (Jelleyman et al., 2015). The study determined that completing 35-minute workouts

three times per week is more maintainable over longer periods of time.

Women that participated in higher amounts of combined strength training and aerobic

activity had a higher reduction in type 2 diabetes prevalence in comparison to those who did

strength and aerobic training individually (Shiroma et al., 2017). After reviewing multiple

studies, as long as an individual implement some sort of significant exercise regimen, it will

assist in lowering hemoglobin A1C in comparison to living a sedentary lifestyle.

Compliance

The continual implementation of these exercises improves their overall health, however,

compliance with these regimens can be difficult. In some cases, there were adverse events. This

type of training can be difficult for individuals to maintain, especially if they do not enjoy

exercising. Additionally, adverse events were reported resulting in decreased compliance, most

commonly muscle pain and discomfort, sometimes hypoglycemia (Johansen et al., 2017).

Limitations were discussed such as some participants had a history of smoking and

drinking (Sawada et al., 2018). An individual's social history can have a significant impact on

whether they can maintain a healthy lifestyle. Smoking and drinking can cause setbacks with

implementing physical activity, and the studies did not clarify their histories before the

research. Many of the studies used a “self-report” method when it came to disclosing the type

and amount of exercise that they did, which could have changed the results depending on if the

reports were accurate. In other cases, follow-ups showed the participants were not adhering to

the exercise regimen long-term.

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Critique and Synthesis

Regarding the prevention of type 2 diabetes and reducing hemoglobin A1C levels, there

is a substantial decrease when resistance and aerobic training are added to an

individual's lifestyle. Resistance and aerobic training have been effective in providing glycemic

and metabolic control amongst individuals. It also shows that in comparison to women who did

not exercise, there was a 30% reduction in type 2 diabetes. (Shiroma et al., 2017). Resistance and

aerobic training is a maintainable strategy if properly implemented to reduce prediabetes and

developing muscle strength (Davy et al., 2017). The majority of the studies specifically identified

a reduction in hemoglobin A1C, such as a 0.4% reduction in 20 weeks (Johansen et al., 2017).

The literature consisted of different lengths in studies, while some continued to follow up

with their participants up to two years later. In regards to the designated PICOT question, three

months is the minimal amount of time to possibly reduce an individual's level. Some of these

studies had a short duration of 20 weeks, while others collected data for 9 months with various

follow-up times. To improve the research, lengthier studies should be used to provide succinct

data due to hemoglobin A1C ability to change only fractions in short amounts of time. To

strengthen these studies, it is also important to have supervised workouts, such as the study

conducted by Davy et al., (2017). This aids in compliance and proper implementation.

Supervised training also provides support for the participants and also makes sure the training is

done properly, also reducing the risk of injury. For these studies to be accurate, it would be

necessary to ensure the blood tests were collected at appropriate times, and in some studies, it

was reported that there was a lapse between the time of the last exercise and post-test blood

collection (Jelleyman et al., 2015). Overall, the posed question concluded that implementing

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exercise into a weekly routine will greatly reduce the prevalence of type 2 diabetes and prevent

high hemoglobin A1C levels.

Gaps in Literature

Certain areas relate to gaps in the literature. The literature did not discuss the availability

of gyms to the participants when it comes to cost, location, and availability. Some women do not

have access to a gym or weights they can use at their homes. Other issues are many of the studies

did not provide the participants' prior fitness abilities or their medical history, such as their

average initial hemoglobin A1C.

Further Research

Further research is needed to determine if strength and aerobic training play a significant

role in reducing hemoglobin A1C and type 2 diabetes prevalence amongst middle-aged women.

For example, researchers need to evaluate the precise amount and intensity of these muscle-

building exercises needed for desired results (Shiroma et al., 2017). Additionally, future

randomized controlled trials with individuals without diabetes need to be conducted to clarify if

combined aerobic and resistance training reduces the risk of type 2 diabetes (Sawada et al.,

2018). A control group of participants who participate in less intense or more intense workouts

needs to be added. Random assignment of one group to strength training, one group to aerobic,

and another to combined training needs to be further researched as well.

Conclusion

As a future APRN, it will be necessary to educate patients on disease prevention.

Diabetes can cause many other cardiovascular, renal, and other chronic conditions. By providing

information and resources to middle-aged women regarding resistance and aerobic training, it

will greatly reduce their hemoglobin A1C and aide in the prevention of other preventable

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diseases. I will be their guide and support to make sure they can comply with an active lifestyle

and also provide education on a healthy diet to promote overall well-being. It will be important

to educate that maintaining an active lifestyle is optimal, and not something to be done for only a

few months.

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