The link between diabetes and physical activity

Nursing Research Assignment

Introduction

There are two main types of diabetes: type 1 and type 2. Type 1 diabetes has peak incidences at age 12 and between 20 and 35 years. It is characterised by such symptoms as polyuria (frequent passing of urine), polydypsia (frequent thirst) and weight loss. It is treated by the injection of insulin together with dietary control (Tuch and Bonnett 2002). Type 2 diabetes is also referred to as late- onset diabetes because it manifests in later adult life. It accounts for approximately 95% of cases of diabetes. It is often treated with dietary control, oral hypoglycaemic medication and sometimes by insulin injections (Bailey and Krentz 2005).

Identify an aspect of care of relevance to the topic area provided – 10%

The chosen area for this assignment is the link between diabetes and physical activity, and the role of the nurse in promoting physical activity for people who have diabetes. There is evidence within the literature to support the contention that physical activity can positively contribute towards the management of diabetes. This is because it helps to lower blood glucose and enhances the action of insulin (Day 2001). Diabetes should not prevent the pursuit of sporting activities, and there are well- known sporting personalities who have diabetes; Steve Redgrave the Olympian rower being a good example. (health.telegraph 2005). There is however, evidence to suggest that people with diabetes are reluctant to engage in regular planned exercise (Frost and Dornhorst 2003). The nurses can play a part in encouraging and educating the individual who has diabetes in order to increase their level of physical activity (Douglas et al 2006).

Systematically evaluate the evidence relating to the identified aspect of care – 60%

The search strategy involved the use of the Athens Access Management System in order to access such databases as The British Nursing Index, MEDLINE, CINAHL and the Cochrane library, The University library was also used in order to conduct a hand search of such relevant journals as The British Journal of Diabetes and Vascular Disease; Diabetic Medicine; Diabetes Care; Journal of Advanced Nursing; Journal of Human Nutrition & Dietetics and the British Medical Journal. As there is quite a lot of information available on the subject of diabetes and physical activity, the search was restricted to articles published since 2000, to ensure recency. The search terms and keywords used were: ‘diabetes’ in combination with ‘exercise’, ‘physical activity’ and ‘nurse’. The search was not restricted to UK articles only, as it was felt that issues relating to diabetes and exercise are transferable globally, and there has been a lot of research conducted in this area on an international scale, which could be valuable in contributing to the body of knowledge applied within a UK context.

Some articles address the preventative function of physical exercise in relation to developing Type 2 diabetes (Allen et al 2007; Jeon et al 2007; Tuomilehto 2007) In relation to prevention, there are research articles which look at the type of interventions that can be used to promote exercise activity among people with diabetes, and people at risk of developing diabetes. Jackson et al (2007) examined the application of the transtheoretical model of change to increase physical activity in people with type 2 diabetes. The transtheoretical model is underpinned by an assumption that health behavioural change is a process that occurs via a series of stages and is applicable to exercise behaviour (Dishman and Buckworth 2002). If nurses are to play a role in promoting physical activity among people with diabetes, then it is important that they have an understanding of the psychological processes that influence adherence to exercise behaviour. It is however, acknowledged that there are constraints on the time available for nurses and other healthcare professionals to be able to devote to exercise promotion, and other approaches have been identified such as the use of web- based intervention; the rationale being that an increasing number of people regularly access the internet (Kim and Kang 2006). It is possible that exercise programmes that are aimed at reducing the incidence of diabetes could be targeted within specific contexts, such as work- based exercise initiatives (Aldana et al 2006). People are more likely to adhere to an exercise programme that is realistic and fits into their lifestyle (BUPA), so an article by Johnson et al 2006) that reports a study that demonstrated that simply increasing their walking speed, can result in an improved metabolic risk profile for people with established type 2 diabetes, is of interest.

The reluctance to exercise among people with diabetes, and among those identified at risk of developing diabetes as identified earlier on (p.1 , para 2 ), has been examined within the research literature (Morrato et al 2007). As a result, recommendations are made to target those at risk, and people who have type 2 diabetes.

Other studies highlight the effect that regular physical activity has on improving insulin sensitivity in Type 2 diabetes (Tonjes et al 2007). There is however a potential problem with exercise enhancing the uptake of insulin in that this could lead to a hypoglycaemic episode, therefore the issue of balance that is associated with the management of diabetes needs to be addressed in terms of adjusting insulin dosage (DIRECNET 2006).

Elsewhere, the research focuses on the function of exercise activity in reducing cardiovascular morbidity among people with diabetes (Kadoglou et al 2007). It would appear however, that it could be misleading to focus on exercise as a single variable in relation to the prevention of type 2 diabetes or the reduction of cardiovascular morbidity in existing type 2 diabetes, and that physical activity should be seen as one aspect of a comprehensive approach to the prevention and effective management of type 2 diabetes. For example, it has been demonstrated that the magnitude of risk in relation to the development of type 2 diabetes, that is contributed by obesity is much greater than that imparted by lack of physical activity (Rana et al 2007). Snowling and Hopkins (2006) concluded that the clinical importance of combining approaches to the management of type 2 diabetes needs further research.

To summarise, there is a lot of evidence within the literature that links the benefits of regular physical activity to the reduction of Type 2 diabetes among those identified as being of high- risk, and to the reduction of cardiovascular morbidity and other complications among people with existing Type 2 diabetes. The importance of a comprehensive approach to the prevention and management of diabetes could be further emphasised and it would be good to see more UK- based research on the subject of physical activity and diabetes.

This section will now proceed to conduct a more detailed critique of one specific article by Lawton et al (2006). A critiquing framework based on the work of Cormack will be used as the tool for a critical analysis of this research article (Appendix I) and has been used elsewhere (South and East Dorset Primary Care Trust 2003).

The rationale for this study is that Type 2 diabetes is at least 4 times more common among British South Asians than in the general population. South Asians also have a higher risk of diabetic complications, a situation which has been linked to low levels of physical activity observed amongst this group. Little is known about the factors and considerations which prohibit and/or facilitate physical activity amongst South Asians. This study adopted a qualitative approach to explore Pakistani (n = 5 23) and Indian (n = 5 9) patients’ perceptions and experiences of undertaking physical activity as part of their diabetes care. Although respondents reported an awareness of the need to undertake physical activity, few had put this lifestyle advice into practice. For many; practical considerations, such as lack of time, were interwoven with cultural norms and social expectations. The researchers concluded that a realistic and culturally sensitive approach needs to be adopted, in order to promote physical activity among this group.

The title of the study is straightforward and unambiguous. It includes the subject, the people, but not the type of approach involved in the study. The reasons for undertaking the research are clearly stated in that not only do South Asians have an increased risk of developing type 2 diabetes, it is also known that there are low levels of physical activity among this group. This article does not contain a separate literature review but does refer to relevant literature within the background section, which supports the reason for carrying out this study. The participants were recruited from five general practices in Edinburgh which had a high population of Pakistani and Indian patients with Type 2 diabetes. The local community were also directly asked for volunteer participants. Efforts were made to access hard- to- reach groups, such as the housebound. Participants had the option of being interviewed in English, Punjabi or Urdu, which optimised the representativeness of the population and did not exclude those whose lack of English- speaking ability might have impacted on their opportunities to engage in exercise activity. The researchers adopted a grounded theory approach which adds rigour to qualitative research by building systematic checks into both data collection and analysis (Charmaz 2006; Patton 2002a). The appropriate sample size within a grounded theory study will not become clear until all component parts of the phenomenon under study have been captured (Lacey and Gerrish 2006), and in this study, recruitment continued until no new themes emerged from the interviews. Also in line with a grounded theory approach, data collection and analysis took place concurrently (Schreiber and Stern 2001). The use of a qualitative research in this study is highly appropriate as it seeks to understand the meaning of phenomena (Patton 2002b). Qualitative approaches aim to represent the true complexities of human behaviour, gaining access to thoughts and feelings that cannot be accessed by using other methods (Flanagan 2005). To quote the researchers: they used single, in-depth interviews which permitted respondents to display their own understandings and meanings (p. 44). The findings are presented in the form of the core categories that emerged from the grounded theory and are ‘brought alive’ by the inclusion of quotes made by the participants. Quotes are used in qualitative research write- ups to validate findings and to vitalise the presentation of those findings (Tashakkori and Teddlie 2003). The researchers do not specifically identify the potential limitations of their study, which is an important omission. Ethical approval was obtained from an ethics committee. Overall this is a potentially valuable piece of work which places emphasis on the cultural differences that can impact upon health, illness and health- related behaviours (Helman 2001).

The focussed nature of this study i.e., in terms of addressing cultural differences can be contrasted with a study like the one by Franz (2007) which adopts a broad- based approach to linking physical activity to diabetes without considering individual variables. On the other hand a study such as the one by Hamilton et al (2007) clearly highlights that different groups (in this case people who have a learning difficulty) will have varying needs in relation to lifestyle modification and moreover, the context of their lives needs to be taken into account (for example whether there is carer involvement).

Propose an appropriate care intervention, demonstrating best practice, based on the available evidence – 30%

An intervention based on protection motivation theory can have a dramatic effect on exercise behaviour (Milne et al 2002). Protection motivation theory attempts to specify the precise characteristics of a health message that influence compliance and the processes that are at work. These characteristics include four categories of information: the severity of the health threat; one’s vulnerability to this threat; how effective the alternative advocated behaviour is at averting the threat and how effective one is at carrying out this advocated behaviour (Brouwers and Sorrentino 1993). The motivation of the patient who has diabetes, or who is at risk of developing diabetes, to adhere to an exercise programme within the framework of this theory, is dependent upon them being cognisant of the protective potential of healthy behaviour; in this case, exercise. The key role of the nurse therefore is to educate the individual about their condition and the benefits of physical activity. Education is considered to be a fundamental element of diabetes care provided by diabetes care teams in primary and secondary care settings. The aim of education for people with diabetes, regardless of treatment regimes, is to empower them with the knowledge and skills to manage their condition (Metcalfe 2004).

Persuasive communication is about providing the right type and amount of information with the intent of bringing about change in an individual’s attitudes and/ or behaviours (Storey 1997). This implies that there is a skill in the use of communication to bring about change in for example, health- related behaviours, in this case influencing somebody to adhere to an exercise programme. It has been suggested that persuasive communication in relation to physical activity might be more effective if the person conveying the message perceives the situation from the perspective of the individual or group they are aiming to influence (Cavill and Bauman 2004). This is why health education campaigns often target specific groups (Naidoo and Wills 2000). In other words, it may not be enough to deliver a broad- based message to a population or even to an individual about the benefits of lifestyle modification, however reliable and valid the information is. Individual differences need to be taken into consideration, such as the way that people interpret information as well as the different priorities and demands that people have in their lives. The article referred to previously (p.3 ) about cultural differences is very relevant here, as is the article about people with learning disabilities (p.4). An important part of the intervention will be taking into account individual differences and planning an approach that meets the needs of specific groups.

As previously identified, specific strategies may need to be mobilised in order to promote adherence to exercise among those at risk of diabetes or people who have diabetes. This could include for example the stage approach involved in the transtheoretical model referred to on p. 2.,

References

Aldana S, Barlow M, Smith R, Yanowitz F, Adams T, Loveday L, Merrill R. A Worksite Diabetes Prevention Program: Two-Year Impact on Employee Health. AAOHN Journal. 54(9) 2006. pp.389-395

Allen D, Nemeth B, Clark R, Randall M, Peterson S, Eickhoff J and Carrel A. Fitness is a Stronger Predictor of Fasting Insulin Levels than Fatness in Overweight Male Middle-School Children. Journal of Paediatrics. 150(4) 2007. pp. 383-387

Bailey C and Krentz A. Type 2 Diabetes in Practice. RSM Press. 2005. p. 1

Brouwers, M and Sorrentino, R. Uncertainty Orientation and Protection Motivation Theory: The Role of Individual Differences in Health Compliance. Journal of Personality and Social Psychology. 65(1)1993pp. 102–112

BUPA. Physical Activity. Factsheet. http://hcd2.bupa.co.uk/fact_sheets/html/exercise.html. Accessed: 11th Aril 2007

Cavill N and Bauman A. Changing the way people think about health-enhancing physical activity: do mass media campaigns have a role? Journal of Sports Sciences 22(8) 2004, pp. 771-790

Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. Sage publications. 2006. pp. 23, 26, 67-9, 113

Day J. Living with Diabetes: The Diabetes UK Guide for those Treated with Diet and Tablets. John Wiley and Sons. 2001. p. 93.

THE DIABETES RESEARCH IN CHILDREN NETWORK (DIRECNET) STUDY GROUP Prevention of Hypoglycaemia During Exercise in Children With Type 1 Diabetes by Suspending Basal Insulin. Diabetes Care. 29(10) 2006. pp. 2200-2204

Dishman R and Buckworth J. Exercise Psychology. Human Kinetics. 2002. p. 221

Douglas F, van Teijlingen E, Torrance N, Fearn P, Kerr A and Meloni S. Promoting physical activity in primary care settings: health visitors’ and practice nurses’ views and experiences. Journal of Advanced Nursing. 55(2). 2006. p. 159.

Flanagan C. Research Methods for AQA ‘A’ Psychology. Nelson Thornes. 2005. p. 46.

Franz M. The Evidence Is In: Lifestyle Interventions Can Prevent Diabetes. American Journal of Lifestyle Medicine 1(2) 2007. pp. 113-121

Frost G and Dornhorst A. Nutritional Management of Diabetes Mellitus. John Wiley and Sons. 2003. p. 21.

Hamilton S, Hankey C, Miller S, Boyle S, Melville C. A review of weight loss interventions for adults with intellectual disabilities. Obesity Reviews. (OnlineEarly Articles). http://www.blackwell-synergy.com/doi/abs/10.1111/j.1467-789X.2006.00307.x?journalCode=obr Accessed: 11^th April 2007.

health.telegraph Helping diabetics to be winners. 2005. http://www.cgsupport.nhs.uk/downloads/NDST/news_article_diabetics_winners.doc Accessed: 11th April 2007

Helman, C.G. Culture, Health and Illness (4th edition). Arnold 2001

Jackson, R, Asimakopoulou and Scammell, A. Assessment of the transtheoretical model as used by dietitians in promoting physical activity in people with type 2 diabetes. Journal of Human Nutrition & Dietetics. 20(1) 2007. pp. 27-36

Jeon C, Lokken R, Hu F, Van Dam R, Physical Activity of Moderate Intensity and Risk of Type 2 Diabetes: A systematic review. Diabetes Care. 30(3) 2007. pp. 744-752

Johnson S, McCargar L, Gordon J, Tudor- Locke C, Harber V and Bell R. Walking Faster: Distilling a complex prescription for type 2 diabetes management through pedometry. Diabetes Care. 29(7) 2006. pp.1654-1655

Kadaglou N, Perrea D, Iliadis F, Angelopoulou N, Llapis C and Alevizos. Exercise Reduces Resistin and Inflammatory Cytokines in Patients With Type 2 Diabetes. Diabetes Care. 30(3) 2007. pp. 719-721

Kim C and Kang D. Utility of a Web-based Intervention for Individuals with Type 2 Diabetes: The Impact on Physical Activity Levels and Glycaemic Control. Computers, Informatics, Nursing. 24(6) 2006 pp.337-345

Lacey A and Gerrish K. The Research Process in Nursing. Blackwell publishing. 2006. p. 184.

Lawton J, Ahmad N, Hanna L, Douglas M and Hallowell N ‘I can’t do any serious exercise’: barriers to physical activity amongst people of Pakistani and Indian originwith Type 2 diabetes. Health Education Research. 21(1). 2006. pp. 43-54.

Metcalfe L. Monitoring skills: diabetes. Nurse Prescriber 1(2) 2006. pp. 1-6

Milne S, Orbell S andSheeran P. Combining motivational and volitional interventions to promote exercise participation: Protection motivation theory and implementation intentions. British Journal of Health Psychology 7 (2) 2002, pp. 163-184(22)

Morrato E, Hill J, Wyatt H, Ghushchyan V and Sullivan P. Physical Activity in U.S. Adults With Diabetes and At Risk for Developing Diabetes, 2003. Diabetes Care. 30(2) 2007. pp.203-209

Naidoo J and Wills J. Health Promotion: foundations for practice. Elsevier Health Sciences. 2000. p. 336.

Patton M. Qualitative Research & Evaluation Methods. Sage Publications. 2002. pp. 1, 489, 555.

Rana J, Li T, Manson J and Hu F. Adiposity Compared With Physical Inactivity and Risk of Type 2 Diabetes in Women. Diabetes Care. 30(1 2007.) pp. 53-58 Sage publications. 2003. p. 344.

Schreiber R and Stern P. Using Grounded Theory in Nursing. Springer publishing. 2001. pp. 4, 57, 58.

Snowling N and Hopkins W. Effects of Different Modes of Exercise Training on Glucose Control and Risk Factors for Complications in Type 2 Diabetic Patients: A meta-analysis. Diabetes Care. 29(11) 2006. pp. 2518-2527

Storey R. The Art of Persuasive Communication. Gower Publishing. 1997. p.2.

South and East Dorset Primary Care Trust. Clinical Effectiveness Strategy. 2003. Appendix IV

Tashakkori A and Teddlie C. Handbook of Mixed Methods in Social & Behavioral Research

Tonjes A, Scholz M, FAsshauer M, Kratzsch J, RAssoul F, Stumvoli M and Bluher M. Beneficial Effects of a 4-Week Exercise Program on Plasma Concentrations of Adhesion Molecules. Diabetes Care. 30(3) 2007

Tuch B and Bonnett R. Diabetes Research. Informa Health Care. 2002. pp. 1-4

Tuomilehto J Counterpoint: Evidence-Based Prevention of Type 2 Diabetes: The Power of Lifestyle Management. Diabetes Care. 30(2) 2007. pp. 435-438

Appendix I

Questions for the Critical Appraisal of a Research Design

1. Does the title of the study tell you what and who the research is about?

Is the subject of the research in the title?

Is the type of people the research is about (i.e. the study population) referred to in the title?

Is the approach to the research referred to in the title?

2. Is (are) the reasons for the study clearly stated?

Is it clear what the study is about?

Is the rationale for doing the study stated?

Are the objectives or the research questions and/ or the hypotheses clearly stated?

3. Is the review of the literature comprehensive?

Is the literature cited in the review up- to- date?

Does the literature identify clearly the need for a research study?

Are any important references you know of omitted?

4. Is the sample appropriate?

Is the type of people the research is about i.e. the population, adequately described?

If a sample is used, is there a description of how the sample was selected?

Is the way the sample was selected and the sample size, appropriate?

5. Are the measurements and/ or data collection likely to be reliable and valid?

Is (are) the data collection methods appropriate given the objectives of the study?

Are there operational definitions for all key terms?

Was a pilot study done to demonstrate the reliability and validity of the data collection tools and processes?

6. Is there a description of any statistical methods used?

Do the statistics seem appropriate for the measurements or data being collected and the study objectives?

Do any tables, graphs or diagrams help understanding of the findings?

Questions for Critical Appraisal of the Conduct of the Research

1. Did the study proceed as planned?

If not, did unplanned situations have an effect on the results?

Are these explained?

2. Were the findings of the research described adequately?

Are the findings presented clearly and in sufficient detail?

Are any key data missing or inadequately described?

3. Are any calculations correct?

Do any numbers add up?

Were any statistical tests performed adequately?

4. For quantitative research, was the statistical significance tested?

How precise were the results that is, what were the confidence intervals??

5. Were ethical considerations planned for and followed?

Were any ethics issued in the research identified and handled appropriately?

Questions for Critical Appraisal of the Outcomes of the Research

1. What do the main findings mean?

Are the findings explained?

Is the clinical significance of the findings explained?

2. For quantitative research, how are the hypotheses interpreted?

Has (have) there been any alternative explanations for the findings?

3. Are the conclusions justified?

Are the conclusions linked to the study objectives?

Are the arguments sensible given your experience?

4. How do the findings compare with what others have found?

Are they consistent?

Are any differences from other studies explained?

5. Applications of findings?

Could the findings and conclusions apply to your patients?

Do any benefits equal or outweigh any new risks or costs?

TO THE CLIENT- I HAVE FOCUSSED ON DIABETES AND EXERCISE, NOT ON LD, AS YOU INDICATED. THIS IS BECAUSE THE MAIN ARTICLE YOU WANTED TO BE CRITIQUED IS NOT CONCERNED WITH THIS CLIENT GROUP.