School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET
Focused Question:
What is the effectiveness of lifestyle interventions including self-management and mindfulness
on perceived quality of life among adults diagnosed with or at risk for type 2 diabetes?
Prepared By:
Kristin Caroza, OTS & Leslie Ramos, OTS
School or Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV 89014
Date Review Completed:
September 23, 2015
Clinical Scenario:
Diabetes mellitus, commonly referred to as diabetes, is a group of chronic diseases that affects
the way the body metabolizes glucose (Mayo Clinic, 2014). There are two types of diabetes:
type 1 diabetes occurs when the pancreas does not produce enough insulin and type 2 diabetes
occurs when the body cannot effectively use the insulin it produces (World Health Organization
[WHO], 2015). Insulin is a hormone that regulates blood glucose levels in the body and glucose
is needed to provide energy for cells to function normally. Type 2 is the most common as it
comprises of 90% of individuals diagnosed with diabetes around the world (WHO, 2015).
Individuals at risk for type 2 diabetes have prediabetes which is when blood glucose levels are
higher than normal but not within range to be classified as diabetes (Mayo Foundation for
Medical Education and Research, 2015). Although the cause of diabetes is unknown, some risk
factors include excessive weight and physical inactivity (WHO, 2015). Despite which type of
diabetes an individual is diagnosed with, abnormally high glucose levels may lead to serious
health problems that should be addressed to prevent further complications.
Due to the rising prevalence of individuals in the United States being diagnosed with diabetes,

new methods toward alternative forms of treatment is being explored. A lifestyle intervention is
a very broad form of treatment that is geared toward helping individuals establish healthpromoting behaviors that are intended to be sustained throughout their lives. Examples of forms
of delivery of lifestyle interventions include health education, self-management, communitybased programs, psychoeducation, and mindfulness based cognitive therapy (MBCT). Lifestyle
interventions are commonly implemented by health practitioners to reduce the chances or
manage type 2 diabetes. Research has found that individuals who maintain a healthy body
weight through physical activity, a healthy diet, and avoid the use of tobacco significantly
decrease the symptoms of the disease (WHO, 2015). Furthermore, the implementation of a
lifestyle intervention as a treatment allows clients to be an active member within their own
treatment.
In order for an individual to begin managing the symptoms of diabetes, he or she needs to be
motivated to make a commitment for changing their lifestyles and routines. Improving quality of
life is important in clinical treatment because it is concerned with an individuals hope, selfconcept, life satisfaction, and overall health-functioning (American Occupational Therapy
Association, 2014). Quality of life can be viewed in both aspects of physical and mental health.
Managing diabetic symptoms of can be quite distressing due to the increase prevalence of life
changing health conditions including limb amputations, adult onset of blindness, and a leading
cause of kidney failure (Office of Disease Prevention and Health Promotion, 2015). Diabetes can
greatly impact an individuals quality of life because of the continuous demands of managing a
chronic disease impacts their daily routines and participation in daily activities. The aim of this
critically appraised topic is to explore the effectiveness of lifestyle interventions on the quality of
life among individuals with or at risk for type 2 diabetes.

Summary of Key Findings:

Summary of Levels I, II and III:
Prevention
A lifestyle intervention that incorporated an interdisciplinary approach including
medical visits, appointments with a dietitian, and educational sessions displayed
higher results in the reduction of blood pressure and plasma glucose, depression,
and an increase in quality of life among individuals at risk for type 2 diabetes
(Cezaretto, Siqueira-Catania, de Barros, Salvador & Ferreira, 2012, Level I).
After four years of an intensive intervention that consisted of a structured 6 hour
group session or an individualized session, participants at risk for diabetes
displayed an increase in quality of life in comparison to the standard intervention
group (Sagarra, Costa, Cabr, Sol-Morales & Barrio, 2014, Level I).
A preventative program using an intensive lifestyle modification such as a low-

fat diet and engagement in physical activity resulted in a decline in health-related

quality of life (HRQoL) among participants at risk for diabetes. Individuals who
were diagnosed during the conduction of the program displayed a more rapid
decline in HRQoL in comparison to the diabetes free participants (Marrero et al.,
2014, Level I).
Psychosocial Treatment Emphasis
Lifestyle interventions that addressed promoting both diet and exercise as well as
the psychosocial implications of the diagnosis of diabetes was significantly
effective for improving healthy behaviors and reports in measures assessing
quality of life compared to a control group. More specifically, intervention
included the implementation of a Mediterranean diet, stress management classes,
education on the importance of smoking cessation, and social support groups
(Toobert et al., 2007, Level I).
Individuals who participated MBCT in an 8 week program ran by certified
clinical psychologists displayed significantly improved levels emotional
management as well as quality of life compared to a control group. The
treatment group reported a significant decrease in perceived stress, physical
quality of life, and mental quality of life. However, findings indicate that there
was no significant difference between groups for diabetes-specific stress,
indicating that MBCT has a more global affect in treating symptoms of an
illness. (Van Son et al., 2013, Level I)
Among individuals who are at risk for type 2 diabetes include those who have
food-related psychological illnesses including binge eating disorder. The
treatment group participated in an intensive intervention program that included
psychoeducative sessions addressing issues related to habits, stress, diet, and
exercise ran by an interdisciplinary team on top of a traditional health education
treatment. Participants of the intensive treatment group reported higher quality
of life and reduced levels of depression compared to a traditional treatment
group (Cezaretto, Siqueira-Catania, de Barros, Salvador & Ferreira, 2012, Level
I).
Community-Based Treatment
Live Well, Be Well is a community based lifestyle intervention program
targeting individuals who are pre-diabetic with a lower socioeconomic status.
Live Well, Be Well provides training on diet modifications and physical activity
through counseling and group workshops. Individuals in the intervention group
displayed an increased in health promotion compared to the control group
through a significant difference in weight loss as well as improved psychological
well-being and quality of life (Kanaya et al., 2012, Level I).

International research supports the use of lifestyle intervention programs in

promoting healthy behaviors and varying aspects of quality of life. In South
Korea, participants of a community based program that included health
education classes, diet training, health monitoring, and group exercises
experienced a significant decrease in weight compared to a non-treatment group.
Outcomes for HRQoL were mixed as the treatment group yielded significant
improvements in general health, vitality, and mental health; however, the
treatment group indicated more incidences of pain that negatively affected their
life (Oh et al., 2010, Level I).

Health Education
An intervention including a 6 hour structured group education focused on
lifestyle factors in comparison to the traditional routine care of unstructured
education on diabetes resulted in no significant difference in quality of life.
However, the intervention group resulted in greater weight loss and better
understanding of diabetes (Khunti et al., 2012, Level I).
An intensive lifestyle intervention including weight loss goals, physical activity,
and meal replacements resulted in improved HRQoL in comparison to the
education alone intervention among overweight or obese adults diagnosed with
type 2 diabetes (Williamson et al., 2009, Level I).
A self-management program that focused on enhancing self-efficacy on diabetes
in addition to education did not show a significant difference in quality of life in
comparison to the education alone group (Wu et al., 2011, Level II).
No Level III studies were appraised
Summary of Level IV and V:
No Level IV and V studies were appraised
Contributions of Qualitative Studies:
No qualitative studies were appraised

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT:
Lifestyle modifications can be an effective treatment for individuals diagnosed or at risk for type
2 diabetes if the intervention is highly structured and individualized. Occupational therapist
specialized in providing holistic and client centered care; therefore, they can addresses what may
hinder or support an individuals success to incorporate a healthier lifestyle in their daily
activities and routines.
Program development:
The development of a lifestyle modification program should address all factors of the individual
including health education, lifestyle choices, and mental health. Through the use of an
interdisciplinary approach, a lifestyle programs effectiveness may improve through the
knowledge base of each discipline. OTs serve a role in implementing strategies to develop a
schedule to promote a healthy diet and incorporate physical activity in an individuals daily
routine. It is important to address the individuals perceived health through acceptance of their
disease. In addition, motivation is essential for the individual to take an active role in changing
their lifestyle.
Societal needs:
It is important to address the increasing prevalence of type 2 diabetes through alternative health
care approaches that will promote health and wellness. Lifestyle interventions can be utilized on
a community level to address a large scale such as populations that may be at a higher risk for
developing type 2 diabetes. OTs are experts in participation in daily life activities and have the
potential to support communities and transition them towards a healthier lifestyle long term.
Healthcare delivery and policy:
Individuals with diabetes are often only referred to OT once they have already been diagnosed
with the disease. Evidence supports the use of lifestyle interventions as a preventative measure
among individuals at risk for type 2 diabetes. Preventative lifestyle interventions are a more
cost-effective method of treatment in order to minimize hospital costs among individuals with
type 2 diabetes. Furthermore, the implementation of lifestyle interventions is currently an
emerging practice within the field of occupational therapy and is often not supported by
traditional health insurance companies which require individuals to pay out of pocket for its
treatment. Helping clients with or at risk for type 2 diabetes establish health promoting
behaviors in order to improve quality of life is within the OT practice, extensive advocacy is
required to gain support from healthcare policy. Lifestyle interventions is a cost effective
method for treating individuals with type 2 diabetes. Evidence supports the use of communitybased lifestyle intervention treatments as an effective method to managing the symptoms of
diabetes and promoting quality of life, allowing a wider and affordable access to treatment.
Although most lifestyle interventions are effective in increasing quality of life and promoting

healthy behaviors during treatment, follow-up meetings with clients may be necessary to ensure
that changes are sustained after treatment. Additionally, the diagnosis of diabetes is also often
paired with comorbid psychosocial issues including stress and anxiety as a result of the disease.
Interventions that only addressed the physical symptoms of diabetes may not be enough to
improve quality of life. Evidence supports the use of psychosocial based treatments as a
component in lifestyle interventions in healthcare delivery.
Education and training of OT students:
OT students need to be educated in the disease of diabetes itself, how it is presented, and how the
diagnosis affects the client as an individual in their ability to engage in occupations. The
implementation of lifestyle interventions requires a client-centered approach to understanding
what may be feasible in modifying lifestyle among individuals of different cultures or
socioeconomic statuses. It is important to teach OT students to be cognizant to cultural
differences while implementing lifestyle interventions. Additionally, OTs and OT students may
require extra training in specific lifestyle interventions such as the Live, Well, Be Well or Look
AHEAD program. Furthermore, OT practitioners require extra certification to perform
Mindfulness-Based Cognitive Therapy among individuals with type 2 diabetes.
Refinement, revision, and advancement of factual knowledge or theory:
Although there is evidence that supports the efficacy of lifestyle interventions directly after
treatment, research should explore follow-up studies after the original study to determine if there
was a long term adherence among treatment groups. Furthermore, more research is needed to
determine the appropriate length and intensity of treatment in order to sustain healthy habits for
longer periods of time. Additionally, exploration of lifestyle interventions that are well suited
toward different cultures to determine methods to deliver the most client-centered care.
Review Process:

PIO area chosen; preliminary search done to ensure literature supports the question
Focus Question identified; submitted to instructor for review
Following focus question approval, MeSH and key terms were utilized to perform a
comprehensive literature search.
Inclusion/exclusion criteria applied and after abstract review, the articles which did not
meet PIO of focused question were removed
Thorough literature search conducted; submitted to instructor for feedback; one article
provided by instructor
Inclusion criteria modified to include mindfulness and self-management as part of a
lifestyle intervention
Full text articles were then reviewed
Evidence Table created and submitted to instructor with clean copy of articles; no

feedback was received

Summarized results to create critically appraised topic (CAT)
CAT worksheet submitted to instructor for feedback

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:

Level I or Level II articles

Written in English
Published within 10 years
Full length articles published in peer reviewed journals
Answered the P, I, and O of the focused question:
o P: Persons aged 18 and above with diabetes or at risk for diabetes
o I: Lifestyle interventions including health promotion, self-management, or
mindfulness based cognitive therapy
o O: Quality of life

Exclusion Criteria:

Level III, IV, or V articles

Non-English
Published before 2005
Dissertation or masters thesis

Search Strategies:
Categories
Patient/Client Population

Intervention

Outcomes

Key Search Terms

MeSH Terms: Adults, diabetes, risk for diabetes
Key Terms: Adults, diabetes, or at risk for diabetes
MeSH terms: Lifestyle intervention*, lifestyle redesign,
health-promot* intervention, lifestyle program,
mindfulness, or self-management
Key Terms: Lifestyle intervention, lifestyle program, healthpromotion, mindfulness
MeSH terms: Quality of life or health related quality of
life

Key Terms: Quality of life, health related quality of life

Databases and Sites Searched

Academic Search Complete
Academic Search Elite
CINAHL Plus with Full Text
ERIC
Google Scholar
MEDLINE
Psych INFO

Quality Control/Peer Review Process:

Focus question was developed by review authors under the consultation of the course
instructor
Search terms were developed by students and course instructor.
Articles selected were reviewed by students for inclusion and exclusion.
Following comprehensive literature review feedback from course instructor, students
changed focused question to increase its clarity.
Focused question, articles, critical appraisal forms, and evidence table were reviewed by course
instructor and peers with feedback and comments to ensure thoroughness and accuracy.
Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of
Evidence
I
II
III
IV
V

Study Design/Methodology of Selected Articles

Systematic reviews, meta-analysis, randomized
controlled trials
Two groups, nonrandomized studies (e.g., cohort,
case-control)
One group, nonrandomized (e.g., before and after,
pretest, and posttest)
Descriptive studies that include analysis of outcomes
(single subject design, case series)
Case reports and expert opinion, which include
narrative literature reviews and consensus statements

Number of Articles
Selected
9
1
0
0
0

Other

Qualitative Studies
TOTAL:

0
10

Limitations of the Studies Appraised:

Levels I, II, and III

Due to the large time commitment, several studies displayed decreased levels of
adherence to the lifestyle intervention (Cezaretto, Siqueira-Catania, de Barros,
Salvador & Ferreira, 2012; Oh et al., 2010; Toobert et al., 2007)
Significant dropouts (Van Son et al., 2013)
The variables between the intervention group and control group were not equally
matched (Khunti, 2012)
Sample does not represent an equal distribution of gender (Kanaya, 2012)
Sample does not provide any demographic information (Sagarra, Costa, Cabr,
Sol-Morales & Barrio, 2014)
Small sample size (Wu et al., 2011; Oh et al., 2010)
Contamination occurred which may lead to potential bias through self-reported
data (Wu et al., 2011)
Results are not generalizable for highly educated individuals due to focused
population on participants with only primary school education (Wu et al., 2011)
Lack of sensitivity in the tool used to determine the impact of diabetes on quality
of life (Khunti et al., 2012; Marrero et al., 2014)
Only captures the outcome after one year of the programs implementation
(Williamson et al., 2009)

Levels IV and V
There are no Level IV or V articles included in this review.
Other
N/A
Articles Selected for Appraisal:
Cezaretto, A., Siqueira-Catania, A., de Barros, C., Salvador, E., & Ferreira, S. (2012). Benefits
on quality of life concomitant to metabolic improvement in intervention program for prevention
of diabetes mellitus. Quality Of Life Research, 21(1), 105-113. doi:10.1007/s11136-011-9919-2

Kanaya, A. M., Santoyo-Olsson, J., Gregorich, S., Grossman, M., Moore, T., & Stewart, A. L.
(2012). The Live Well, Be Well study: A community-based, translational lifestyle program to
lower diabetes risk factors in ethnic minority and lower-socioeconomic status adults. American
Journal of Public Health, 102(8), 1551-1558. doi: 10.2105/AJPH.2011.300456
Khunti, K., Gray, L. J., Skinner, T., Carey, M. E., Realf, K., Dallosso, H., & ... Davies, M. J.
(2012). Effectiveness of a diabetes education and self management programme (DESMOND) for
people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster
randomised controlled trial in primary care. BMJ: British Medical Journal (Overseas & Retired
Doctors Edition),344(7860), 15. doi:10.1136/bmj.e2333
Marrero, D., Pan, Q., Barrett-Connor, E., de Groot, M., Zhang, P., Percy, C., . . . Rubin, R. R.
(2014). Impact of diagnosis of diabetes on health-related quality of life among high risk
individuals: The Diabetes Prevention Program outcomes study. Quality of Life Research: An
International Journal of Quality of Life Aspects of Treatment, Care & Rehabilitation, 23(1), 7588. doi: 10.1007/s11136-013-0436-3
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: Clinical And
Experimental, 59(7), 1035-1043. doi: 10.1016/j.metabol.2009.10.027
Sagarra, R., Costa, B., Cabr, J. J., Sol-Morales, O., & Barrio, F. (2014). Lifestyle interventions
for diabetes mellitus type 2 prevention. Revista Clnica Espanla, 214(2), 59-68. doi:
10.1016/j.rce.2013.10.005
Toobert, D. J., Glasgow, R. E., Strycker, L. A., Barrera, M., Ritzwoller, D. P., & Weidner, G.
(2007). Long-term effects of the Mediterranean lifestyle program: A randomized clinical trial for
postmenopausal women with type 2 diabetes. The International Journal of Behavioral Nutrition
and Physical Activity, 4. doi: 10.1186/1479-5868-4-1
Van Son, J., Nyklcek, I., Pop, V. J., Blonk, M. C., Erdtsieck, R. J., Spooren, P. F., . . . Pouwer, F.
(2013). The effects of a mindfulness-based intervention on emotional distress, quality of life, and
HbA1c in outpatients with diabetes (DiaMind): A randomized controlled trial. Diabetes Care,
36(4), 823-830. doi: 10.2337/dc12-1477
Williamson, D. A., Rejeski, J., Lang, W., Van Dorsten, B., Fabricatore, A. N., & the Look
AHEAD Research Group, K. (2009). Impact of a weight management program on health-related
quality of life in overweight adults with type 2 diabetes. Archives of Internal Medicine, 169(2),
163171. doi:10.1001/archinternmed.2008.544

Wu, S. V., Liang, S., Wang, T.-J., Chen, M., Jian, Y., & Cheng, K. (2011). A self-management
intervention to improve quality of life and psychosocial impact for people with type 2 diabetes.
Journal of Clinical Nursing, 20(17/18), 26552665. doi: 10.1111/j.1365-2702.2010.03694.x
Other References:
American Occupational Therapy Association. (2014). Occupational therapy practice framework:
Domain and process, (3rd ed). American Journal of Occupational Therapy, 68 (Suppl.1), S1
S48. http://dx.doi.org/10.5014/ajot.2014.682006
American Psychological Association (2009). Publication manual of the American Psychological
Association (6th ed.). Washington DC: Author Psychological Association. ISBN: 978-1-43380561-5
Centers for Disease Control and Prevention. (2015). Diabetes home. Retrieved from
http://www.cdc.gov/diabetes/basics/index.html
Mayo Clinic. (2014a). Prediabetes. Retrieved from http://www.mayoclinic.org/diseasesconditions/prediabetes/basics/definition/CON-20024420
Mayo Clinic. (2014b). Type 2 diabetes. Retrieved from http://www.mayoclinic.org/diseasesconditions/diabetes/basics/definition/con-20033091
Office of Disease Prevention and Health Promotion. Diabetes. Retrieved from
http://www.healthypeople.gov/2020/topics-objectives/topic/diabetes
World Health Organization. (2015). Diabetes. Retrieved from
http://www.who.int/mediacentre/factsheets/fs312/en/
Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05