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Literature Review

Literature Review

Danielle Porter

Health Communication and Advocacy

HLTH 634

September 13, 2015


In the United States in 2014, 29.1 million people or 9.3% of the population had diabetes.1 Because of that high statistic it is unlikely that anyone in the United States has not been affected by diabetes or knows someone who has. There is no debating that diabetes exists or that it is an incredibly concerning problem. The question is what can public health professionals do to lower the incidence rate of diabetes? First one needs to know that there are three types of diabetes, Type 1, Type 2 and Gestational. Of the three types, Type 2 has the most influencable risk factors. Everyone is at risk for diabetes in some form or another. Type 2 diabetes, formerly called adult-onset diabetes, is the most common type of diabetes. About 95 percent of people with diabetes have type 2. People can develop type 2 diabetes at any age, even during childh

ood. However, this type of diabetes develops most often in middle-aged and older people.2 The most controllable risk factors for Type 2 diabetes are obesity, high blood pressure, high cholesterol and a sedentary lifestyle. Changing two of these directly correlates to a change in the other two. Lowering your overall body weight 10% dramatically reduces your risk factors for diabetes.3 Increasing your activity level and adopting a plan for healthy eating will lead to a reduction in body weight, which also can positively effect ones blood pressure and cholesterol level.

Nourish 927 in partnership with the Montgomery County Health Department is planning a health communication intervention that aims to educate Montgomery County and Fort Campbell residents on the rising concern of Type 2 diabetes and what they can do to lower their risk factors. A social media intervention is proposed, concentrating on social networking groups that host residents of these two defined areas. Since Type 2 diabetes is a big concern for the middle age group the intervention is targeted at those who are between the ages of 25-40. This age group has a greater chance of effectively turning their risk factors around before they get to the point of medical intervention.

The following literature review will be organized by categories of research. These categories include demographics affected, prior efforts at interventions and the use of social media in health interventions.

The literature was reviewed based on the standard academic criteria. These criteria included being published in the last 7 years, peer reviewed, journal published and governmental sources. Sources from newspapers, book reviews, dissertations or any material published over 7 years ago was excluded for reasons including invalidity or not being the most current information possible. All population statistics reported are from 2012-2015.

Body of Evidence

Demographics Affected

While anyone at any point in time can be affected by diabetes for reasons that are still unknown to science there are certain demographics that are affected more frequently. Differences have been observed across many demographics, but a recent study by White-Means, Franklin and Brown stated that, overall, women were significantly more likely to present with hypertension than men, although percentages for blacks were significantly higher. Ulcers were more prevalent in men versus women, highest among white men. As they predicted, overall hospital charges related to diabetes were highest among blacks.4 In an effort to reduce the overall incidence of Type 2 diabetes and prediabetes, men and women are often confronted differently about the issue. Health communications interventions can be highly tailored to fit the receiving demographic. The global epidemic of type 2 diabetes has led to a number of large clinical trials examining the feasibility and efficacy of prevention strategies, including both lifestyle modification and drug therapy.5 Lifestyle modification is the method of risk reduction Nourish 927 in partnership with the Montgomery County Health Department intend to pursue with their health communication intervention. The study in 2008 done by Barrett-Connor, et al. found decided that the goals for the participants assigned to intensive lifestyle modification were to achieve and maintain a weight reduction of at least 7% in initial body weight through a healthy low-calorie, low-fat diet and to engage in physical activity of moderate intensity, such as brisk walking, for at least 150 min per week.5 Which are the similar goals as the health communication intervention proposed with Nourish 927. Barrett-Connor, et al. found that meeting the 7% weight loss goal was strongly correlated with the prevention of diabetes in both sexes. Surprisingly, in the ILS group, men lost significantly more weight and were more active than women and yet incident diabetes (or return to normal glucose tolerance) did not differ significantly by sex.5 Barrett-Connor’s study focused on the differences between intervention in the demographic of sex, but there have been many much more general efforts at intervention.

Prior Efforts at Interventions

As Type 2 diabetes incidence has risen in the past 10 years in the United States many efforts have been made to quell the rates. On such intervention was done in 2013 by Farland, et al. They staged a cohort study and set up at 7 different staging centers across Tennessee. The results of their study indicated that pharmacist-physician collaborative management at multiple practice locations and types of setting (eg, private, academic, Veterans Affairs medical center) had a positive impact on glycemic control and diabetes-related health maintenance.6 Farland, et al. claims to have had a positive impact using a medical approach. There are other studies who emphasize lifestyle modification also can positively impact a persons medical profile regarding diabetes. One such study presented by Lavigne-Robichaud, Vermeer, Azzi, et al. invited rural living adults to participate in a client-centered 6-month lifestyle education program. This program focused on healthy lifestyle changes rather than on weight loss. They ascertained that it is reasonable to conclude that a prediabetes intervention program, with emphasis on healthy lifestyle, could help rural adults with Type 2 diabetes risk factors management.7 Another program based out of Australia, preformed in 2014 by Aguiar, Morgan, Collins, Plotnikoff, Young and Callister was a 6-month, self-administered, gender-tailored lifestyle intervention, with a multicomponent approach (weight loss, dietary modification, aerobic exercise and resistance training).8 Naming their program PULSE, meaning Prevention Using LifeStyle Education, they sought to positively influence men ages 18-65 regarding diabetes prevention and prediabetes management. Their study also utilized a minimal face-to-face contact model, similar to that of the proposed Nourish 927 intervention. They decided their intervention has great potential for widespread dissemination into community and health care settings, namely because it reduced patient–practitioner contact time and cost of transport and facility use. Also, because of the lack of face-to-face time participants claim they felt more comfortable being independent.8 Other national interventions have taken place in recent years as well.

In 2013 Albright and Gregg wrote an article summarizing the CDC’s National Diabetes Prevention Program. In this article they highlight the CDC’s evidence for lifestyle change prevention programs. Each major intervention achieved substantial reductions in total dietary intake, total and saturated fat intake, and achieved increases in leisure-time physical activity, and in some cases, increased fiber intake. Each study integrated behavioral principles and self-monitoring using diet and exercise diaries to assist behavior change.9 The CDC claims that, the strongest and clearest evidence for the prevention of type 2 diabetes is from lifestyle change in which people at high risk for type 2 diabetes are exposed to a structured lifestyle intervention that addresses nutrition, physical activity, and behavior change strategies that result in modest weight loss.9 It’s clear through these examples that no matter which type of intervention is initiated, the end conclusion is that diabetes needs to be addressed when it is still considered prediabetes. Hundreds of studies, not all focusing on diabetes, both medical and lifestyle focused are done each year, some of which focus on a less face-to-face approach, similar to the one Nourish 927 and the Montgomery County Health Department are proposing. Some of this center around the social media aspect of health communication.

Use of Social Media in Health Interventions

Social media is such a pervasive force in communication across the United States. Information becomes viral in mere seconds and people are highly influenced by what they see their peers interacting with online through “likes”, “shares” and “comments”. Doctors Cheston, Flickinger and Chisolm performed a study examining the power of social media in medical interventions. For educators, the efficacy of social media tools in enhancing medical education grows daily. They also advise, in developing and implementing future interventions, educators should consider ways to maximize the opportunities provided by social media, such as active learning through engagement in user-generated content, facilitation of communication and feedback, collaboration, and access to resources and interaction without physical location restrictions.10 Phillips writes in his article that, “today’s Facebook users will be the elderly of tomorrow, and they will expect health care to be delivered in a very different way than it is today. The challenge for health professionals is how to respond to this need.”11 This speaks loudly to the challenge of providing interactive, educational, correct information in a social media spectrum.

Summary and Conclusions

Diabetes is a problem that is not going to go away without serious nationwide overhaul. There are a variety of ways interventions have positively impacted the incidence rate of diabetes, ranging from purely medical, such as the Farland study, to a more holistic way of lifestyle change in the Lavigne-Robichaud et al., Aguiar et al., and Albright and Gregg lead studies. While both types of interventions produce seemingly similar results on an individual level. Where the real difference is seen is through the financial investment route. The CDC estimates that $1400 per participant, is expended during a intensive lifestyle change intervention.9 This may seem like an expense too great, but when set in contrast to the per capita healthcare expenditure for a person with diabetes of $11,700,9 $1,400 seems like an inexpensive fix.

No matter your opinion of social media it is undeniable that it is a driving force behind people’s daily lives. Inserting the health communication intervention that Nourish 927 and the Montgomery County Health Department proposes, 8 weeks of targeted education campaigns inserted into local social networking groups on Facebook focused on lifestyle modification in an effort to reduce ones risk factors for Type 2 diabetes, should follow the lifestyle modification interventions of the above mentioned studies. Middle Tennessee needs an intervention and the social media campaign can bring an inexpensive light to the issue with minimal cost and minimal personal investment.


  1. 2014 Statistics Report | Data & Statistics | Diabetes | CDC. 2015. Available at: Accessed September 13, 2015.

  2. Am I at Risk for Type 2 Diabetes? Taking Steps to Lower Your Risk of Getting Diabetes. 2015. Available at: Accessed September 3, 2015.

  3. Accessed September 3, 2015.

  4. White-Means S, Franklin B, Brown L. PDB26 RACE AND GENDER DIFFERENCES IN ECONOMIC BURDEN OF DIABETES HOSPITALIZATIONS IN TENNESSEE. Value in Health. 2009;12(3):A101. doi:10.1016/s1098-3015(10)73570-1.

  5. Barrett-Connor, Elizabeth, et al. "Sex differences in diabetes risk and the effect of intensive lifestyle modification in the Diabetes Prevention Program." Diabetes Care July 2008: 1416+. General OneFile. Web. 8 Sept. 2015.

  6. Farland M, Byrd D, McFarland M et al. Pharmacist-Physician Collaboration for Diabetes Care: The Diabetes Initiative Program. Annals of Pharmacotherapy. 2013;47(6):781-789. doi:10.1345/aph.1s079.

  7. Lavigne-Robichaud M, Vermeer A, Azzi S et al. Lessons Learned from a Type 2 Diabetes Prevention Group Program Using a Healthy Lifestyle Education Approach. Canadian Journal of Diabetes. 2015;39:S55. doi:10.1016/j.jcjd.2015.01.209.

  8. Aguiar E, Morgan P, Collins C, Plotnikoff R, Young M, Callister R. The PULSE (Prevention Using LifeStyle Education) trial protocol: a randomized controlled trial of a Type 2 Diabetes Prevention programme for men. Contemporary Clinical Trials. 2014;39(1):132-144. doi:10.1016/j.cct.2014.07.008.

  9. Albright A, Gregg E. Preventing Type 2 Diabetes in Communities Across the U.S. American Journal of Preventive Medicine. 2013;44(4):S346-S351. doi:10.1016/j.amepre.2012.12.009.

  10. Cheston C, Flickinger T, Chisolm M. Social Media Use in Medical Education. Academic Medicine. 2013;88(6):893-901. doi:10.1097/acm.0b013e31828ffc23.

  11. Phillips J. Social media and health care: an interactive future. British Journal Of Community Nursing [serial online]. October 2011;16(10):504. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed September 9, 2015.

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