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Patient Education and Counseling

Review a systematic literature review of diabetes self-management education features to improve diabetes education in women of black african/caribbean and hispanic/latin american ethnicity.

This systematic literature review aims to identify diabetes self-management education (DSME) features to improve diabetes education for Black African/Caribbean and Hispanic/Latin American women with Type 2 diabetes mellitus.

We conducted a literature search in six health databases for randomized controlled trials and comparative studies. Success rates of intervention features were calculated based on effectiveness in improving glycosolated hemoglobin (HbA1c), anthropometrics, physical activity, or diet outcomes. Calculations of rate differences assessed whether an intervention feature positively or negatively affected an outcome.

From 13 studies included in our analysis, we identified 38 intervention features in relation to their success with an outcome. Five intervention features had positive rate differences across at least three outcomes: hospital-based interventions, group interventions, the use of situational problem-solving, frequent sessions, and incorporating dietitians as interventionists. Six intervention features had high positive rate differences (i.e. ≥50%) on specific outcomes.

Different DSME intervention features may influence broad and specific self-management outcomes for women of African/Caribbean and Hispanic/Latin ethnicity.

Practical implications

With the emphasis on patient-centered care, patients and care providers can consider options based on DSME intervention features for its broad and specific impact on outcomes to potentially make programming more effective.

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Research Design and Methods

Article information, literature review of type 2 diabetes management and health literacy.

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Rulla Alsaedi, Kimberly McKeirnan; Literature Review of Type 2 Diabetes Management and Health Literacy. Diabetes Spectr 1 November 2021; 34 (4): 399–406.

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The purpose of this literature review was to identify educational approaches addressing low health literacy for people with type 2 diabetes. Low health literacy can lead to poor management of diabetes, low engagement with health care providers, increased hospitalization rates, and higher health care costs. These challenges can be even more profound among minority populations and non-English speakers in the United States.

A literature search and standard data extraction were performed using PubMed, Medline, and EMBASE databases. A total of 1,914 articles were identified, of which 1,858 were excluded based on the inclusion criteria, and 46 were excluded because of a lack of relevance to both diabetes management and health literacy. The remaining 10 articles were reviewed in detail.

Patients, including ethnic minorities and non-English speakers, who are engaged in diabetes education and health literacy improvement initiatives and ongoing follow-up showed significant improvement in A1C, medication adherence, medication knowledge, and treatment satisfaction. Clinicians considering implementing new interventions to address diabetes care for patients with low health literacy can use culturally tailored approaches, consider ways to create materials for different learning styles and in different languages, engage community health workers and pharmacists to help with patient education, use patient-centered medication labels, and engage instructors who share cultural and linguistic similarities with patients to provide educational sessions.

This literature review identified a variety of interventions that had a positive impact on provider-patient communication, medication adherence, and glycemic control by promoting diabetes self-management through educational efforts to address low health literacy.

Diabetes is the seventh leading cause of death in the United States, and 30.3 million Americans, or 9.4% of the U.S. population, are living with diabetes ( 1 , 2 ). For successful management of a complicated condition such as diabetes, health literacy may play an important role. Low health literacy is a well-documented barrier to diabetes management and can lead to poor management of medical conditions, low engagement with health care providers (HCPs), increased hospitalizations, and, consequently, higher health care costs ( 3 – 5 ).

The Healthy People 2010 report ( 6 ) defined health literacy as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Diabetes health literacy also encompasses a wide range of skills, including basic knowledge of the disease state, self-efficacy, glycemic control, and self-care behaviors, which are all important components of diabetes management ( 3 – 5 , 7 ). According to the Institute of Medicine’s Committee on Health Literacy, patients with poor health literacy are twice as likely to have poor glycemic control and were found to be twice as likely to be hospitalized as those with adequate health literacy ( 8 ). Associations between health literacy and health outcomes have been reported in many studies, the first of which was conducted in 1995 in two public hospitals and found that many patients had inadequate health literacy and could not perform the basic reading tasks necessary to understand their treatments and diagnoses ( 9 ).

Evaluation of health literacy is vital to the management and understanding of diabetes. Several tools for assessing health literacy have been evaluated, and the choice of which to use depends on the length of the patient encounter and the desired depth of the assessment. One widely used literacy assessment tool, the Test of Functional Health Literacy in Adults (TOFHLA), consists of 36 comprehension questions and four numeric calculations ( 10 ). Additional tools that assess patients’ reading ability include the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Literacy Assessment for Diabetes. Tests that assess diabetes numeracy skills include the Diabetes Numeracy Test, the Newest Vital Sign (NVS), and the Single-Item Literacy Screener (SILS) ( 11 ).

Rates of both diabetes and low health literacy are higher in populations from low socioeconomic backgrounds ( 5 , 7 , 12 ). People living in disadvantaged communities face many barriers when seeking health care, including inconsistent housing, lack of transportation, financial difficulties, differing cultural beliefs about health care, and mistrust of the medical professions ( 13 , 14 ). People with high rates of medical mistrust tend to be less engaged in their care and to have poor communication with HCPs, which is another factor HCPs need to address when working with their patients with diabetes ( 15 ).

The cost of medical care for people with diabetes was $327 billion in 2017, a 26% increase since 2012 ( 1 , 16 ). Many of these medical expenditures are related to hospitalization and inpatient care, which accounts for 30% of total medical costs for people with diabetes ( 16 ).

People with diabetes also may neglect self-management tasks for various reasons, including low health literacy, lack of diabetes knowledge, and mistrust between patients and HCPs ( 7 , 15 ).

These challenges can be even more pronounced in vulnerable populations because of language barriers and patient-provider mistrust ( 17 – 19 ). Rates of diabetes are higher among racial and ethnic minority groups; 15.1% of American Indians and Alaskan Natives, 12.7% of Non-Hispanic Blacks, 12.1% of Hispanics, and 8% of Asian Americans have diagnosed diabetes, compared with 7.4% of non-Hispanic Whites ( 1 ). Additionally, patient-provider relationship deficits can be attributed to challenges with communication, including HCPs’ lack of attention to speaking slowly and clearly and checking for patients’ understanding when providing education or gathering information from people who speak English as a second language ( 15 ). White et al. ( 15 ) demonstrated that patients with higher provider mistrust felt that their provider’s communication style was less interpersonal and did not feel welcome as part of the decision-making process.

To the authors’ knowledge, there is no current literature review evaluating interventions focused on health literacy and diabetes management. There is a pressing need for such a comprehensive review to provide a framework for future intervention design. The objective of this literature review was to gather and summarize studies of health literacy–based diabetes management interventions and their effects on overall diabetes management. Medication adherence and glycemic control were considered secondary outcomes.

Search Strategy

A literature review was conducted using the PubMed, Medline, and EMBASE databases. Search criteria included articles published between 2015 and 2020 to identify the most recent studies on this topic. The search included the phrases “diabetes” and “health literacy” to specifically focus on health literacy and diabetes management interventions and was limited to original research conducted in humans and published in English within the defined 5-year period. Search results were exported to Microsoft Excel for evaluation.

Study Selection

Initial screening of the articles’ abstracts was conducted using the selection criteria to determine which articles to include or exclude ( Figure 1 ). The initial search results were reviewed for the following inclusion criteria: original research (clinical trials, cohort studies, and cross-sectional studies) conducted in human subjects with type 2 diabetes in the United States, and published in English between 2015 and 2020. Articles were considered to be relevant if diabetes was included as a medical condition in the study and an intervention was made to assess or improve health literacy. Studies involving type 1 diabetes or gestational diabetes and articles that were viewpoints, population surveys, commentaries, case reports, reviews, or reports of interventions conducted outside of the United States were excluded from further review. The criteria requiring articles to be from the past 5 years and from the United States were used because of the unique and quickly evolving nature of the U.S. health care system. Articles published more than 5 years ago or from other health care systems may have contributed information that was not applicable to or no longer relevant for HCPs in the United States. Articles were screened and reviewed independently by both authors. Disagreements were resolved through discussion to create the final list of articles for inclusion.

FIGURE 1. PRISMA diagram of the article selection process.

PRISMA diagram of the article selection process.

Data Extraction

A standard data extraction was performed for each included article to obtain information including author names, year of publication, journal, study design, type of intervention, primary outcome, tools used to assess health literacy or type 2 diabetes knowledge, and effects of intervention on overall diabetes management, glycemic control, and medication adherence.

A total of 1,914 articles were collected from a search of the PubMed, MEDLINE, and EMBASE databases, of which 1,858 were excluded based on the inclusion and exclusion criteria. Of the 56 articles that met criteria for abstract review, 46 were excluded because of a lack of relevance to both diabetes management and health literacy. The remaining 10 studies identified various diabetes management interventions, including diabetes education tools such as electronic medication instructions and text message–based interventions, technology-based education videos, enhanced prescription labels, learner-based education materials, and culturally tailored interventions ( 15 , 20 – 28 ). Figure 1 shows the PRISMA diagram of the article selection process, and Table 1 summarizes the findings of the article reviews ( 15 , 20 – 28 ).

Findings of the Article Reviews (15,20–28)

SAHLSA, Short Assessment of Health Literacy for Spanish Adults.

Medical mistrust and poor communication are challenging variables in diabetes education. White et al. ( 15 ) examined the association between communication quality and medical mistrust in patients with type 2 diabetes. HCPs at five health department clinics received training in effective health communication and use of the PRIDE (Partnership to Improve Diabetes Education) toolkit in both English and Spanish, whereas control sites were only exposed to National Diabetes Education Program materials without training in effective communication. The study evaluated participant communication using several tools, including the Communication Assessment Tool (CAT), Interpersonal Processes of Care (IPC-18), and the Short Test of Functional Health Literacy in Adults (s-TOFHLA). The authors found that higher levels of mistrust were associated with lower CAT and IPC-18 scores.

Patients with type 2 diabetes are also likely to benefit from personalized education delivery tools such as patient-centered labeling (PCL) of prescription drugs, learning style–based education materials, and tailored text messages ( 24 , 25 , 27 ). Wolf et al. ( 27 ) investigated the use of PCL in patients with type 2 diabetes and found that patients with low health literacy who take medication two or more times per day have higher rates of proper medication use when using PCL (85.9 vs. 77.4%, P = 0.03). The objective of the PCL intervention was to make medication instructions and other information on the labels easier to read to improve medication use and adherence rates. The labels incorporated best-practice strategies introduced by the Institute of Medicine for the Universal Medication Schedule. These strategies prioritize medication information, use of larger font sizes, and increased white space. Of note, the benefits of PCL were largely seen with English speakers. Spanish speakers did not have substantial improvement in medication use or adherence, which could be attributed to language barriers ( 27 ).

Nelson et al. ( 25 ) analyzed patients’ engagement with an automated text message approach to supporting diabetes self-care activities in a 12-month randomized controlled trial (RCT) called REACH (Rapid Education/Encouragement and Communications for Health) ( 25 ). Messages were tailored based on patients’ medication adherence, the Information-Motivation-Behavioral Skills model of health behavior change, and self-care behaviors such as diet, exercise, and self-monitoring of blood glucose. Patients in this trial were native English speakers, so further research to evaluate the impact of the text message intervention in patients with limited English language skills is still needed. However, participants in the intervention group reported higher engagement with the text messages over the 12-month period ( 25 ).

Patients who receive educational materials based on their learning style also show significant improvement in their diabetes knowledge and health literacy. Koonce et al. ( 24 ) developed and evaluated educational materials based on patients’ learning style to improve health literacy in both English and Spanish languages. The materials were made available in multiple formats to target four different learning styles, including materials for visual learners, read/write learners, auditory learners, and kinesthetic learners. Spanish-language versions were also available. Researchers were primarily interested in measuring patients’ health literacy and knowledge of diabetes. The intervention group received materials in their preferred learning style and language, whereas the control group received standard of care education materials. The intervention group showed significant improvement in diabetes knowledge and health literacy, as indicated by Diabetes Knowledge Test (DKT) scores. More participants in the intervention group reported looking up information about their condition during week 2 of the intervention and showed an overall improvement in understanding symptoms of nerve damage and types of food used to treat hypoglycemic events. However, the study had limited enrollment of Spanish speakers, making the applicability of the results to Spanish-speaking patients highly variable.

Additionally, findings by Hofer et al. ( 22 ) suggest that patients with high A1C levels may benefit from interventions led by community health workers (CHWs) to bridge gaps in health literacy and equip patients with the tools to make health decisions. In this study, Hispanic and African American patients with low health literacy and diabetes not controlled by oral therapy benefited from education sessions led by CHWs. The CHWs led culturally tailored support groups to compare the effects of educational materials provided in an electronic format (via iDecide) and printed format on medication adherence and self-efficacy. The study found increased adherence with both formats, and women, specifically, had a significant increase in medication adherence and self-efficacy. One of the important aspects of this study was that the CHWs shared cultural and linguistic characteristics with the patients and HCPs, leading to increased trust and satisfaction with the information presented ( 22 ).

Kim et al. ( 23 ) found that Korean-American participants benefited greatly from group education sessions that provided integrated counseling led by a team of nurses and CHW educators. The intervention also had a health literacy component that focused on enhancing skills such as reading food package labels, understanding medical terminology, and accessing health care services. This intervention led to a significant reduction of 1–1.3% in A1C levels in the intervention group. The intervention established the value of collaboration between CHW educators and nurses to improve health information delivery and disease management.

A collaboration between CHW educators and pharmacists was also shown to reinforce diabetes knowledge and improve health literacy. Sharp et al. ( 26 ) conducted a cross-over study in four primary care ambulatory clinics that provided care for low-income patients. The study found that patients with low health literacy had more visits with pharmacists and CHWs than those with high health literacy. The CHWs provided individualized support to reinforce diabetes self-management education and referrals to resources such as food, shelter, and translation services. The translation services in this study were especially important for building trust with non-English speakers and helping patients understand their therapy. Similar to other studies, the CHWs shared cultural and linguistic characteristics with their populations, which helped to overcome communication-related and cultural barriers ( 23 , 26 ).

The use of electronic tools or educational videos yielded inconclusive results with regard to medication adherence. Graumlich et al. ( 20 ) implemented a new medication planning tool called Medtable within an electronic medical record system in several outpatient clinics serving patients with type 2 diabetes. The tool was designed to organize medication review and patient education. Providers can use this tool to search for medication instructions and actionable language that are appropriate for each patient’s health literacy level. The authors found no changes in medication knowledge or adherence, but the intervention group reported higher satisfaction. On the other hand, Yeung et al. ( 28 ) showed that pharmacist-led online education videos accessed using QR codes affixed to the patients’ medication bottles and health literacy flashcards increased patients’ medication adherence in an academic medical hospital.

Goessl et al. ( 21 ) found that patients with low health literacy had significantly higher retention of information when receiving evidence-based diabetes education through a DVD recording than through an in-person group class. This 18-month RCT randomized participants to either the DVD or in-person group education and assessed their information retention through a teach-back strategy. The curriculum consisted of diabetes prevention topics such as physical exercise, food portions, and food choices. Participants in the DVD group had significantly higher retention of information than those in the control (in-person) group. The authors suggested this may have been because participants in the DVD group have multiple opportunities to review the education material.

Management of type 2 diabetes remains a challenge for HCPs and patients, in part because of the challenges discussed in this review, including communication barriers between patients and HCPs and knowledge deficits about medications and disease states ( 29 ). HCPs can have a positive impact on the health outcomes of their patients with diabetes by improving patients’ disease state and medication knowledge.

One of the common themes identified in this literature review was the prevalence of culturally tailored diabetes education interventions. This is an important strategy that could improve diabetes outcomes and provide an alternative approach to diabetes self-management education when working with patients from culturally diverse backgrounds. HCPs might benefit from using culturally tailored educational approaches to improve communication with patients and overcome the medical mistrust many patients feel. Although such mistrust was not directly correlated with diabetes management, it was noted that patients who feel mistrustful tend to have poor communication with HCPs ( 20 ). Additionally, Latino/Hispanic patients who have language barriers tend to have poor glycemic control ( 19 ). Having CHWs work with HCPs might mitigate some patient-provider communication barriers. As noted earlier, CHWs who share cultural and linguistic characteristics with their patient populations have ongoing interactions and more frequent one-on-one encounters ( 12 ).

Medication adherence and glycemic control are important components of diabetes self-management, and we noted that the integration of CHWs into the diabetes health care team and the use of simplified medication label interventions were both successful in improving medication adherence ( 23 , 24 ). The use of culturally tailored education sessions and the integration of pharmacists and CHWs into the management of diabetes appear to be successful in reducing A1C levels ( 12 , 26 ). Electronic education tools and educational videos alone did not have an impact on medication knowledge or information retention in patients with low health literacy, but a combination of education tools and individualized sessions has the potential to improve diabetes medication knowledge and overall self-management ( 20 , 22 , 30 ).

There were several limitations to our literature review. We restricted our search criteria to articles published in English and studies conducted within the United States to ensure that the results would be relevant to U.S. HCPs. However, these limitations may have excluded important work on this topic. Additional research expanding this search beyond the United States and including articles published in other languages may demonstrate different outcomes. Additionally, this literature review did not focus on A1C as the primary outcome, although A1C is an important indicator of diabetes self-management. A1C was chosen as the method of evaluating the impact of health literacy interventions in patients with diabetes, but other considerations such as medication adherence, impact on comorbid conditions, and quality of life are also important factors.

The results of this work show that implementing health literacy interventions to help patients manage type 2 diabetes can have beneficial results. However, such interventions can have significant time and monetary costs. The potential financial and time costs of diabetes education interventions were not evaluated in this review and should be taken into account when designing interventions. The American Diabetes Association estimated the cost of medical care for people with diabetes to be $327 billion in 2017, with the majority of the expenditure related to hospitalizations and nursing home facilities ( 16 ). Another substantial cost of diabetes that can be difficult to measure is treatment for comorbid conditions and complications such as cardiovascular and renal diseases.

Interventions designed to address low health literacy and provide education about type 2 diabetes could be a valuable asset in preventing complications and reducing medical expenditures. Results of this work show that clinicians who are considering implementing new interventions may benefit from the following strategies: using culturally tailored approaches, creating materials for different learning styles and in patients’ languages, engaging CHWs and pharmacists to help with patient education, using PCLs for medications, and engaging education session instructors who share patients’ cultural and linguistic characteristics.

Diabetes self-management is crucial to improving health outcomes and reducing medical costs. This literature review identified interventions that had a positive impact on provider-patient communication, medication adherence, and glycemic control by promoting diabetes self-management through educational efforts to address low health literacy. Clinicians seeking to implement diabetes care and education interventions for patients with low health literacy may want to consider drawing on the strategies described in this article. Providing culturally sensitive education that is tailored to patients’ individual learning styles, spoken language, and individual needs can improve patient outcomes and build patients’ trust.

Duality of Interest

No potential conflicts of interest relevant to this article were reported.

Author Contributions

Both authors conceptualized the literature review, developed the methodology, analyzed the data, and wrote, reviewed, and edited the manuscript. R.A. collected the data. K.M. supervised the review. K.M. is the guarantor of this work and, as such, has full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Prior Presentation

Portions of this research were presented at the Washington State University College of Pharmacy and Pharmaceutical Sciences Honors Research Day in April 2019.

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Diabetes Literature Reviews Samples For Students

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Regardless of how high you rate your writing skills, it's always an appropriate idea to check out an expertly written Literature Review example, especially when you're dealing with a sophisticated Diabetes topic. This is precisely the case when collection of sample Literature Reviews on Diabetes will prove useful. Whether you need to come up with a fresh and meaningful Diabetes Literature Review topic or survey the paper's structure or formatting peculiarities, our samples will provide you with the necessary data.

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Literature review: Diabetes as risk factor for cardiovascular disease

Comment by elisa dal canto and joline wj beulens, eapc diabetes and cvd educational programme amsterdam university medical centers – location vu.

Diabetes mellitus (DM) is an important risk factor for cardiovascular disease (CVD), which in turn represents the principal cause of disability and mortality in individuals with DM. The pathophysiological basis of this link is atherosclerosis, which accounts for the majority of CVD and it is accelerated by DM. However, conventional vascular risk factors (e.g., obesity, physical inactivity, hypertension and high cholesterol level) cannot fully explain the excess CVD risk associated with DM, although HbA1c appears to be an important mediator (1).

Furthermore, while myocardial infarction (MI) and stroke are the most commonly investigated complications of DM, the associations of DM with other vascular disorders are for a large part unknown. Two recent large scale studies that thoroughly investigated the relationship between DM and the risk of CVD shed some light on this topic. A meta-analysis of 102 studies from the Emerging Risk Factors Collaboration including data of 698,782 people without initial CVD evaluated the associations between DM and fasting plasma glucose (FPG) concentrations and a wide range of fatal and non-fatal cardiovascular outcomes (2). According to their results, DM accounted for 11% of vascular deaths which corresponds to an estimated 325,000 death/year in high income countries alone. Subjects with DM compared to those without it, had about a two-fold higher risk for (CHD), ischaemic stroke, unclassified stroke, and deaths for other vascular diseases, independently of other risk factors (age, sex, smoking status, BMI, and systolic blood pressure) (2). Interestingly, greater HRs for CHD with DM were found in groups at lower absolute cardiovascular risk, such as younger individuals, women, non-smokers, those with below average BMI and with below average systolic blood pressure. In subjects with DM, FPG concentrations were non-linearly related to risk of CHD or ischaemic stroke (2), but information about haemoglobin A1c (HbA1c), which is known to be more strongly associated with CVD as compared with FPG (3), were not provided. A large prospective cohort using health records from the CALIBER programme implemented the knowledge on the link between DM and CVD evaluating the association between diabetes status and 12 different initial cardiovascular presentations, including angina, MI, peripheral arterial disease, heart failure (HF), abdominal aortic aneurysm (4). The cohort consisted of 1,921,260 individuals, of whom 34,198 (1.8%) had type 2 DM. 113,638 cardiovascular events occurred during a median follow-up time of 5.5 years; among these, peripheral arterial disease was the first presentation in 992 (16.2%) of the 6137 subjects with type 2 DM who had cardiovascular events whereas HF was the first presentation in 866 (14.1%) of them (5). This result is consistent with the previous finding of a high prevalence of HF among diabetic patients (30.6%); interestingly, the proportion of patients with preserved (HFpEF) vs reduced ejection fraction (HFrEF) was considerably higher (24.8% vs 5.8%) (5). This suggests that other pathophysiological mechanisms, in addition to atherosclerosis, affect the myocardium of subjects with DM, such as cardiomyocyte hypertrophy, caused by hyperinsulinemia and endothelial dysfunction caused by hyperglycaemia (6). While hyperglycaemia is one of the principal causes of macrovasculopathy In DM, it also represents the driver of microvascular complications (retinopathy, nephropathy, and neuropathy). In this regard, macro- and microvascular complications can be seen as part of the same spectrum, as the two disorders are strongly interconnected, and thus require a common preventive strategy. Taken together these data not only confirm that DM represents a strong and independent risk factor for CVD, but they also point out that the association is not restricted to CHD or stroke goes but concerns multiple acute and chronic cardiovascular outcomes.

Moreover, DM confers an increased risk of CHD even in those categories such as women and young individuals which are traditionally regarded as low risk groups. These findings have several important implications; the surveillance and prevention of DM complications should be directed towards multiple diseases and multiple subgroups of patients, and DM clinical trials should start considering other CV events, in addition to MI and stroke, as possible outcomes.

Note : The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology

Elisa Dal Canto, Joline WJ Beulens were commenting on these articles:

Emerging Risk Factors Collaboration, Sarwar N, Gao P, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375(9733):2215-22.

Shah AD, Langenberg C, Rapsomaniki E, et al. Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1.9 million people. Lancet Diabetes Endocrinol. 2015;3(2):105-13

1. Khaw KT, Wareham N, Luben R, Bingham S, Oakes S, Welch A, Day N. Glycated haemoglobin, diabetes, and mortality in men in Norfolk cohort of european prospective investigation of cancer and nutrition (EPIC-Norfolk). BMJ. 2001 Jan 6;322(7277):15-8. 2. Emerging Risk Factors Collaboration, Sarwar N, Gao P, et al. Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. Lancet. 2010;375(9733):2215-22. 3. Selvin E, Steffes MW, Zhu H, et al. Glycated haemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med. 2010;362(9):800-11. 4. Shah AD, Langenberg C, Rapsomaniki E, et al. Type 2 diabetes and incidence of cardiovascular diseases: a cohort study in 1.9 million people. Lancet Diabetes Endocrinol. 2015;3(2):105-13. 5. Boonman-de Winter LJ, Rutten FH, Cramer MJ, et al. High prevalence of previously unknown heart failure and left ventricular dysfunction in patients with type 2 diabetes. Diabetologia. 2012;55(8):2154-62. 6. Petar M. Seferović, Walter J. Paulus; Clinical diabetic cardiomyopathy: a two-faced disease with restrictive and dilated phenotypes, Eur Heart J. 2015;36(27):1718-27.

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Diabetes patient education research: an integrative literature review


Purpose: The purpose of this study is to summarize the accumulated state of knowledge in the area of diabetes patient education research and highlight important issues that research has left unanswered.

Methods: An integrative literature review was conducted on the topic of diabetes patient education between the years 1985 and 1998. Keywords used in the computerized search were diabetes mellitus, patient education, health education, research, and behavior change. The databases searched were MEDLINE, CINAHL, HealthSTAR, EMBASE, and CHID-HE. A total of 78 papers were reviewed.

Results: Most studies lacked a theoretical framework and the majority of studies were conducted in an outpatient setting. HbA1c was the most frequently employed outcome measure, with little, if any, description of the interventions.

Conclusions: Much has been learned in terms of the effectiveness of diabetes education on improving knowledge. However, other topic areas and outcomes need further exploration.

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Diabetes - Literature review Example


Extract of sample "Diabetes"

The study "Diabetes" will help to understand history, types and prevalence of this disease. The Egyptian manuscript from c. 1500 BCE had described diabetes among the first diseases and mentioned it as "too great emptying of the urine". The cases that were initially described are believed to be of the type 1 diabetes. This disease was then identified at the same time by the Indian physicians and they categorized it to be the "honey urine" or madhumeha taking into account that fact that ants would be attracted by urine.

The diseases are known by "diabetes" which mean "to pass through" was used by the Greek Appollonius of Memphis first in the 230 BCE. At that time, it was taken to be rare in presence at the time of the Roman empire, and Galen had commented to this that only two cases were witnessed by him at the period of his career. This may have happened because of the life-style and diet maintained by the primitive people or may have been due to the observation of the clinical symptoms in the course of the advanced stage of the disease.

The disease, diabetes, was named as "diarrhea urinoma" (diarrhea of the urine) by Galen. Aretaeus of Cappadocia has performed the initial work to be surviving now and having a detailed reference with regards to during the period of early 3rd century CE. The symptoms and duration of the disease were described by him, and he attributed theses to the coldness and moisture which mirrored the beliefs carried by the "Pneumatic School".


Periodontal disease and diabetes, service project for diabetes, obesity and diabetes ( obesity is known to cause diabetes, general information on diabetes, love diabetes summary, living with diabetes, bariatric surgery & type2 diabetes, diabetes type 1.

example of literature review on diabetes

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How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes .

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, frequently asked questions, introduction.

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

Literature review guide

Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

You can also check out our templates with literature review examples and sample outlines at the links below.

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Prevent plagiarism. Run a free check.

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).


The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.


If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:


A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

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A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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Writing in the Health and Social Sciences: Literature Reviews and Synthesis Tools

Systematic Literature Reviews: Steps & Resources

example of literature review on diabetes

These steps for conducting a systematic literature review are listed below . 

Also see subpages for more information about:

Literature Review & Systematic Review Steps

1. Develop a Focused   Question 

Consider the PICO Format: Population/Problem, Intervention, Comparison, Outcome

Focus on defining the Population or Problem and Intervention (don't narrow by Comparison or Outcome just yet!)

"What are the effects of the Pilates method for patients with low back pain?"

Tools & Additional Resources:

2. Scope the Literature

A "scoping search" investigates the breadth and/or depth of the initial question or may identify a gap in the literature. 

Eligible studies may be located by searching in:

When searching, if possible, translate terms to controlled vocabulary of the database. Use text word searching when necessary.

Use Boolean operators to connect search terms:

Search:  pilates AND ("low back pain"  OR  backache )

Download a Boolean worksheet (PDF)

3. Refine & Expand Your Search

Expand your search strategy with synonymous search terms harvested from:


(pilates OR exercise movement techniques) AND ("low back pain" OR backache* OR sciatica OR lumbago OR spondylosis)

As you develop a final, reproducible strategy for each database, save your strategies in a:

4. Limit Your Results

Use database filters to limit your results based on your defined inclusion/exclusion criteria.  In addition to relying on the databases' categorical filters, you may also need to manually screen results.  

NOTE: Many databases allow you to filter to "Full Text Only".  This filter is  not recommended . It excludes articles if their full text is not available in that particular database (CINAHL, PubMed, etc), but if the article is relevant, it is important that you are able to read its title and abstract, regardless of 'full text' status. The full text is likely to be accessible through another source (a different database, or Interlibrary Loan).  

5. Download Citations

Selected citations and/or entire sets of search results can be downloaded from the database into a citation management tool. If you are conducting a systematic review that will require reporting according to PRISMA standards, a citation manager can help you keep track of the number of articles that came from each database, as well as the number of duplicate records.

In Zotero, you can create a Collection for the combined results set, and sub-collections for the results from each database you search.  You can then use Zotero's 'Duplicate Items" function to find and merge duplicate records.

File structure of a Zotero library, showing a combined pooled set, and sub folders representing results from individual databases.

6. Abstract and Analyze

Covidence is a web-based tool that enables you to work with a team to screen titles/abstracts and full text for inclusion in your review, as well as extract data from the included studies.

Screenshot of the Covidence interface, showing Title and abstract screening phase.

7. Create Flow Diagram

The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram is a visual representation of the flow of records through different phases of a systematic review.  It depicts the number of records identified, included and excluded.  It is best used in conjunction with the PRISMA checklist .

Example PRISMA diagram showing number of records identified, duplicates removed, and records excluded.

Example from: Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review. Current Diabetes Reports, 2 (11), 46.

8. Synthesize & Report Results

There are a number of reporting guideline available to guide the synthesis and reporting of results in systematic literature reviews.

It is common to organize findings in a matrix, also known as a Table of Evidence (ToE).

Example of a review matrix, using Microsoft Excel, showing the results of a systematic literature review.

Steps modified from: 

Cook, D. A., & West, C. P. (2012). Conducting systematic reviews in medical education: a stepwise approach.   Medical Education , 46 (10), 943–952.

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A Review of Systematic Reviews Evaluating Diabetes Interventions

This article reviews the literature on definitions and issues related to measurement of quality of life in people with diabetes and summarizes reviews of evidence of intervention studies, with a particular focus on interventions targeted for underserved and minority populations.

An integrative literature review of reviews was conducted on adult diabetes interventions and outcomes. Five electronic databases were searched. Eligible publications were those published between 1999 and 2006 that described outcome measures. Twelve review articles are included.

Review studies were heterogeneous in terms of intervention type, content, participants, setting, and outcome measures. Interventions used variable operational definitions and frequently lacked adequate description; therefore, comparisons of findings proved difficult. A clinical outcome, A1C, was the most frequently assessed, with little inclusion of quality-of-life measures. Several reviews and independent studies did not explicitly consider interventions aimed at the underserved. When quality of life was considered, measures and operational definition of domains were limited.


Understanding the relationship between interventions and resulting outcomes, particularly quality of life, will require attention to operational definitions and better conceptual models. There is an evidence base emerging about important characteristics of effective intervention programs. This evidence base can guide public health and clinical program planners to better understand and make prudent decisions about assessment, planning, implementation, and evaluation of interventions for people with complex chronic illnesses such as diabetes.

As the personal, social, and economic burden of diabetes mellitus (DM) continues, 1 so does the concern for building the evidence for efficacious and effective primary, secondary, and tertiary prevention strategies. It is important to focus on the outcomes of DM intervention efforts and to individualize diabetes self-management education (DSME). 2 , 3 Community involvement and collaboration can effectively build and deliver culturally centered interventions. 4 , 5 Documenting the effectiveness of interventions requires explicit indicators specific to DSME interventions, 3 along the continuum of outcomes categories: immediate (learning), intermediate (behavior change), post intermediate (clinical improvement), and long term (health status improvement). 6 Given the important intervention focus on DSME and its related impact on longterm outcomes, the patient’s perceptions and sociocultural context, including quality of life, are also important.

The American Association of Diabetes Educators (AADE) offers the following working definition for diabetes education:

Diabetes education, also known as diabetes self-management training (DSMT), is a collaborative process through which people with or at risk for diabetes gain the knowledge and skills needed to modify behavior and successfully self-manage the disease and its related conditions. The intervention aims to achieve optimal health status, better quality of life and reduce the need for costly healthcare. Diabetes education focuses on seven self-care behaviors that are essential for improved health status and greater quality of life. The AADE 7 Self-Care Behaviors are: healthy eating, being active, monitoring, taking medication, problem solving, healthy coping, and reducing risks. 7

Currently, the success of diabetes interventions is primarily assessed by traditional clinical measures, such as A1C, blood pressure, and blood glucose levels for a variety of reasons. African Americans are at a greater risk for complications related to DM. This article first reviews the definitions and issues related to measuring quality of life in people with diabetes. It then summarizes the published reviews of intervention studies with respect to outcome measures with a special focus on quality-of-life measures and studies that explicitly consider interventions for African Americans.

Improved outcomes in people with type 2 diabetes are related to several complex factors, which operate at many levels: public policy, health system, organizations, and individual provider and patient. Population subgroups, notably African Americans, face greater risks to health status and quality of life. 8 - 11 The public health community is paying considerable attention to health disparities and the role of improved health systems in reducing the burden of DM.

Classically defined, health outcomes are the changed state or condition of an individual as a consequence of medical care over time. 12 However, evidence demonstrates that individual and population health status are affected by access to and quality of health care, as well as complex factors at multiple levels, including patient and provider behavior and utilization over time, as noted in Figure 1 . 13 , 14 Outcomes can be traditional health status endpoints, such as mortality or morbidity; clinical measures or biological indicators, such as A1C or blood pressure; predisposing and behaviors such as medication compliance; or psychosocial and patient-centered measures such as satisfaction, well-being, or quality of life.

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Object name is nihms-328133-f0001.jpg

Strategies to improve outcomes. DSMT, diabetes self-management training; DM, diabetes mellitus; ADA, American Diabetes Association; AADE, American Association of Diabetes Educators. Adapted from Wagner 13 and Zapka et al. 14

Definition and Measurement of Quality of Life

Health-related quality of life (HRQOL) is considered a patient-assessed or patient-centered outcome that relates to the individual’s health perceptions, well-being, and functioning. 15 - 17 Moreover, health perceptions reflect the context of cultural and value systems. Various societal and individual determinants influence physical health, psychological state, social relationships, environmental factors, and beliefs. 18 , 19 Several studies report lower HRQOL in people diagnosed with diabetes. 20 , 21 Furthermore, evidence suggests the level of HRQOL is dependent on the presence of comorbidities and the severity of complications and has been significantly correlated with socioeconomic and/or familial barriers. 21 , 22

In the health literature, the terms quality of life (QOL), health-related quality of life, well-being, health status, and satisfaction are used interchangeably. 15 , 16 Healthy People conceptualized QOL as reflecting a “general sense of happiness and satisfaction with our lives and environment. General quality of life encompasses all aspects of life, including health, recreation, culture, rights, values, beliefs, aspirations, and the conditions that support a life containing these elements.” 23(p10) Overall QOL includes health-related factors and nonmedical phenomena such as personal relationships, employment, spirituality, 15 and a sense of well-being. 24 QOL is frequently defined as “an individual’s perception of their position in life in the context of culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns.” 19

In comparison, “HRQOL reflects a personal sense of physical and mental health and the ability to react to factors in the physical and social environments.” 23 HRQOL is a multidimensional construct of an individual’s subjective appraisal of health and well-being involving physical, psychological, and social functioning. 25 HRQOL includes health perception of risk and conditions such as social support, as well as socioeconomic and functional status. 10 The literature, although discordant, concedes that HRQOL is patient centered and is grounded in one’s reality. Because HRQOL is a measure of subjective health status and quality of life, health care providers are encouraged to consider HRQOL as a priority outcome, in addition to traditional physiologic and functional indicators.

Disease-specific instruments are designed to be used in a specific patient group, sensitive to treatment and natural history, and are more responsive to changes in health. 18 , 26 Important contributions have been made to identify and understand available diabetes-specific measures of HRQOL. Garratt and colleagues 18 reviewed available instruments, summarized the psychometric evidence, and made recommendations for their use. Although it is beyond the scope of this article to review all the findings of Garratt and colleagues’ extensive work, Table 1 reports important dimensions of existing instruments that reflect the personal and social outcomes important to living with diabetes.

To determine the state of evidence of HRQOL as a measured outcome in interventions designed specifically for adults with type 2 diabetes, the following were searched (1996-2006) for systematic or critical reviews and meta-analysis articles: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Educational Resources Information Center (ERIC), Cochrane Library, and PsycINFO databases. Inclusion criteria included English-language and review articles reported to include patient outcomes published between 1999 and 2006. The subject headings used for search included disease management, case management, care management, community, health system, self-management, self-management education, blacks, African Americans, health-related quality of life, quality of life, intervention, and outcomes, all in association with type 2 diabetes. In addition, selected bibliographic references and diabetes journals of relevance were searched by hand. Twelve review articles met the inclusion criteria and were included in this integrative review.

The analyses included review of criteria for inclusion in the review, the number and design of studies included, intervention description (components, content, and setting), and the impact, process, and outcomes assessed. This study includes comments about QOL instruments and consideration of minority and disadvantaged populations.

Table 2 reports the key analysis points for each review article, listed in alphabetical order by first author. The reviews covered studies conducted between 1966 and 2006, although the reviews were published between 1999 and 2006.

RCT, randomized controlled trial; DSME, diabetes self-management education; DM, diabetes mellitus; BP, blood pressure; FBG, fasting blood glucose; BMI, body mass index; QOL, quality of life; HRQOL, health-related quality of life; DQOL, diabetes quality of life; DCCT, Diabetes Control and Complications Trial Research Group; SES, socioeconomic status; PCP, primary care provider; CT, controlled trial; BGSM, blood glucose self-monitoring; DNS/NCM, diabetes nurse specialist/nurse case manager; SMBG, self-monitoring of blood glucose.

Inclusion and Exclusion Criteria for the Included Review Articles

Variable criteria were considered within each individual review. For example, some included only randomized trials (RCTs), 27 - 32 whereas others included RCT, quasiexperimental, and/or other comparative design methods. 33 - 37 Exclusion criteria also varied considerably across reviews. For example, some studies were excluded because they evaluated short-term effects 32 or included only patient interventions. 34

Intervention Type and Content

Numerous intervention approaches in a variety of settings were reported 33 , 38 and included delivery by lay leaders and professionals from diverse health care disciplines. 30 , 31 Many interventions included multiple components or strategies. Intervention content was loosely defined and, again, was broad and varied within each review. 29 Content ranged from being unspecified to diet, nutrition, goal setting, problem solving, or simply described as “standard diabetes education curriculum.”

Terms such as disease management and case management are widely used, and their operational definitions are exceptionally broad and variable. 35 , 37 The goal of disease management is improved short- and long-term health and/or economic outcomes. In particular, disease management interventions have been promoted, especially for costly, chronic conditions such as diabetes mellitus. For the included studies, settings were urban centers of managed care organizations and outpatient and community health clinics. A range of organizational, professional, and patient intervention components and strategies was included and supported multisystem approaches, which could lead to improvements in patient outcomes as well as process of care. 35

Case management, one component of a multisystem collaborative approach, delivered in conjunction with disease management, can serve an important role for people at high risk for adverse outcomes and excess health care utilization. Furthermore, assessment, planning, linking, monitoring, advocacy, and outreach, described as essential core functions of case management, are complementary with the chronic care model (CCM). 39 Yet, multicomponent approaches incorporating both disease and case management have been shown to improve outcomes as well as the process of care. 30 , 34 , 35 The evidence suggests that DSME was routinely delivered across disease management and case management interventions. Moreover, integrating DSME across interventions could potentially help to costeffectively optimize outcomes, such as metabolic control and quality of life, and prevent complications. 40 , 41

Impact, Process, and Outcomes Assessed

Seven of the review articles included in this review primarily focused on DSME interventions, 27 - 29 , 31 - 33 , 36 specifically, the effect of DSME interventions on multiple physiological, psychological, behavioral, and knowledge processes and outcomes 27 , 28 , 33 and, to a lesser extent, HRQOL. 29 , 36 Notably, Steed and colleagues 36 completed a systematic review of psychological outcomes (eg, psychological well-being and QOL) in 36 studies. They found that self-management interventions had more positive impact than educational interventions where patients received information only. Nine of the 36 studies reviewed by Steed et al used diabetes-specific QOL instruments; of these, 5 used the diabetes quality of life (DQOL). 42 Six of the 9 trials found QOL improvement postintervention, with no significant difference reported in 3 of the studies. Overall, 6 trials found QOL improvement postintervention. However, no significant difference was reported in 3 of the 5 studies using the DQOL.

Outcome measures varied substantially across studies, making it difficult to compare results across interventions, and many studies lacked sufficient detail for replication. Even when glycemic control was assessed, a variety of different methods and reference values was used. 32 , 34 Although outcomes for diabetes education research have historically focused on knowledge and glycemic control (A1C), 43 , 44 researchers and clinicians generally agree that DSME should be integrated across multiple intervention strategies and encompass behavioral approaches to improve self-management outcomes. 44 Also, several RCTs have demonstrated the value of blood pressure and other outcome variables. In addition, the outcomes of disease management, case management, and/or multisystem approaches to diabetes interventions are more often physiologic measures, as evidenced in Table 2 .

The reviews identified few studies focusing on African Americans, particularly older African Americans. For example, in a review of self-care interventions designed to improve glycemic control or QOL in older, African American, or Latino adults, only 1 study among African Americans (n = 39) examined QOL. 29

Discussion and Recommendations

Several key observations emerged from this review of reviews. Statements about the “state of sciences” are enormously challenging as the reviews demonstrate great heterogeneity in terms of intervention type, content, participants, and outcome measures. The language used to describe interventions varies, and diverse disciplines were involved in the delivery of sometimes complex interventions. The limited description of intervention and content included in these approaches limits the possibility of replication and necessitates cautious comparison between studies. Although a diabetes intervention taxonomy 45 is suggested and sometimes used 28 , 46 to systematically describe the components of interventions, intervention heterogeneity remains commonplace in the current literature, making it difficult to compare results. Thus, researchers and educators should seriously consider opportunities to uniformly categorize interventions, at least for descriptive purposes.

With respect to the operational definition of outcome categories, 6 clearly the most frequently used clinical improvement (postintermediate) outcome measured was A1C, and the least measured were health status improvement and QOL (long-term) outcome measures. 10 , 16 , 47 , 48 Review articles reported limited information about instruments used in the included studies. Where available, identified QOL instruments have been included in Table 2 . Overall, the most frequently cited instruments were the SF-36 49 and DQOL 50 to measure general and diabetes-specific QOL, respectively. Moreover, when considering key outcomes for studies, in addition to including physiological outcomes, additional patientreported outcomes should be considered. Addressing the importance of patients’ perceptions of the effects of chronic illness and its treatment has the potential to significantly improve overall DM management. 51 Noted researchers 32 emphasized the exclusion of outcomes such as QOL as a limitation. As telling, having looked at only A1C, other review authors 28 suggest their work would have been enhanced with the inclusion of behavioral outcomes. Given the complexity of factors at many levels, which can affect processes, impact, and outcomes of care, investigators and clinicians should mindfully seek clarity in operational definitions and in better understanding the relationships of the various factors.

Interventions tailored toward high-risk populations, such as African Americans or the aged, or those with limited literacy skills have been emphasized, yet cultural relevance, literacy, and age-related concerns of interventions have been neglected in the current literature. Although several review authors 31 - 33 , 46 suggest sociocultural context as an important indicator, only 3 of 12 review articles were solely dedicated to such areas. For example, Sarkisian et al 29 was the only review specifically focused on older high-risk racial and ethnic groups, whereas Eakin et al 33 and Glazier et al 46 defined their populations of interest as low socioeconomic status (SES) or socially disadvantaged ethnic and racial adults.

The broader behavioral literature regarding tailoring of interventions must describe the lessons learned. Complete and accurate descriptions of interventions will encourage further analysis and determine interventions’ effectiveness, structure, process, and outcomes. Although attempts have been made to characterize interventions 28 , 33 , 46 and employ meta-analysis, 28 , 31 , 32 incomplete study descriptions and variations in content and components continue to hamper comparability. There is an urgent need to provide and document well-designed studies, systematically describing components. More important, presenting adequate information for assessments regarding study quality and broader comparability can advance the science and care of diabetes.

There are several limitations to this review of reviews. The authors were able to evaluate only what was reported, not what may in fact have been done. Together with the methodological strengths and weaknesses of the included studies, limitations of the reviews must also be considered. Finally, the search strategy and inclusion criteria for the current review may be perceived as too narrow, given that only published studies in English-language journals were selected. It is acknowledged that journal space limits what may be included in articles. Unfortunately, descriptions of intervention research fail to provide evidence of culturally tailored interventions. Also, literacy, which is known to affect care and outcomes, has not been adequately addressed. Very few studies included and/or focused on African Americans; thus, enormous gaps related to racial and ethnic groups in the literature remain.

In conclusion, this review of reviews of intervention studies shows that effects on long-term health and quality-of-life outcomes have not been adequately assessed in the current literature. 30 , 34 , 35 Previous reviews 26 , 52 provide evidence that patient-assessed health status differs from those proxy assessments made by health professionals. Although several important conceptual frameworks 13 , 53 - 55 and proponents have confirmed the relevance of HRQOL as an outcome capable of affecting the effectiveness of interventions and utilization behavior, the available evidence fails to actualize HRQOL as a priority targeted outcome. Research is needed to assess long-term outcomes, such as HRQOL and its impact on specific components of interventions, particularly among diverse populations. Other researchers 10 , 16 , 47 , 48 suggest that the initial priority should be on evaluating and refining existing HRQOL instruments. Our review confirms minimal to no testing in certain high-risk groups ( Table 2 ). The need for disease-specific instruments, specifically validated in African Americans, becomes particularly evident in this context. Both qualitative and quantitative methods can and should be used to assess and refine existing instruments, as well as in using population-specific validated instruments to measure outcomes of clearly articulated and described interventions.

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Literature Review: Diabetes, Inflammation and Obesity

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    National Center for Biotechnology Information

  17. Literature Reviews and Synthesis Tools

    2. Scope the Literature. A "scoping search" investigates the breadth and/or depth of the initial question or may identify a gap in the literature. Eligible studies may be located by searching in: Background sources (books, POC tools) Article databases; Trial registries; Grey literature; Cited reference searching; Reference lists


  19. Literature Review: Diabetes, Inflammation and Obesity

    Islet cell autoantibodies, antibodies to insulin, antibodies to glutamic acid decarboxylase (GAD 65) and antibodies to the tyrosine phosphatases, IA-2 and IA-2β are markers for the immune destruction of the pancreatic β-cells. About 5-10% cases of diabetes are that of type 1 diabetes.