evidence-based practice project paper - alicia nix, …...evidence based project. this is a level...

Running head: EVIDENCE-BASED PRACTICE PROJECT PAPER 1

Reducing Insulin Levels and Type Two Diabetes in Children and Adolescents

Evidence-Based Practice Project Paper

Alicia Nix

Auburn University

EVIDENCE-BASED PRACTICE PROJECT PAPER 2

Evidence-Based Practice Project Paper

Abstract

This paper looks at an evidence based project to reduce insulin levels in type 2 diabetes

among children and adolescents. Type 2 diabetes is a potentially devastating disease that is on

the rise among youth. Identifying this potential progression of disease in insulin resistance

youth enables intervention before the development of type 2 diabetes. This paper explores the

best related evidence in lowering insulin resistance. The most recent literature regarding insulin

resistance and adolescent was obtained and applied. For this project, the Iowa model was

implemented as a framework to guide us to the best evidence based practice. In researching for

this project the evidence narrows on three possible interventions. A healthy diet is shown to

lower insulin levels. Exercise lowers the body’s need for insulin thus lowering insulin resistance.

Although not recognized as acceptable treatment, Pharmacological intervention is also shown to

lowering insulin resistance. For this purpose of this project, we chose to focus on reducing the

insulin levels by implementing moderate 30 minutes of exercise daily. This was a grade one

recommendation. This small test of change was conducted on adolescents with elevated insulin

levels at a privately owned pediatric practice in North Alabama. . The participants signed consent

forms and 14 adolescents with elevated insulin levels were instructed and educated on daily

moderate exercise. They were contacted weekly to provide support and education. At the end of

6 weeks, they returned for a recheck on their BMI and insulin levels .Based on the outcomes of

this project, the average insulin level and BMI were reduced. Based on the outcomes, Tennessee


Valley Pediatrics adapted their recommendations for the insulin resistant adolescent to include

the evidence based recommendation of daily moderate activity. This protocol change will greatly

benefit the insulin resistant adolescent in this practice.

Introduction

Insulin resistance is the leading cause of diabetes. Diabetes is the sixth leading cause of

death according to the CDC (2012). Type 2 diabetes is on the rise among children and

adolescents. An article regarding obesity and cardiovascular risk factors in children and

adolescents. (2008) advises on the growing number of obese adolescents. The author

notes that according to the National Center for Health Statistics, the percentage of

overweight and obese children and adolescents in the year 2000 was 15%. This figure

has quadrupled from 1963 to 1970 when the percentage was 4% in children 6 to 11 years

old and 5% in adolescents 12 to 19 years old. The article also states that up to 80% are

still obese in adulthood. This is a staggering statistic that is concerning in that obesity

frequently leads to type 2 diabetes. This is in part due to the increasing BMI among the

adolescent population. In fact two million children ages 12-19 years of age in the United States

have pre-diabetes. The alarming thing is that this is a preventable disease. If caught early type 2

diabetes is reversible (Scott, 2013). Another staggering statistic is that type diabetics are

suspected of having impaired glucose tolerance for 7-10 years prior to diagnosis (Scott, 2013, p.

190). One important fact regarding this subject is if insulin resistance is diagnosed, there is

currently no recognized treatment for children (Quinn, Baur, Garnett, & Cowell, 2010, p. 722).

There are many factors that can influence insulin resistance. Children with elevated BMI are

at risk for the development of insulin resistance (Simmons, Alexander, Ewing, & Whetzel 2012

para. 1). Unfortunately, there is an increase in BMI among the adolescent population. If


adolescents are identified with elevated BMI’s, measures can be taken to reduce the BMI. This

intervention can either prevent diabetes or reduce insulin levels. According to the Center for

Disease control 17% of children age 2-19 year olds are above the 95th

percentile for weight

(2012). This project will explore reducing BMI with diet and exercise. For this project, the main

focus will be on children and adolescents who have elevated insulin levels to develop a treatment

plan to lower insulin levels based on the best evidence.

Exercise is an intervention that can lower insulin levels. Exercise has been proven to lower

the bodies need for insulin. Studies have shown that even exercising 30 minute a day can lower

blood sugar significantly (Farias, 2012). Most children and adolescents do not get enough

exercise therefore the body’s need for insulin may increase. In this project, educating the patient

on exercise as a way of lowering the bodies’ requirement for insulin will be explored as one

option. This will also help develop healthy lifestyles changes that may continue into adulthood.

Diet is another factor that contributes to insulin resistance in children and adolescents. Many

take in more calories than their body uses. Adolescents as a group do not make the best food

choices. Health disparity may play a role in this issue. Healthy food is more expensive than fast

food ( Niklas, 2008). If a family is on a limited budget, they may not be able to afford healthy

foods. Habits and potential causes will need to be identified and educated accordingly. Many

times this can be something that the entire family needs to have addressed. After identifying

ways to reduce insulin levels, the project focuses on education of those concepts. The children

and adolescent patient needs to understand the ramifications of the disease. The parents will also

need education regarding diabetes.

PICO Question:


In patients under age 18 that have elevated insulin levels, what evidence-based interventions

most affect insulin levels and future risk of type 2 diabetes?

P-The population of focus is children or adolescents who had their insulin level checked due to

obesity or elevated BMI.

I-“evidence-based dietary changes, education and daily exercise” The intervention in this

population will come from evidence-based interventions for dietary changes and exercise. It will

also instruct the patient on information regarding the possible progression of insulin resistance.

C- “Compared to routine care” The current office-based instruction.

O-“lowering insulin levels and BMI” The desired outcome measurement is a lowered insulin

level and BMI. .

Framework

The Iowa Model Characteristics

The Iowa model was chosen to help implement strategies and guide development on the

entire project. After identifying the problem, the first step in the Iowa model is to examine the

research evidence. After researching the the evidence, the Iowa model recommends combining


the evidence found along with past clinical experiences with assessment of the setting. This

allows the researcher to then set a goal based on the evidence found. This also determines

whether there is enough evidence needed to implement a practice change. The Iowa model

recommends implementing the test of change and to set a timeline to evaluate data.

In identifying the problem, labs from insulin resistant patients are easily recognized. In

searching data bases related to obesity and insulin resistance in teenagers, the research does

support a correlation between the two. The Iowa model looks at education deficits and solving

the problem at hand. Insulin resistance is often due to lack of education on the subject. It also

walks the Practitioner through the steps of the evidence-based process (Melnyk & Finout-

Overholt, 2005, p. 254). With the Iowa model, being able to reevaluate the BMI of the patient as

well as recheck their insulin level will tell us if the change is appropriate. This model will

provide the steps necessary to implement a practice change (Melnyk & Finout-Overholt, 2005).

The Iowa model has proven to be effective in a variety of settings. The Iowa model’s application

results are also consistent even when the user has little experience (Schaffer, Sandau, &Diedrik,

2012).

Iowa Model Rationale

In looking at the PICO question “In patients under age 18 that have elevated insulin levels,

what evidence-based interventions most affect insulin levels and future risk of type 2 diabetes?”

The Iowa model will question whether insulin resistance is an area of concern for a practice. A

large part of the intervention for this project is educating on diet and exercise. . The Iowa model

focuses on educational deficits. With the Iowa model, being able to reevaluate the BMI of the


patient as well as recheck their insulin level will tell us if the change is appropriate. This model

will provide the steps necessary to implement a change (Melnyk & Fineout-Overholt, 2005). The

focus by the Iowa model on education is ideal in this particular EBP project.

Review of literature

In reviewing the Literature, an extensive search was conducted looking through Auburn

University Library. CINAHL, EBSCO and The Cochrane data bases were used. Also The

American Academy of Pediatrics website provided additional articles related to this paper. The

search terms that were used consisted of: obesity, diabetes, insulin resistance, and adolescents.

CINAHL and The American Academy of Pediatrics provided the bulk of the articles. In

searching the AAP website, 10 articles were obtained by searching “insulin resistance” The first

article is a systematic review by Quinn, Baur, Garnett, and Cowell (2010). This study looked at

five electronic databases in search of randomized trial that lasted over two months. The study

looked at using metformin alone or with lifestyle changes. This systematic review and meta-

analysis results show that Metformin along with lifestyle changes has lowering outcome on BMI

and fasting insulin. This is true in looking at children and adolescents with insulin resistance or

diabetes. With this article dealing with specific treatment of insulin resistance, this relates to the

evidence based project. This is a level one article.

A meta-analysis by Fedewa, Gist, Evans, Dishman (2013) concluded that exercise reduces

insulin resistance in children and adolescents. This randomized trial included children and

adolescents in the trial from 546 sources. One interesting fact regarding this study is that dietary

changes along with exercise were excluded from this study. This provides more concrete


evidence on the effects of exercise on insulin resistance. It is also important to note that this

study involved all genders and races. Incorporating exercise into adolescents and children who

are either at risk or have insulin resistance was shown to have a small to moderate effect on

lowering insulin levels. This meta-analysis is relevant to this project and is a level 1 article.

An RCT by Davis. Pollock, Waller, Allison, Dennis, Gowler (2012) looked at the effects of

exercise on visceral fat and insulin resistance. This study took place in Georgia and included

counties near Augusta. The participants included in the study were adolescents who had an

elevated BMI and reported a sedentary lifestyle. The span of this study was four years. This was

a large study with 222 participants. The participants were assigned to either a 20 or a 40 minute

per day exercise regimen. After 13 weeks insulin levels and BMI were obtained. At the end of

13 weeks results showed that both groups had a lowered fasting insulin level as well as visceral

fat. This was without any dietary restrictions. This article is a level one article.

In a 12 week quasi-experimental study Monzavi, Dreimane, ,Geffner, Braun, Conrad,

Klier, Kaufman (2006) 109 adolescents that had been referred to weight management and also

had insulin resistance were invited to participate in a 12 week program. The program involved

education from a dietitian once a week on healthy eating. The program also involved

participating for 90 minutes of physical activity per week. Although not statistically significant,

there was a reduction in insulin levels in the participants. This is a level two article.

An article discussing obesity and glucose levels Lee, Yoo, Kim, Lee, Kim, Lim, Yang

(2011) focuses on connecting the relationship between the two. The purpose of this study was to

to compare the fasting serum proinsulin levels of children with normal BMI to prepubertal

overweight or obese children. This is a correlational study. A total of 109 prepubertal children


(mean age, 8.6 years) were included in this study. The data suggested that obesity itself or insulin

resistance may independently cause fasting hyperproinsulinemia in proportion to

hyperinsulinemia in children. This result was with children that had normal glucose tolerance but

had insulin resistance. Since the project is lowering insulin resistance levels and decreasing the

incidence in development of type 2 diabetes, it is important to understand the relationship

between elevated pro insulin levels and the development of insulin resistance. This is a level IV

evidence article It is supported by other articles and therefore is relevant the project.

The key component to this EBP project is reducing insulin resistance. In an article by

Sumanmo, Schellenberg, Dryden, Vandermeer Ha, Korowynk (2014) insulin resistance and

physical activities are examined. This article provides evidence regarding how much exercise is

needed to reduce insulin levels. The purpose of this recommendation is to provide a guideline for

physical activity in children and adolescent children. These guidelines sets a precedence in the

amount of physical activity needed to help prevent type two diabetes and insulin resistance. This

is a critical guideline review. The guideline is providing a recommendation for physical activity

which is a goal of my EBP. This is an acceptable screening tool that could be used in my EBP

project. This is a level 1 article.

A cross-sectional design by Oftedal, Bru, Bjorg (2011) supports that diet and exercise

habits can improve with education. This article examines type 2 diabetes and how exercise and

diet expectations relate to the behaviors developed. This study included a postal questionnaire

that investigated diet and exercise management. This questionnaire also looked at other factors of

motivation including expectations of lab values. A sample comprising 425 adults with type two

diabetes aged between 30 and 70 completed the questionnaire. The results suggest that the

subjects had a high level of expectation of being able to follow the diet and exercise


recommendation. It should be noted that the participants followed diet recommendations to a

greater extent than those pertaining to physical activity. The results showed that with education

subjects are motivated to improve their diet and exercise habits. This article relates to the EBP

project in that education as a factor in reducing insulin resistance. This article helps prove that

with education on the disease most subjects want to make better lifestyle choices. This is a level

IV article.

Multiple articles show a connection between type two diabetes, diet and exercise. A meta-

analysis and systematic review Sumanmo, Schellenberg, Dryden, Vandermeer, Ha, Korowynk

(2014) is a level one article that provide this evidence. Five data bases were pooled together for

the data given. The study included nine randomized controlled trials. This study show diet and

exercise can have a real impact on the prevention of type 2 diabetes demonstrating a change in

metabolic risk factors and abnormal glucose levels. The duration of the interventions ranged

from 6 to 72 months, with follow-ups between 3 and 20 years. The lifestyle interventions

included diet and exercise. The subjects also received individual and group counseling. The

studies reported positive outcomes. Most studies reported positive effects for secondary

outcomes, including changes in body composition, metabolic variables, physical activity, and

dietary intake. This is relevant to my EBP project.

Critical Appraisal of Evidence

Quality

The evidence from guidelines, meta-analysis, RCT’s and systematic reviews provide

significant evidence and relevance for my topic of lowering insulin resistance and prevention of


type two diabetes in children and adolescents. In evaluating the use of Metformin daily on

children and adolescents with insulin resistance, we see two systematic reviews that support this

recommendation. Two systematic reviews Quinn et al. (2010) and Sumanmo et al. (2014)

support the use of Metformin to lower insulin resistance. Both of these articles provide level one

evidence. They also have supportive data relating to diet and exercise. Diet and exercise were

shown to decrease in insulin resistance and diabetes. The articles give a clinical recommendation

of engaging in daily exercise and health eating habits to lower insulin levels. The evidence in

these articles provides information that strongly suggests a correlation between diet, exercise and

pharmacological management and the treatment and prevention of insulin resistance. Both of the

above studies involved prescribing medications and lifestyles changes. The studies are clearly

stated and contain strong evidences. The possible concern of Quinn et al. (2010) is the relatively

small sample size. Another concern with Sumanmo et al. (2014) is that this study focused on

measures such a weight change and blood pressure to measure positive outcomes. There was

limited study bias in that both reviews contained a meta-analysis.

Two articles show strong evidence for the use of exercise alone. The first was a meta-

anaylsis by Fedewa et al. (2010) that provides sufficient evidence that exercise and physical

activity produces the desired result. Resistance training and aerobic exercise provided the same

outcomes of lowered insulin levels. This article combined peer-reviewed research that ranged

from 1999-2013. The second article that provided recent quality evidence regarding exercise was

a randomized controlled trial by Davis et al. (2013). In this RCT conducted from 2003-2007

physical activity of 20-40 minutes per day decreased insulin resistance in adolescents. This was

consistent regardless of race or sex.


Quantity

In researching insulin resistance in adolescents, eight quality articles provided consistent

evidence regarding what factors provide the best evidence to lower insulin resistance. Many of

the articles overlapped in terms of recommending the three components of exercise, diet, and

pharmacological intervention. While three articles focused on diet alone. Two levels I articles

provide sufficient evidence to feel confident in making the recommendation regarding exercise.

Many of the articles provided large samples sizes which added validity to the project. The

timeframe that was reviewed varied from 6 months to a 13 year follow up.

One study showed a correlation between insulin resistance and obesity. (Lee, 2011) This

study compared fasting insulin levels in lean, overweight and obese children.

Metformin with dietary changes were shown to lower insulin sensitivity in a study by Quinn et

al. (2010). In Monzavi et al. (2006) the quasi-experimental looked at family oriented lifestyle

changes such as exercise and dietary changes to reduces insulin levels in youth. Another study

that states the benefits of diet and exercise to reduce insulin levels is Oftedal et al. (2011)

In Fedewa et al. (2013) exercise was the focus of reducing insulin resistance. The physical

activity duration ranged from 30 minutes to 90 minutes. This was based on 2-4 times weekly.

This study ranged from 6-52 weeks. An RCT by Davis et al (2012) also showed that exercise

reduces the insulin resistance in obese children and adolescents. A clinical guidelines regarding

recommendation of exercise provided expert advice in the prevention of type 2 diabetes (2000).

Another article showed that exercise and dietary changes slows the progression of type 2

diabetes Sumanmo et al. (2013).


Consistency

The collective and combined results span over 10 years of study. The RCT’s, Systematic

reviews and Meta-analysis that are included in the both level one study provide sufficient

evidence. This ensures that multiple sources yield the same results on this subject. These studies

were conducted by Medical doctors, nurse educators, and nurses with doctorates. The common

thread among the studies was that insulin dependence and diabetes can be prevented. The

evidence shows that type 2 diabetes can be prevented. Also adolescents with elevated insulin

levels can take steps to lower them. The evidence shows that exercise will reduce insulin levels

in adolescents. The evidence also supports exercise with conjunction of diet and pharmacological

measures.

Summary of Evidence

The strongest points of the appraisal of the literature suggest that medications, education, diet,

and exercise can lower insulin levels. This project will implicate a plan based on the evidence

collected to implement changes in this population .Through these recommendations we will

strive to have the outcome of a decrease insulin level. This project will also promote healthy

lifestyle changes that will carry throughout the lifespan.

Recommendations

From the review of literature and critical appraisal of the level I and level II evidence

contained in Appendix A, key recommendations are graded. The recommendations from the

critical appraisal in Table 1 provide a synthesis of the best evidence to develop the EBP practice


change. The clinical question intervention element can be further developed into the practice

setting for testing based on the recommendations.

Table 1

Recommendations from Critical Appraisal

PICO QUESTION: In patients under age 18 that has elevated insulin levels, what evidence-

based interventions most affect insulin levels and future risk of type 2 diabetes?

Grade Recommendations

A Engage in daily exercise at least 30 minutes to lower insulin levels:

Participate in 30 minutes of moderate activity daily

. Evidence Level 1

Davis,C.L., Pollock,N.K., Waller,J.L., Allison, J.D., Dennis, B.A.,....Gowler,


B.A.(September, 2012) Exercise dose and diabetes risk in obese children; A

randomized trial JAMA (308)1103-1121 Retrieved from

https://www.academia.edu/1853577

Evidence Level 1

Fedewa, M.V., Gist, N. H., Evans, E.M., Dishman, R. K. (2013) Exercise and insulin

resistance in youth: A meta-analysis. Pediatrics Official Journal of the American

Academy of Pediatrics 133 (1) 163-173 doi: 10.1542/peds.2013-2718

(Evidence Level I)

Sumanmo,E.,Schellenberg,B.S, Dryden,D.,Vandermeer,M.S., Ha,C.,

Korowynk,C.(2014) Lifestyle interventions for patients with and at risk for type 2

diabetes. Annals of Internal Medicine 159 (8) 543-551 doi: 2013;159:543-551.

A Begin adolescents and children with elevated insulin levels on the drug Metformin

500 mg twice daily.

Ensure the patient understands the dosage, side effects, frequency, purpose and

possible interaction.

.(Evidence Level I) Quinn, S. M., Baur, L. A., Garnett, S. P., & Cowell, C. T. (2010,

October). Treatment of clinical insulin resistance in children: a systematic

review [article]. Obesity Reviews: An Official Journal Of The International

Association For The study Of Obesity, 11(10), 722-730.

http://dx.doi.org/10.1111/j.1467-789X.2009.00697.x

(Evidence Level I)Sumanmo,E.,Schellenberg,B.S, Dryden,D.,Vandermeer,M.S.,

Ha,C., Korowynk,C.(2014) Lifestyle interventions for patients with and at risk for


type 2 diabetes. Annals of Internal Medicine 159 (8) 543-551 doi: 2013;159:543-551

A Increase fruits and vegetables and to decrease the sugar intake (Evidence Level I)

Sumanmo,E.,Schellenberg,B.S, Dryden,D.,Vandermeer,M.S., Ha,C.,

Korowynk,C.(2014) Lifestyle interventions for patients with and at risk for type 2

diabetes. Annals of Internal Medicine 159 (8) 543-551 doi: 2013;159:543-551.

Clinical Setting Assessment

This is a large pediatric practice that serves patients ranging from birth to college age. The

practice is made of of three pediatricians and four nurse practitioners. Three of the practitioners

are family nurse practitioners, while the fourth is a pediatric nurse practitioner. The practice is

made of a diverse range of patients. Approximately forty percent have private insurance. The

remaining sixty percent have Alabama Medicaid. Every social class is represented. The practice

is multi-racial with Caucasian, Hispanic, African-Americans, Indians and Asian Americans. The

practice has around 10,000 active patients. The practice sees about 150 patients per day. Of this

number, approximately 30 patients per day are adolescents. This leads to the conservative

number of around 7000 adolescents seen and treated per year.


This project focuses on the treatment of insulin resistance and obesity in hopes of changing

lifestyles and preventing type 2 diabetes. This is an area of concern in this pediatric practice.

There is a mutual consensus by all providers that obesity and insulin resistance has become an

epidemic among their patients. The challenges in treatment at this clinic occur after the initial

visit. After identifying insulin resistance in lab results, the child’s caretaker is called one time

and educated regarding treatment and follows up. The fast pace nature of the office hinders the

providers from giving more education and making sure that the patient comes back in for follow

up. Also, the practice does not have a policy in place of speaking to the actual patient.

The administrator of the office states that the providers always speak to the caregiver regarding

education. Another concern is related to the follow up appt. Even though the office has a call

back system for follow ups appointment, the providers usually verbally tell the caregiver to call

back and schedule. This leaves the office with no way to ensure an appointment is ever made.

There are some potential barriers identified by the staff. Even though education is needed for

both the patient and the caretaker, families may want to convey the education to their children.

Also, many of their patients are difficult to reach. Another possible barrier is the unwillingness to

change lifestyles in a large portion of their patients. The plan itself will not cost the practice.

However, if this plan is successful they anticipate needing an RN to spend approximately two

hours per week calling patients and making follow up appointments. At the current rate that their

nurses are compensated this would add around 2,600 dollars to their yearly budget. The

administration states that the only required approval for this project would be a signed HIPPA

agreement.


Implementation Plan

Two million children age 12 to 19 years in the United States have pre-diabetes. (Scott, 2013,

p. 190) According to the American Diabetes Association, diabetes is the 6th leading cause of

death. Another staggering statistic is that type 2 diabetics are suspected of having impaired

glucose tolerance for 7-10 years prior to diagnosis. (Scott, 2013, p. 190). That statistic includes

many adolescents. Another concern for the adolescent population is treatment if it does progress.

There is currently no recognized treatment for pre-diabetes in children. (Quinn, Baur, Garnett, &

Cowell, 2010, p. 722). Tennessee Valley Pediatrics is a large privately owned pediatric practice

in North Alabama. The facility has around 8000 active patients ranging in age from newborn to

18 years. Having worked in pediatrics for 18 years, I am alarmed at the increasing number of

insulin resistance. Implementing a program that focused on educating patients on insulin

resistance and type two diabetes could greatly impact the patients. This change could become a

lifestyle change that can continue throughout adulthood.

At well check ups and sick visits patients with elevated BMI’s will be identified as potentially

at risk for insulin resistance. Every patient’s weight and height is obtained at each visit. The EHR

system at the facility automatically calculates the BMI which makes identifying the patients

simple. A weekly email will be sent to remind providers and nurses to help identify patients at

risk for insulin resistance. Providers seeing the patient will discuss their concern for potential

insulin resistance. A good rapport with the patient will be essential for this stage of the process.

This group will then have insulin levels drawn to access their risk.

Patients with elevated insulin levels will contacted regarding their results. This will occur

after the provider has reviewed the labs. The telephone triage RNs will be responsible for making


contact with the patient. This will require approximately one hour of extra work per week for

these nurses. This also increases their pay by 400 dollars per month for a total cost of 4800

dollars per year. Patients unable to be contacted by phone will be mailed a letter to contact the

office .Initially, they will be educated on the potential progression of insulin resistance. They

will be advised that insulin resistance can lead to type two diabetes. Patients will be told that

insulin resistance is thought to be caused from the insulin’s inability to regulate sugar. They will

further be educated on the evidence-based discovery that dietary changes, exercise and

supportive medications can help lower insulin resistance. The target population consists of three

evidence based choices. . The group will be advised to engage in moderate physical activity for

at least 30 minutes per day. Another intervention is dietary changes. Reducing sugar intake

along with increasing fruits and vegetables will be the recommended dietary change. This is in

contrast to the current recommendations by the facility which were to decrease greasy foods and

lower caloric intake. Also, fruits and vegetables typically cost more than other food.

There are potential barriers for this plan. Many families do not come in for regular well visits.

This would make it vital to identify these patients at sick visits. Another barrier is that when we

are addressing adolescents, their parents must be on board with the recommendations. The

parents must be willing to not only encourage but also bring the patient back in for follow up

Weather conditions can be another factor when you are recommending exercise.

The next step in the EBP process involves continuing education and encouragement of the

patient. Weekly the patient and caregiver will be contacted. This will also be implemented by the

telephone triage nurses. They will answer any questions that the patient has regarding diet and

exercise. Having supportive nurses that develop a relationship and essentially become

“cheerleaders” to this group will be vital in the outcome of this project. Hard to reach patients


may cause more time than allotted for the EBP project. Initially, it will be important to make

sure we have good contact information for the patient.

Once a month the patient will return to the office to recheck their weight and BMI. This will

give the provider a chance to assess their progress. A potential barrier is that some insurance may

not cover frequent rechecks. Also, two months after the first lab draw the patient will come back

into the office for a recheck. The telephone triage nurses will need to schedule this appointment.

The office does have an automated system that will remind the patient of their appointment.

Potentially, some patients may be hard to contact or may not come for a follow up visit. Patients

that feel they might have a poor outcome may be reluctant to follow up. At this visit their weight,

height and a BMI will be taking upon arrival and before they are examined by the provider. The

provider will examine the patient and order an insulin level. They will also be available to

answer any questions or concerns regarding their disease process. Patients will be questioned

regarding their dietary changes and their eating habits. Additional education will be provided if

needed. Although the insulin levels will not be readily available, this visit will provide either

positive or negative clinical information. A decrease in BMI and weight would be a positive

finding and encouraging for the patient. This will be presented on a flow chart through the EHR

system.

The insulin level will take approximately 24 hours to result. The providers will review the

labs and give recommendations to the nurse. The telephone triage nurse will then contact the

patient and specifically discuss their progress if the results are favorable. Patients who have no

change or an increase in insulin level will also be contacted. Patients with decreased insulin

levels will be encouraged to continue their current regimen. They will continue to be followed

for an additional 5 months for the EBP project. Patient’s that have the same or an increase in


insulin levels will be interviewed by the telephone triage nurses to identify potential problems in

the implementation of the recommendations. Further education will be provided and they will

also be followed for an additional 5 months.

An evaluation plan will be needed to determine the success of the EBP project. A long term

goals would be to successfully develop a protocol at this facility for insulin resistant teens. This

plan aims to establish this protocol for anyone that either has insulin resistance or is at risk for

insulin resistance. The long term goal that is imperative for the implementation of this protocol

is the decrease in insulin resistance among the test patients. Another long term goal would be a

decrease in insulin levels on the patients that are in the project. There are several short term goals

for this plan. One short term goal would be to successfully educate the patient and the parent on

the insulin resistance. It is important to have the patient and the caregiver working together to

obtain the same outcome. Another short term goal would be the weight loss or a drop in BMI at

their monthly visit. Yet another goal would be the patient reporting that their attitude regarding

exercise had improved since the beginning of the project.

Several tools will be used to measure outcomes. Interviewing the patient to discuss their

current eating habits and exercise habits will add subjective data. Height and weight will be

measured and graphed on a growth chart provided by the AAP. BMI will be recorded on a BMI

calculator. The insulin level requires venous access. Insulin levels greater than 24mcu/ml will be

reported as elevated by the lab.

Providers will identify patients that are at risk for elevated insulin levels. The provider will

obtain the baseline labs, weight and BMI at the initial visit. Upon receiving labs that confirm that

the patient has insulin resistance, the provider will notify the RNs and the patient. The EBP

project manager will be contacted and given the demographic information regarding the patient.


Patients that are selected for the small test of change will be monitored weekly and rechecked in

the office monthly. Data will be collected by reviewing the EHR record. Another important

factor in monitoring the data is the ability to track the patient’s progress. The EHR system in

place allows the facility to search patients based on diagnosis only. Patients who have had the

diagnosis of insulin resistance will be printed to provide a list of patients that need intervention.

Phone calls to the telephone triage nurse will be made weekly to evaluate the progress of the

EBP project. Also, the facility will be able to contact the EBP project manager during the

process. The EBP project manager will also be available to assist in any step of the process.

Small Test of Change

After looking at all the evidence provided from research, one area was chosen to implement.

The recommendation of 30 minutes of moderate exercise was selected for my small test of

change. The IRB was submitted and approved through Auburn University This involved

recruiting adolescents that already had elevated insulin levels. The office was able to run a

report based on the diagnosis of obesity and insulin resistance. This was very helpful in that it

provided a list of potential adolescents with insulin resistance. Patients with current insulin

resistance were brought into the office for a recheck. They had their weight and height taken to

calculate. Their BMI was recorded. Out of 29 patients scheduled, 22 signed consent for the

small test of change. Patients that consented were told to use a fitness app such as my fitness pal

to keep track of their activity. Patients were given suggestion of exercise from the American

Academy of Pediatrics. Patients and their parents were told to incorporate moderate daily

exercise of 30 minutes daily. This was in addition to dietary changes which were previously

recommended during their initial visit. We contacted the patient and or parent weekly to provide


encouragement and answer any arising questions. At the end of 6 weeks they were brought back

into the office for a recheck on their BMI and insulin levels

Financially, the small test of change total is currently unknown. Initially the cost to the

practice was the cost of paying a registered nurse for two extra hours weekly. However, it is yet

to be known how often insurances will pay for insulin levels to be rechecked. Another concern is

the office recheck. How often is acceptable to recheck and manage patients with insulin

resistance? Currently, the practice was only rechecking these patients yearly. It is yet to be

determined if these visits will be covered under insurance.

While performing the small test of change, some participants did not complete the process

Only 14 actually returned to the office for their recheck. This was 8 males and 5 females. Also

there were 8 Caucasian and 5 African Americans. The mean age was 14.71. In measuring the

short term goals, patients were measured on their receptiveness to being educated. Short term,

successfully making weekly contact provides another short term goal. The return visit provided

objective ways of measuring the success of the small test of change. The patient came in to the

office and met with a provider. There they had their height and weight calculated to measure

their BMI. An insulin level was also redrawn. This provided the answers to the effectiveness of

the small test of change. The measuring tool was did they have a 15 percent reduction on their

insulin level.


Results

Category 1 grey Pre BMI

Category 1 orange post BMI

Category 3 grey Pre Insulin

Category 2 orange Post Insulin


After calculating the information collected using SPSS, we found the following results. The

mean BMI dropped from 39.29 down to 37.93. The mean insulin level changed from a 34.21 pre

small test of change to 30.64. Although the results were not statistically significant, we do see a

trend that moderate exercise does lower BMI and insulin resistance. The owner and providers in

this pediatric practice feel this is a worthwhile recommendation and in the future will

recommend daily moderate exercise to their current recommendations.

Application in Overall Project

During this process I learned that it is difficult for one person to manage the project. In the

future, it would be easier if each nurse was responsible for their provider’s patients that had

insulin resistance. This would prevent frustration and time concerns. The process was too short

in length; ideally the change should be evaluated after 4-6 months to see any major changes. This

might also increase the likeliness of insurances covering the visit. I learned that adolescents also

do not like talking on the phone. In the future, a simple reminder text might be a better idea for

this age group. This project also reiterated that education can and does make a difference. In

applying this project in the future, I would include more education in the initial visit. This

education should include the disease process diabetes and potential complications that arise from

being a diabetic.

Conclusions


In concluding this small test of change, it is evident that this project did provide future skills

for an advanced practice nurse. Understanding and being able to conduct sound research on

topics is a valuable skill for an advanced practice nurse. The importance of distinguishing the

difference in the level of evidence is crucial to health care providers. Presenting this small test of

change promotes confidence and independence. The discovery of reducing insulin resistance in

adolescents is a worthy topic that will continue to be visited. As an advanced practice nurse with

plans to work in a pediatric setting that my small test of change was conducted will provide

insight as one change roles from an RN to a nurse practitioner.


References

CDC provides national estimates, general information on diabetes. (2012).chart10(4)5-8

retrieved from http://www.cdc.gov.

Clinical practice guidelines: Physical fitness and activity in schools. [Journal]. (2000).

Pediatrics, The Official Journal of the American Academy of Pediatrics, (105), 1156. doi:

10.1542/peds.105.5.1156

Davis,C.L., Pollock,N.K., Waller,J.L., Allison, J.D., Dennis, B.A.,....Gowler, B.A.(September,

2012) Exercise dose and diabetes risk in obese children; A randomized trial JAMA

(308)1103-1121 Retrieved from https://www.academia.edu/1853577

Evaluating obesity and cardiovascular risk factors in children and adolescents. (2008).

Retrieved June 10, 2014, from

https://www.pediatriccareonline.org/pco/ub/view/Bright-

Futures/135046/0/Adolescence_11_to_21_Years?amod=aapea&login=true&nfstatus

Farias, J. M. (2012, October 10th). Exercise training performed simultaneously to a high-fat diet

reduces the degree of insulin resistance and improves adipoR1-2/APPL1 protein levels in

mice. [Article]. Lipids in Health and Disease, 11, 34. http://dx.doi.org/10.1186/1476-

511X-11-134


Fedewa, M.V., Gist, N. H., Evans, E.M., Dishman, R. K. (2013) Exercise and insulin resistance

in youth: A meta-analysis. Pediatrics Official Journal of the American Academy of

Pediatrics 133 (1) 163-173 doi: 10.1542/peds.2013-2718

Garnett, S. P., Baur, L. A., Noakes, M., Steinbeck, K., Woodhead, H. J., Burrell, S., ... Cowell,

C. T. (2010, September 25). Researching Effective Strategies to Improve Insulin

Sensitivity in Children and Teenagers - RESIST. A Randomized control trial

investigating the effects of two different diets on insulin sensitivity in young people with

insulin resistance and/or pre-diabetes. [article]. BMC Public Health, 10, 575.

http://dx.doi.org/10.1186/1471-2458-10-575

Garnett, Sarah P.; Gow, Megan; Ho, Mandy; Baur, Louise A.; Noakes, Manny; Woodhead,

Helen J.; Broderick, Carolyn R.; Burrell, .... Cowell, Chris T. (2013, May) Optimal

acmronutrient content of the diet for Adolescents with prediabetes; RESIST a

Randomised Control Trial . The Journal of Clinical Endocrinology & Metabolism,

98(5),2116-2125 doi: 10.1210/jc.2012-4251

Lee, Y. A., Yoo, J. H., Kim, J. H., Lee, S. H., Kim, J. H., Lim, L. H., ... Yang, S. W. (2011,

May). Independent relationships of obesity and insulin resistance with serum proinsulin

level in prepubertal children with normal glucose tolerance. [Article]. Pediatric Diabetes,

12(3), 235-241. http://dx.doi.org/10.1111/j.1399-448.2010.00696.x

Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing and

Healthcare (2 ed.). Philadelphia: Lippincott Williams & Wilkins

Monzavi,R.,Dreimane,D.,Geffner, M.E., Braun,S., Conrad, B., Klier,

M.Kaufman,F.R.(June,2006) Improvement in risk factors for metabolic syndrome and

insulin resistance in overweight youth who are treated with lifestyle interventions.

http://dx.doi.org/10.1186/1471-2458-10-575


Pediatrics Official Journal of the American Academy of Pediatrics (117)1111-1118 doi:

10.1542/peds.2005-1532

Niklas, T. S. (2008, June). Association between 100% juice consumption and nutrient intake and

weight of children aged 2 to 11 years. [Comparitive study]. Pediatric and Adolescent

Medicine, 162(6), 557-565. http://dx.doi.org/10.1001/archpedi.162.6.557

Oftedal,B.,Bru,E. Bjorg,K.,(2011) Motivation for diet and exercise management among adults

with type 2 diabetes,Scandianavia Caring Science (25)2, 735-744 doi: 10.1111/j.1471-

6712.2011.00884

Simmons, S., Alexander, J. L., Ewing, H., & Whetzel, S. (2012, November 23). SNAP

participation in preschool-aged children and prevalence of overweight and obesity

[Journal article]. Journal of School Health, 1(23), 548-552. http://dx.doi.org/

10.1111/j.1746-1561.2012.00735

Sumanmo,E.,Schellenberg,B.S, Dryden,D.,Vandermeer,M.S., Ha,C., Korowynk,C.(2014)

Lifestyle interventions for patients with and at risk for type 2 diabetes. Annals of Internal

Medicine 159 (8) 543-551 doi: 2013;159:543-551

Wilson, V. (2013, March). Type 2 diabetes: an epidemic in children. [Article]. Nursing Children

and Young People, 25(2), 14-17. Retrieved from

Quinn, S. M., Baur, L. A., Garnett, S. P., & Cowell, C. T. (2010, October). Treatment of clinical

insulin resistance in children: a systematic review [article]. Obesity Reviews: An Official

Review Of The International Foundation For The Study of Obesity. 11(10) 722-730 doi:

11(10), 722-730. http://dx.doi.org/10.1111/j.1467-789X.2009.00697.x


Alicia Nix Evidence grid

Level1

Sumanmo,E.,Schellenberg,B.S,

Dryden,D.,Vandermeer,M.S.,

Ha,C., Korowynk,C.(2014)

Lifestyle interventions for

patients with and at risk for type

2 diabetes. Annals of Internal

Medicine 159 (8) 543-551 doi:

2013;159:543-551

Purpose

To

systematically

review the

effectiveness of

lifestyle

interventions

on minimizing

progression to

diabetes in

high-risk

patients

or progression

to clinical

Design A Systematic

Review and

Meta-analysis

sampling

5 electronic

databases

(1980 to June

2013),

reference

lists, and gray

literature.

Two

Major findings

relevant to

project

Comprehensive

lifestyle

interventions

effectively

decrease

the incidence of

type 2 diabetes

in high-risk

patients. In

patients who

already have

Critique of

validity, bias and

significance for

your project

Most trials focused

on surrogate

measures (such as

weight change,

blood pressure, and

lipids) for which

clinical relevance

was unclear.

Significance

This is relevant to


outcomes (such

as

cardiovascular

disease and

death) in

patients with

type 2 diabetes.

The literature

search

identified 1289

citations.

The lifestyle

intervention

had to

include an

exercise

component, a

diet component,

and at

least 1 other

component

(such as

counseling,

smoking

cessation,

and behavior

modification

reviewers

independently

identified

randomized,

controlled

trials of

lifestyle

interventions

(_3 months’

duration)

that included

exercise, diet,

and at least 1

other

component;

the

comparator

was standard

care.

The literature

search

identified

1289

citations.

Twenty

unique studies

in 58

publications

were included

Nine studies

addressed

patients at

increased risk

for type 2

diabetes; 11

studies

addressed

patients

diagnosed

with type

2 diabetes

type 2 diabetes,

there is no

evidence of

reduced all-

cause mortality

and insufficient

evidence to

suggest

benefit on

cardiovascular

and

microvascular

outcomes

my EBP project in

that my project’s

aim is to prevent

diabetes.

Level 1

Level1

Quinn, S. M., Baur, L. A.,

Garnett, S. P., & Cowell,

C. T. (2010, October).

The objective

of this study

was to evaluate

the

Design: randomized

controlled

trial (True

6 months of

metformin with

or without

lifestyle

The review question

was clearly stated.

The search strategy

was effective.


Treatment of clinical

insulin resistance in

children: a systematic

review [article]. Obesity

Reviews: An Official

Journal Of The

International

Association For The

study Of Obesity, 11(10),

722-730.

http://dx.doi.org/10.1111

/j.1467-

789X.2009.00697.x

effectiveness of

interventions

aimed at

improving

clinical insulin

resistance

and/or pre-

diabetes in

children

experimental)

Sampling

method Five

electronic

databases

were searched

for

randomized

controlled

trials of at

least 2-

months’

duration

Sample size

four trials

were eligible

for inclusion

in the

systematic

review.

Interventions

none

Outcomes

Fasting

insulin,

HOMA-IR

BMI

interventions

showed a

statistical

difference in

fasting insulin

After 6 months

when using

metformin the

subjects had a

decrease in BMI

with or without

physical activity

The combined

effect of

metformin and

individualized

lifestyle

intervention

resulted in the

greatest decrease

in fasting insulin

and had the

additional effect

of decreasing

BMI

this systematic

review shows

that

metformin,

whether used

alone or in

combination

with lifestyle

interventions,

improves

markers of

insulin

sensitivity,

fasting insulin

and HOMA and

reduces BMI.

Comprehensive

search methods and

appropriate

databases were

used.

The review methods

are clearly

documented, as well

as the search

strategy, inclusion

criteria, and

methods used.

The sample size

was extremely

small, with only 3

being acceptable to

be included in the

meta-analysis so the

statistical power

after the pooling of

data is low.

Second, of the three

trials that provided

sufficient detail

to determine

attrition rate (15–

17), the mean value

was

20%, with more

people in the

control group (25%)

compared

with the

intervention group

(16%) discontinuing

trial participation.

This highlights the

difficulties with

implementing

treatment regimens

in this age group.

One study (17) had

a particularly high

attrition rate in both

the control (36%)


and intervention

arm (33%); the

authors attributed

this to the

prolonged dose

loading regimen of

2 months decreasing

the impact of the

intervention on

weight

loss and

consequently

resulting in

participant

dissatisfaction with

the treatment.

Significance-

Although no trials

on lifestyle

interventions alone

were identified, this

systematic review

shows that

metformin, whether

used alone or in

combination with

lifestyle

interventions,

improves markers

of insulin

sensitivity, fasting

insulin and HOMA

and reduces BMI.

Several features of

clinical insulin

resistance, including

In applying

to my

project,

starting

patients on

metformin

might be a

recommenda

tion added


to diet and

exercise

when the

goal is

lowering

insulin

levels

.

-

Level 1

Clinical practice guidelines:

Physical fitness and

activity in schools.

[Journal]. (2000).

Pediatrics, The Official

Journal of the American

Academy of Pediatrics,

(105), 1156. doi:

10.1542/peds.105.5.1156

Purpose

To provide a

guideline for

physical

activity in

children and

adolescents

with certain risk

factors can

detect insulin

resistance and

diabetes early

in the disease

progression.

design Clinical

Guideline

Review of

Published

Meta-

Analyses

Systematic

Review

No

interventions

Outcomes

this guideline

was put in

place to give

clinicians and

parents a

guideline as

to how much

physical

activity for

optimal health

in children

Major findings

relevant to

project

These guidelines

sets a

precedence in

the amount of

physical activity

needed to help

prevent type 2

diabetes and

insulin

resistance.

Validity

This is a valid study

in that it used expert

consensus

Significance. It was

also weighted

according to the

weighted scheme.

with no bias

The guideline is

providing a

recommendation for

physical activity in

is also the ultimate

goal of my EBP.

An acceptable

screening tool

would be a tool that

could be used in my

EBP project


and

adolescents

while in a

school setting

Article Level 1

Fedewa, M.V., Gist, N. H., Evans,

E.M., Dishman, R. K. (2013)

Exercise and insulin resistance in

youth: A meta-analysis. Pediatrics

Official Journal of the American

Academy of Pediatrics 133 (1) 163-

173 doi: 10.1542/peds.2013-2718

This

systematic

review and

meta-analysis

provides a

quantitative

estimate of the

effectiveness

of exercise

training on

fasting insulin

and insulin

resistance in

children and

adolescents.

.

Design RCT

Sampling

method

Analysis was

limited to

randomized

controlled

trials by

using

combinations

of the terms

adolescent,

child,

pediatric,

youth,

exercise

training,

physical

activity,

diabetes,

insulin,

randomized

trial, and

randomized

controlled

trial. Sample

size:The

authors

assessed 546

sources, of

which 4.4%

(24 studies)

were eligible

for inclusion.

Major findings

These results

support the use of

exercise training in

the

prevention and

treatment of type 2

diabetes.

Critique of

validity, bias

Analysis was

limited to

randomized

controlled

trial. Only 24

studies were

included in

the trial. Also

effects were

independently

calculated by

multiple

authors.


Thirty-two

effects were

used to

estimate the

effect of

exercise

training on

fasting

insulin, with

15 effects

measuring the

effect on

insulin

resistance.

Outcomes:

Based on the

cumulative

results from

these studies,

a small

to moderate

effect was

found for

exercise

training on

fasting

insulin

and

improving

insulin

resistance in

youth -

Level 3

Oftedal,B.,Bru,E. Bjorg,K.,(2011)

Motivation for diet and exercise

management among adults with type

2 diabetes,Scandianavia Caring

The aim of this

study was to

investigate diet

and

exercise

A cross-

sectional

design

including a

postal

Reported diet

management was

more in accordance

with

recommendations

Large sample

size But a

questionnaire

was mailed to

obtain data.


Science (25)2, 735-744 doi:

10.1111/j.1471-6712.2011.00884

management

and how

indicators of

intrinsic

motivation

such as ability

expectations

and values are

associated

with diet and

exercise

management

among

adults with

type 2

diabetes.

Background:

Motivational

problems are

probably one

questionnaire

that

investigated

diet and

exercise

management

as well as

intrinsic

motivational

factors such

as ability

expectations

and values

related to

these

behaviors

was used to

collect the

data. A

sample

comprising

425 adults

with type 2

diabetes aged

between 30

and 70

completed the

questionnaire.

than reported

exercise

management. Yet

results indicated

equally high ability

expectations and

positive values for

exercise and diet

management.

This might

have been in

one small

area of the

country so

not a true

random study

Also self

reported data

This provides

evidence to

my project

due to the

promotion of

diabetes and

exercise

among type 2

diabetics

Level IV

Lee, Y. A., Yoo, J. H., Kim, J. H.,

Lee, S. H., Kim, J. H., Lim, L.

H., ... Yang, S. W. (2011,

May). Independent

relationships of obesity and

insulin resistance with serum

proinsulin level in prepubertal

children with normal glucose

tolerance. [Article]. Pediatric

Diabetes, 12(3), 235-241.

http://dx.doi.org/10.1111/j.13

99-

448.2010.00696.x

Purpose of

study. to

compare the

fasting serum

proinsulin

levels in lean,

overweight,

and obese

prepubertal

children with

normal

glucose

tolerance

and also

evaluated the

relationship

- Design

Coorelational

- Sampling

method

118

prepubertal

children (80

males, 38

females) who

were assessed

between

December

2007 and

January 2009.

- sample size

data suggest that

obesity itself or

insulin resistance

may independently

cause fasting

hyperproinsulinemia

in proportion to

hyperinsulinemia in

prepubertal

children with

normal glucose

tolerance test.

. Measuring the

serum

level of proinsulin

might be useful as a

Strength; This study had a large sampling population which contributes to the validity of the study Statistical analysis was used.


between

fasting

proinsulin

level

and indices of

insulin

resistance

to compare the

fasting serum

proinsulin

levels in lean,

overweight,

and obese

prepubertal

children with

normal

glucose

tolerance

and also

evaluated the

relationship

between

fasting

proinsulin

level

and indices of

insulin

resistance

A total of 109

prepubertal

children

(mean age,

8.6 years)

were included

in this study

- Brief

description

of

interventions

(if any)

None

- outcomes

measured

(30 points)

Determining

the patients

insulin level

helps

determine b-

cell overload

in children

marker of β-cell

overload in obese

children.

Weakness- the fasting insulin levels were only collected once. A limitation of this cross-sectional study was that we could not investigate what is the value of using both proinsulin and insulin in screening vs. the use of insulin alone to predict the development of T2DM or metabolic syndrome later. Significance. Since my project is lowering insulin resistance levels and decreasing the incidence in development of type 2


diabetes, it is important to understand the relationship between elevated pro insulin levels and the development of insulin resistance.

Level 2

Monzavi,R.,Dreimane,D.,Geffner,

M.E., Braun,S., Conrad, B., Klier,

M.Kaufman,F.R.(June,2006)

Improvement in risk factors for

metabolic syndrome and insulin

resistance in overweight youth who

are treated with lifestyle

interventions. Pediatrics Official

Journal of the American Academy of

Pediatrics (117)1111-1118 doi: 10.1542/peds.2005-1532

Quasi-

experimental

To evaluate

the prevalence

of risk factors

that are

associated

with the

metabolic

syndrome and

insulin

resistance in

overweight

youth and to

determine

the effect of a

short-term,

family-

centered,

lifestyle

intervention on

various

associated

anthropometric

and metabolic

measures

Overweight

youth who were

between 8 and 16

years of age

participated

in a 12-week,

family-centered,

lifestyle

intervention

program.

Anthropometric

and metabolic

measures were

assessed before

the program in

all participants (n

_ 109) and after the

program in a

subset of the

participants (n _ 43).

Overweight youth have

multiple risk factors

associated with the

metabolic

syndrome. A 12-week

lifestyle program may

have a positive effect on

reducing risk factors for

the metabolic syndrome

and insulin resistance in

overweight

youth. www

Possible recruitment bias. The primary care physician referred the patient So it was not a blind study. Also there was a small number of participants

Level 1 Davis,C.L., Pollock,N.K., Waller, J.L., Allison, J.D., Dennis,

The Aim of the study is to test the

Design: RCT Sampling

In this trial, after 13 weeks, 20 or 40 min/d of

Although there was an adequate


B.A.,....Gowler, B.A.(September, 2012) Exercise dose and diabetes risk in obese children A randomized controlled trial JAMA (308)1103-1121 Retrieved from https://www.academia.edu/1853577

effect of different doses of aerobic training on insulin resistance, fatness, visceral fat, and fitness in overweight, sedentary children and to test moderation by sex and

race.

size and Method Randomized controlled efficacy trial conducted from 2003 through 2007 in which 222 overweight or obese sedentary children (mean age, 9.4 years; 42% male; 58% black) were recruited from 15 public schools in the Augusta, Georgia, area

aerobic training improved fitness and demonstrated dose-response benefits for insulin resistance and general and visceral adiposity in sedentary overweight or obese children, regardless of sex or race

sample size, the recruitment came from one city of one state This study specifically relates to my project. This provides evidence that physical activity reduces insulin resistance This is relevant to my project in that we are looking at exercise reducing the risk of type 2 diabetes. Insulin resistance is the leading cause of type 2 diabetes.

evidence-based practice project paper - alicia nix, …...evidence based project. this is a level...

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