With 47% of the veteran population aged 65 years or older, an age group with the highest prevalence of type 2 diabetes (T2D), prevention of T2D is critical within the Veterans Health Administration (VHA) system (1). Resist Diabetes (RD), a Social Cognitive Theory-based resistance training program, has been shown to reduce the prevalence of prediabetes by 34% in prediabetic older adults (2). The RD program could fill the gap within the VHA system for a structured diabetes prevention program not focused on weight, but instead focused on exercise. This thesis describes a mixed-methods investigation to determine what adaptations to the RD program are needed to implement the program within the Salem Veterans Affairs Medical Center (VAMC) patients. Salem VAMC care providers and veteran patients were recruited to gauge perceptions of the RD program, and identify barriers and facilitators to the referral process and program implementation. Semi-structured open-ended questionnaires and interview guides based upon the Consolidated Framework for Implementation Research (CFIR) (3) were utilized to determine major and minor themes within the provider and veteran responses. Quantitative data was also obtained to assess provider perceptions and participant characteristics. Major findings included: positive perceptions by providers for RD program acceptability, appropriateness and feasibility (4) within the Salem VAMC, positive perceptions of Intervention Characteristics of RD by veterans, major barriers to participation lied within the Outer Setting domain with travel, transportation, and time constraints. Major facilitators to program implementation lied within the Inner Setting domain with promotion by primary care. These findings could be used to inform a future version of the RD program adapted for the VHA system. / Master of Science / With 47% of the veteran population aged 65 years or older, an age group with the highest prevalence of type 2 diabetes (T2D), prevention of T2D is critical within the Veterans Health Administration (VHA) system. Resist Diabetes, a Social Cognitive Theory-based resistance training program, reduced the prevalence of prediabetes by 34% in prediabetic older adults in the Roanoke, VA area. This thesis describes a mixed-method investigation to determine what adaptations to the Resist Diabetes program are needed to implement the program within the Salem Virginia Veterans Affairs Medical Center.

Altered vasoreactivity and mechanical properties of skeletal muscle arterioles could impact peripheral insulin resistance and hypertension observed in type 2 diabetes. The purpose was to determine if increased vasoconstrictor reactivity, decreased vasodilator reactivity and alterations in the structural properties of 1A arterioles from both high-oxidative and low-oxidative glycolytic skeletal muscles is present during prediabetes as well as acute and chronic diabetes, and to determine if this dysfunction precedes the development of elevated arterial pressure in type 2 diabetes. Zucker Diabetic Fatty (ZDF) rats and lean age-matched controls were studied at 7 (prediabetes), 13 (acute diabetes) and 20 (chronic diabetes) weeks of age. Following measurement of arterial pressure, vasoconstrictor responsiveness to norepinephrine (NE), potassium chloride (KCl), and increasing intraluminal pressure (MYO), vasodilator responsiveness to acetylcholine (ACh), sodium nitroprusside (SNP) and intraluminal flow and passive mechanical properties were examined in arterioles from soleus and gastrocnemius muscles. Vasoconstriction to NE was enhanced in gastrocnemius muscle arterioles during prediabetes and preceded elevated arterial pressure. Alterations in the passive mechanical properties of arterioles from both muscles were observed throughout the progression of diabetes. Flow-induced vasodilation was decreased in the high-oxidative muscle arterioles during acute diabetes, and was coincident with the emergence of elevated arterial pressure. During chronic diabetes, vasodilation to ACh and flow were reduced in soleus muscle arterioles. The reduced vasodilation to ACh was the result of a loss of NO. Although the vasodilator capacity of low-oxidative glycolytic skeletal muscle arterioles was not diminished throughout the progression of diabetes, the contribution of NO to AChinduced dilation was lost in the prediabetic and acute diabetic rats. The data demonstrate that alterations in both the vasoconstrictor and passive properties of low-oxidative glycolytic skeletal muscle arterioles are present during prediabetes, and precede the development of type 2 diabetes, and that although endothelial dysfunction does not become manifest in these skeletal muscle arterioles, alterations in the signaling mechanisms to achieve that vasodilation are present in prediabetes. Moreover, overt type 2 diabetes results in endothelial dysfunction and altered mechanical properties in high-oxidative skeletal muscle arterioles.

Altered vasoreactivity and mechanical properties of skeletal muscle arterioles could impact peripheral insulin resistance and hypertension observed in type 2 diabetes. The purpose was to determine if increased vasoconstrictor reactivity, decreased vasodilator reactivity and alterations in the structural properties of 1A arterioles from both high-oxidative and low-oxidative glycolytic skeletal muscles is present during prediabetes as well as acute and chronic diabetes, and to determine if this dysfunction precedes the development of elevated arterial pressure in type 2 diabetes. Zucker Diabetic Fatty (ZDF) rats and lean age-matched controls were studied at 7 (prediabetes), 13 (acute diabetes) and 20 (chronic diabetes) weeks of age. Following measurement of arterial pressure, vasoconstrictor responsiveness to norepinephrine (NE), potassium chloride (KCl), and increasing intraluminal pressure (MYO), vasodilator responsiveness to acetylcholine (ACh), sodium nitroprusside (SNP) and intraluminal flow and passive mechanical properties were examined in arterioles from soleus and gastrocnemius muscles. Vasoconstriction to NE was enhanced in gastrocnemius muscle arterioles during prediabetes and preceded elevated arterial pressure. Alterations in the passive mechanical properties of arterioles from both muscles were observed throughout the progression of diabetes. Flow-induced vasodilation was decreased in the high-oxidative muscle arterioles during acute diabetes, and was coincident with the emergence of elevated arterial pressure. During chronic diabetes, vasodilation to ACh and flow were reduced in soleus muscle arterioles. The reduced vasodilation to ACh was the result of a loss of NO. Although the vasodilator capacity of low-oxidative glycolytic skeletal muscle arterioles was not diminished throughout the progression of diabetes, the contribution of NO to AChinduced dilation was lost in the prediabetic and acute diabetic rats. The data demonstrate that alterations in both the vasoconstrictor and passive properties of low-oxidative glycolytic skeletal muscle arterioles are present during prediabetes, and precede the development of type 2 diabetes, and that although endothelial dysfunction does not become manifest in these skeletal muscle arterioles, alterations in the signaling mechanisms to achieve that vasodilation are present in prediabetes. Moreover, overt type 2 diabetes results in endothelial dysfunction and altered mechanical properties in high-oxidative skeletal muscle arterioles.

Type 2 Diabetes Mellitus (T2DM) is a growing healthcare problem in the United States that increases the risk for numerous health complications if left unidentified and untreated. Prediabetes, while not a clinical diagnosis, is a state of increased risk of developing T2DM based on elevated blood glucose laboratory markers such as hemoglobin A1C (HbA1C). There are numerous risk factors that predispose individuals to prediabetes and T2DM. Researchers have shown that targeting those risk factors that are modifiable, such as physical inactivity and obesity, with exercise and diet interventions can increase physical activity, decrease weight, decrease HbA1C, and decrease the incidence of T2DM in prediabetics. Tools such as pedometers that track physical activity in the form of step count can be used in interventions to improve upon these metrics. Researchers have also shown that pedometers can enhance interventions aimed at improving physical activity, weight, HbA1C, and incidence of T2DM. Recently, electronic tools that are wearable such as the Fitbit Flex2 have gained in popularity due to their additional interactive features with users. These electronic wearable devices employ behavior change techniques approved by the US Preventive Services Task Force to motivate individuals to be more physically active. Current research has shown that these electronic wearable devices enhance interventions aimed at improving physical activity, weight loss, and HbA1C in those with T2DM. Yet, there is a gap in current research that examines the effect that these devices have on HbA1C in prediabetics. The proposed study seeks to examine if the Fitbit Flex 2 wrist device, in conjunction with a standard diet and exercise intervention, improves HbA1C measures in prediabetic individuals over a one-year period. Results from the proposed study could support the future use of these devices to help decrease HbA1C measures and the risk of development of T2DM and other T2DM- health complications in prediabetics. Electronic wearable devices could alter the way in which clinicians monitor lifestyle interventions aimed at T2DM risk reduction and treatment. The use of electronic wearable devices may also serve as a more cost effective treatment alternative for those at risk of developing, as well as those diagnosed with, T2DM.

Prediabetes innebär en förhöjd glukosnivå och är ett förstadium till att utveckla typ 2- diabetes och är ett folkhälsoproblem inte bara i Sverige utan även i hela världen. Cirka 171 miljoner människor i världen hade diabetes år 2000 och siffran förutspås att vara 366 miljoner år 2030, resurser måste därför sättas in för att förhindra att fler insjuknar. Sjuksköterskans vårdande roll handlar bland annat om att arbeta förebyggande för att förhindra att sjukdomar uppstår. Syftet med detta examensarbete är att beskriva patienters upplevelse av att genomföra en förändring av levnadsvanor vid prediabetes. Examensarbetet är en litteraturstudie och baseras på åtta stycken kvalitativa och två stycken kvantitativa artiklar som granskats och systematiserats. Fyra huvudteman växte fram i analysprocessen: Faktorer som motiverar patienterna att sträva efter hälsa, Patientens hindrande omständigheter, Patientens behov av information och Stödet från hälso-och sjukvården. Patienterna beskrev vad som motiverade dem till att genomföra de livsstilsförändringar som behövdes för att uppnå en bättre hälsa, men även vilka förhindrande omständigheter de upplevde. För att kunna genomföra förändringar av levnadsvanor måste patienterna ha tillräckligt med information och kunskap om hur de ska gå tillväga, samt få individuellt anpassat stöd av hälso- och sjukvården. I diskussionen belyses vilka faktorer det är som gör att vissa patienter lyckas att bedriva egenvård med stöd av sjuksköterskan och vad de patienter som inte lyckas lika bra behöver för stöd. Sjuksköterskans vårdande roll lyfts fram och vikten av att patienten får rätt information och professionellt stöd för att lyckas att genomföra livsstilsförändringar för att få en hållbar utveckling av vården i framtiden.

Prediabetes, a condition in which glucose levels are higher than normal but not high enough to be diagnosed as type 2 diabetes, affects approximately 37% of adults in the United States and is a major public health concern. Extensive research has evaluated the association between physical activity (PA) and type 2 diabetes; however, few studies have examined the association between PA and prediabetes. Therefore, we evaluated the association between PA (including leisure time, occupational and total) and prediabetes status among adults, stratified by gender, using multinomial logistic regression models fit to serial cross-sectional 2007-2014 National Health and Nutrition Examination Survey data. After adjusting for age, race, body mass index, smoking status, family history of hypertension and education, results suggest that the association between leisure time [moderate PA: 0.98 (95% CI: 0.80–1.21); tertile 3: 1.05 (95% CI: 0.75–1.49)] and total PA [tertile 1: 1.15, (95% CI: 0.96–1.38); tertile 2: 1.00, (95% CI: 0.79–1.27); tertile 3: 0.96, (0.77–1.20)] and undiagnosed prediabetes and was not statistically significant among women. However, compared to women who engaged in no occupational PA, engaging in the highest tertile was statistically significantly associated with lower odds of undiagnosed prediabetes [tertile 3: 0.75, (95% CI: 0.58–0.97)]. Compared to men who engaged in no leisure time PA, men engaging in the highest tertile of leisure time PA had a statistically significant lower odds of undiagnosed prediabetes [Tertile 3: 0.79, ( 0.65–0.98)]. Compared to men who did not engage in any PA, men engaging in any PA did not have a statistically significant decrease in odds of undiagnosed prediabetes [tertile 1: 0.90, (0.71–1.16); Tertile 2: 0.93, (0.74–1.18); Tertile 3: 0.99, (0.80–1.21)]. Overall, our results show that for both men and women, there was a general lack of association between leisure-time, occupational, and total physical activity and prediabetes status in adjusted analyses.

Objective: To determine if a prediabetes lifestyle intervention program, tailored to rural adults from Southwestern Ontario, could decrease the risk of Type 2 Diabetes (T2D) development through positive lifestyle changes. Methods: Forty-nine intervention participants and 34 controls partook in the study. At baseline individuals diagnosed with prediabetes chose the lifestyle intervention group (6 sessions) or control group (1 session). Intervention participants were provided with tailored education which promoted positive lifestyle changes known to help prevent or delay the development of T2D. Results: Lifestyle changes and long-term improvement of T2D modifiable risk factors were achieved by the intervention participants from baseline to post-program, unlike their control counterparts, such as increasing their average daily intake of vegetables and fruit servings (p<0.001) and reducing their fasting glycemia (p=0.003). Conclusion: Positive lifestyle changes through this 6-month tailored community-based intervention was successful in helping many rural adults with prediabetes prevent the development of T2D

Background: Prediabetes is strongly related to an unhealthy lifestyle and it is a growing public health problem. It is of great importance to start a lifestyle change at an early stage to prevent type 2 diabetes. The primary care nurse ́s mission is to support patients with prediabetes to a lifestyle change. Objective: The aim of the study was to describe experiences of lifestyle changes on adult patients with prediabetes. Method: Qualitative study with semi-structured interviews. Adult persons with prediabetes were interviewed. The interviews were analyzed with a qualitative manifest content analysis. Results: Four main categories and ten subcategories were identified from the analysis. The main categories were consisted of: The importance in personal health in lifestyle change, which described the impact of the physical and mental health in lifestyle change. The importance of self- motivation, the main motivation to implement lifestyle change was the concern of developing type 2 diabetes. To succeed with the lifestyle change, the patients needed to create new routines and habits. The importance of healthcare relationship, emphasising the need for support from the nurse. The relationship with the nurse and the receiving of the patients was of high significance to succeed with the lifestyle changes. The impact of the surrounding, family and friends were described to have booth a positive and a negative impact on the implementation in lifestyle change. Conclusion: The patients with prediabetes had the insight that they needed to make a lifestyle change. Despite reaching the insight, the patients found it difficult to implement and sustain the lifestyle change. The nurses role and supportive functions were of great significance for facilitating a lifestyle change. / Bakgrund: Prediabetes är starkt relaterat till en ohälsosam livsstil och är ett växande folkhälsoproblem. Det är av stor vikt att påbörja livsstilsförändring i ett tidigt stadium för att förhindra utveckling till diabetes typ 2. Distriktssköterskans uppdrag innebär att stödja patienter med prediabetes till livsstilsförändringar. Syfte: Syftet med studien var att beskriva vuxna patienters erfarenheter av livsstilsförändring vid prediabetes. Metod: Kvalitativ studie med semistrukturerade intervjuer. Nio vuxna personer med prediabetes intervjuades. Data analyserades genom kvalitativ manifest innehållsanalys. Resultat: Utifrån analysen identifierades fyra huvudkategorier och tio underkategorier. Huvudkategorierna bestod av: Den egna hälsans betydelse vid livsstilsförändring, som beskriver den fysiska och psykiska hälsans påverkan vid livsstilsförändring. Den egna motivationens betydelse, den främsta motivationen att genomföra livsstilsförändring var oron att insjukna i diabetes typ 2. För att lyckas med livsstilsförändringar behövde patienterna skapa nya rutiner och vanor. Vårdrelationens betydelse, framhäver behovet av stöd från sjuksköterskan. Relationen med sjuksköterskan och bemötandet var betydelsefullt för att lyckas med livsstilsförändring. Omgivningens påverkan, familj och vänner beskrevs ha både en positiv och negativ inverkan vid genomförande av livsstilsförändring. Slutsats: Insikten fanns hos patienter med prediabetes att de behövde göra en livsstilsförändring. Trots insikten kunde det vara svårt att genomföra samt bibehålla livsstilsförändringen. Sjuksköterskans roll och stödjande funktion var betydelsefull för att främja livsstilsförändringen.

Introduktion: Prediabetes är ett förstadium till typ-2 diabetes och går ofta obemärkt förbi. Tidig diagnos och livsstilsinriktade insatser har påvisats vara en viktig del i det hälsofrämjande arbetet för att minska risken för typ-2 diabetes. Få studier har dock fördjupat sig i hur patienterna upplever hälsofrämjande insatser i samband med tillståndet. Syfte: Att beskriva vuxna patienters uppfattningar om hälsofrämjande insatser vid prediabetes. Metod: Systematisk litteraturstudie med deskriptiv design och utgångspunkt från Polit och Becks (2017) flödesschema för litteraturöversikter. Litteratursökning genomfördes i databaserna Cinahl och Pubmed, där totalt 12 kvalitativa artiklar inkluderades efter kvalitetsgranskning. Utvalda artiklar analyserades induktivt med kvalitativ innehållsanalys enligt Graneheim och Lundman (2004). Resultat: Resultat sammanfattades i tre kategorier och åtta underkategorier relaterat till vuxna personers uppfattningar om hälsofrämjande insatser vid prediabetes. De tre kategorierna var Den sociala kontexten påverkar, Inre faktorer påverkar samt Yttre faktorer påverkar. Slutsats: Hälsofrämjande insatser uppfattas på olika sätt av personers med prediabetes. Människan är komplex och tankegångarna speglar individens livsvärld med olika förutsättningar utifrån social kontext, inre och yttre påverkan. I vårdmötet bör hälsofrämjande omvårdnad individanpassas för att öka motivation och egenmakt i riktning mot god hälsa. / Introduction: Prediabetes is a precursor to type-2 diabetes and often goes unnoticed. Early diagnosis and lifestyle-oriented interventions have been shown to be an important part of the health promotion work to reduce the risk of type-2 diabetes. Few studies have delved into how patients experience health-promoting interventions in connection with the disease.Aim: The aim of the systematic review was to describe the perceptions of health-promoting interventions in adult prediabetic patients’. Method: A systematic literature study with descriptive design and a starting point from Polit and Beck's (2017) flow chart for literature reviews. Literature search was performed in the databases Cinahl and Pubmed, where a total of 12 qualitative articles were included after quality review. Selected articles were inductively analyzed with qualitative content analysis according to Graneheim and Lundman (2004). Results: Results are summarized in three categories and eight subcategories related to adults' perceptions of health-promoting interventions in prediabetes. The three categories were; The influence of the social context, Internal influence and External influence. Conclusion: Health-promoting initiatives are perceived in different ways by people with prediabetes. Man is complex and the ways of thinking reflect the individual's world of life with different conditions based on social context, internal and external influences. In the care meeting, health-promoting nursing should be individually adapted to increase motivation and autonomy in the direction of good health.

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