1. Introduction
Diabetes is one of the most critical health challenges worldwide. During the past three decades, the number of diabetic cases has increased more than twofold [1, 2]. The prevalence of vulnerability to diabetes is growing rapidly and will reach approximately 625 million people in all quarters of the globe by 2045 [3]. According to the estimations by the international diabetes federation in the year 2015, about 75% of adult diabetics are living in low-income countries [4]. Some risk factors of vulnerability to type 2 diabetes are unchanging, such as age and family background; however, other risk factors, such as weight gain, blood sugar, and triglyceride, change dramatically with lifestyle correction [5]. Monitoring the metabolic indicators, such as blood pressure, body weight, blood sugar, HbA1c, and lipid, is imperative for managing diabetics [6]. Studies have shown that pharmaceutical interventions and lifestyle modification can effectively control Hyperglycemia [7]. Correcting the lifestyle and mood factors, self-confidence, and social support can save pre-diabetics from the risk of vulnerability to this illness [8, 9]. About 50% to 80% of the people with diabetes have no adequate skills and knowledge of self-care and illness management [10]. Numerous studies have demonstrated that healthcare strategies engaging the diabetics' family members cause higher awareness and self-efficacy concerning self-care in patients with diabetes [11]. In recent years, the US and UK diabetes associations have confirmed the effect of a low carbohydrate diet in lowering weight and improving blood glucose and lipid regulation in mellitus diabetics [12, 13]. Combinatorial diet programs and physical activity promotion plans may hinder and delay the progress of type 2 diabetes [14-17]. Disease management programs have introduced particular instructions as the best strategy for diabetes prevention in which the increase in physical activity [18, 19], decrease of consumable calories, and training of patients together with the support by peer groups are among the most crucial disease management programs [20-26]. Despite the variety and frequency of the interventions to control and treat type 2 diabetes in different countries, the knowledge and awareness of the methods and the relevant consequences are crucial for the science community. They can be counted as a decisive step toward promoting this science. A systematic review is a comprehensive study based on a predetermined and accurate protocol. Many studies do not have good interpretive power for various reasons; however, the systematic review and meta-analysis that often follows will combine studies to reach a larger sample size; therefore, they can be examined with greater power and ultimately provide better conclusions. Accordingly, this study aims to determine effective non-pharmacological interventions in controlling and treating type 2 diabetes by systematic review method. This study has been conducted to find answers to the following questions:
1) What are the types of non-pharmacological interventions used in intervention studies to control or treat type 2 diabetes?
2) Which non-pharmacological intervention is primarily recommended in controlling or treating type 2 diabetes in intervention studies?
3) What have been the outcomes of non-pharmacological interventions in controlling or treating type 2 diabetes?

2. Methods
This study is a systematic review of the papers published on the non-pharmaceutical intervention arrangements in controlling and treating patients with type 2 diabetes. The authors have used the standard systematic review guideline (PRISMA), including 27 items [27]. 
The search included the electronic data banks, including Medline, Science Direct, Embase, Scopus, Cochrane Library, and the Google Scholar search engine. The main selected keywords were as follows: “Clinical trial,” “treatment,” “type-2 diabetes,” and “control.” Their equivalents were also searched in MeSH: “NIDDM” and “diabetes mellitus.” The words “AND” and “OR” were used to combine the keywords. Searching was restricted to all relevant English papers published and indexed from June 2014 to the end of 2020. 

Inclusion criteria
The inclusion criteria of selected papers were from scientific research journals, the language of the paper was in English, and the documents were full-text papers. The criteria for selecting articles were as follows: Type of participants=type 2 diabetes, type of interventions=non-pharmaceutical interventions, type of comparator=intervention performed, type of outcome=control or treatment, study type=clinical trial or empirical. 

Exclusion criteria
The exclusion criteria of papers were inaccessibility to the full text, letters to the editors, and exclusively descriptive and review papers. 

Data extraction, variables, and data analysis
A researcher-made data extraction form based on the study objective was used to analyze the papers. This form included parts of the article details, including the authors’ names, publication year, paper’s objective, study design, study methodology, information relevant to type 2 diabetes, and final results and outputs. Two researchers were involved in the selection work and data extraction activities. The main features of the studies and their results have been summarized considering the following variables:
Type of study: The papers from clinical trials or empirical studies were selected.
Target population: The patients with type 2 diabetes and gestational diabetes (GDM). 

Types of interventions
Types of interventions in this study were classified into four categories, namely “lifestyle,” “education,” “traditional treatment,” and “Treatment devices,” based on the World Health Organization (WHO) interventions category guidelines [28], and the study objectives that embraced only the non-pharmaceutical interventions. 
Two reviewers worked independently to determine whether a study met the inclusion criteria. They collected information to assess each study's methodological validity (degree of protection against confounding and bias). They also extracted data from the included studies using structured and standardized data extraction forms. The reviewers resolved discrepancies by jointly reviewing any study in question. A third reviewer would enter as an external peer reviewer if no consensus were reached. The third author was unaware of the other reviewers’ determinations and functioned as an arbitrator.

3. Results
Searching of the data sources was performed for two months based on the keywords and searching strategies, and a total of 41 papers were selected from 529 articles after three selection steps. The authors systematically considered the title and abstract of all papers in the indices in the first step based on the relevancy to the study subject in addition to the inclusion and exclusion criteria. Accordingly, a total of 198 articles were entered into the study. Meanwhile, 35 articles were excluded from the study due to inaccessibility to the full text or duplication (indexed in different sites). An expert panel thoroughly analyzed the remaining articles (n=163) with two expert reviewers (after a full-text reading of the articles). Eventually, 68 articles with more comprehensive and relevant information were selected. The full text of the above 68 papers was then handed to two independent expert authors, and finally, 36 articles were selected. Then, 5 articles were added from among the articles’ references, and 41 papers were selected. The flow chart of article selection is presented in Figure 1.  Table 1 represents the main features of the selected articles in addition to their aims and results.








The result indicated that the above 41 selected articles were from the outcome of studies performed in 21 different countries. Most of the randomized controlled trial (RCT) studies (82.9%) and interventions were related to lifestyle (61%). Meanwhile, most studies (53.7%) represented an improvement in the patient’s status and a decrease in HbA1c, while the reduction of HbA1c accompanied the outcome of most diet intervention studies (88.9%). The percentage and frequency of the under-study variables in terms of the type of study, type of intervention, the comparison group, and the interventions’ outcomes are shown in Table 2.


In response to the first question of the study:
1) What are the types of non-pharmacological interventions used in intervention studies to control or treat type 2 diabetes?
In the present study, it was determined that the researchers had used the interventions, such as “changing the lifestyle (diet, physical activity, and social support),” “treatment devices,” “treatment-other,” “traditional treatment,” and other interventions (education).
In response to the second and third questions of the study:
2) In intervention studies, which non-pharmacological intervention is most recommended in controlling or treating type 2 diabetes?
3) What have been the outcomes of non-pharmacological interventions in controlling or treating type 2 diabetes?
Most non-pharmacological intervention to control and improve type 2 diabetes was related to lifestyle (60.9%), although only 4.9% of the studies had investigated all lifestyle elements. Among the lifestyle variables, the highest frequency was diet and nutritional supplements (19.5%). Subsequently, physical activity (26.8%) and social support (7.3%) had the highest frequencies, respectively.
About 65.9% of interventions resulted in controlling and improving blood sugar and decreasing HbA1c. Meanwhile, 7.3% of the studies represented satisfaction and increased patients’ quality of life; only 26.8% showed no significant statistical result. The study's results also demonstrated that all diet-related interventions produced the outcome of better control and improvement of blood sugar and decreased HbA1c, which indicates the importance of diet as an essential factor in controlling and preventing type 2 diabetes. 

4. Discussion
Articles related to diabetes have dramatically increased worldwide in recent years. The Medline website contains more than 60 thousand papers published in the past seven years on this subject, hence confirming the importance of the issue and the concerns felt by all countries regarding the prevalence of diabetes and their serious attempt to find ways to prevent and control this disease. Using non-pharmaceutical interventions to treat and control diabetes while avoiding expenses for the patient and society prevents drug side effects. Hence, the use of non-pharmaceutical interventions is preferable to pharmaceutical ones. 
WHO has classified the intervention types into 12 classes as follows: Behavior, diagnosis, early detection, lifestyle, placebo, prevention, rehabilitation, treatment devices, treatment-drugs, treatment-surgery, and treatment-other and other. The results of this study were classified into four categories: 1) Lifestyle, 2) Treatment-devices, 3) Treatment-other (traditional treatment), and 4) Other (education).

Lifestyle
US Diabetes Association considers lifestyle management a principal aspect of preventing and controlling type 2 diabetes [29]. Although lifestyle interventions are the major element of care in type 2 diabetes cases [30] and lifestyle can prevent the micro- and macro-vascular complications accompanied by type 2 diabetes [31], due to the complexity and time-consuming nature of complete intervention in lifestyle, a minimal number of studies are often conducted. Most studies consider only one of the elements involved in the lifestyle as an individual variable. This is while numerous factors, including smoking, alcohol consumption, physical activities, diet, social support and spiritual dimensions, and stress in lifestyle are also involved [32-34]. Based on the findings of this study, among the lifestyle components, most of the components, including physical activity, nutrition, and social support, have been studied.

Diet 
Most of the articles reviewed in this study have investigated the diet component as an essential factor in lifestyle. Low carbohydrates, low-calorie diet [35-36], traditional beverages [37], brown rice [38], β carotene-enriched foods [39], nutritional supplements containing several low-glucose nutrients with breakfast [40], low-fat diet [41], and prepared food with high protein and low glucose concentration in enteral nutrition [42] have been effective in better blood sugar control and reduction of HbA1c level in type 2 diabetes patients. However, whey protein supplementation was not effective [43]. Vitamin D supplementation did not affect type 2 diabetes incidence or insulin resistance [44]. 
Accordingly, the results of this study are indicative of the essential role of diet in controlling the blood sugar of people with type 2 diabetes; therefore, it is recommended that considering the native and local nutritional cultures of each country and ease of access to foodstuffs, the necessary education is given to this type of diabetics. The latest guidelines for type 2 diabetes in China also introduce medical nutrition therapy as an essential component of the control and treatment of these patients [45]. 

Physical activity
In this study, it was confirmed that acute exercise with various intensities is ineffective in controlling the blood sugar of type 2 diabetes patients [46]; however, the use of vegetable supplements, such as fenugreek seed with physical activity, in addition to the reduction of blood sugar, would significantly decrease the body fat percentage [47]. The results of studies also indicate the effect of following a regular and uninterrupted exercise program throughout life on controlling glucose metabolism [48] and programmed structured exercise on the blood sugar level after delivery in the GDM [49].
Physical activity affects lipids, blood sugar, cardiovascular incidents, and life quality and is additionally considered an essential element in predicting and controlling type 2 diabetes. Physical activity with moderate weight loss can decrease the vulnerability risk of type 2 diabetes by up to 58% in high-risk populations [50]. Aerobic exercise, on land and in water, may improve blood sugar and nerve function in type 2 diabetes [51, 52]. Ghanbarzadeh (2017) also demonstrated that a balanced and low-fat diet maintained with (aerobic or anaerobic) exercise can be effective in decreasing the blood sugar of diabetics [53]. In some studies, the intensity of physical exercise is known as the main determinant of metabolic improvement and is also effective on blood sugar [54, 55]. 
According to the contradictory results of studies [56-60], the effective role of physical activity in decreasing weight and physical health is not unknown. Still, due to a lack of knowledge on the type of activity, intensity, and frequency of exercises that could be effective on the blood sugar of type 2 diabetes patients, the whole issue needs further investigation.

Social support
This study determined that the family's social support, especially with their participation in the health care program of type 2 diabetes patients, results in blood sugar control [61]. Peer social support had a satisfactory effect on diabetic behavior, diabetes-related knowledge, and self-management of diabetic patients in rural China [ ]; however, peer-supportive interventions were ineffective in controlling blood sugar and side effects [56]. 
The results of other studies are in line with the results of this study that community-based social support will be associated with better health [63] and is effective on the HbA1c level and lifestyle as well as self-efficacy [64-66].‎‎

Lifestyle
The study results indicate the effects of the lifestyle interventions on better sexual performance of the patients and their satisfaction [67]. Also, better stress control has been accompanied by diet self-efficacy and higher life quality, although with no evident changes in the biochemical variables [68].

Treatment-devices
Continuous glucose monitor (CGM) devices were effective in the patients' blood sugar control and satisfaction [38]. Although telemonitoring was effective in controlling the blood sugar and improving the HbA1c level of type 2 diabetes patients, this effectiveness was weakened six months after the termination of such monitoring [69]. In GDM, telemedicine can be associated with better diabetes control and maternal and neonatal outcomes [70].
The diabetes monitoring device may include sensors to supervise one or more of the following items: Blood sugar level, physical activity, energy consumption, and insulin dose [71]. Although numerous interventions have reported the significance and effect of telemedicine and telemonitoring interventions on controlling and preventing diabetes complications [72-74], telemedicine services must facilitate infrastructure, including continuous support services and service guideline training, to be effective. Therefore, the capacity of telemedicine providers will be far more critical than the competence of their recipients in the success of telemedicine services [75].

Traditional treatment
Although the result of this study is indicative of the ineffectiveness of using cinnamon nutritional supplements [76] in reducing the blood sugar of type 2 diabetes patients, the consumption of bee propolis [77] and sesame seeds [78] achieved the fetal bovine serum reduction outcome besides reducing the HbA1c level. 

Education
Targeted training in diabetes management (TTIM) improved psychiatric symptoms and heightened the knowledge level of diabetes [79, 80]. Diabetes self-management and education can, in addition to decreasing body weight, improve the HbA1c level [81, 82]. Although the training DVD was not effective in controlling blood sugar in type 2 diabetics, the video-based lifestyle education program was effective in improving glycemic control in patients with type 2 diabetes [83, 84].
Diabetes self-management and education support facilitate the knowledge, skill, and ability required for self-care in diabetics [85, 86]. Based on the results reported by numerous studies, education currently represents one of the most essential elements in preventing and controlling diabetes [87, 88]. Peer support for educational intervention and simulation education in diabetes control will be useful [89, 90]. However, assessing educational needs is necessary for the success of every educational program [91]. The self-management education must be appropriate to the specific population considering the ethnic, social, cognitive, literacy, and cultural factors. There is a need to improve access to and absorption of diabetes self-management programs across the globe [92], and comprehensive research should be conducted on the manner, period, and method of interaction with the trainer. It is recommended that in every educational group, first, the preliminary educational needs assessment is performed. Then, based on the literacy level, cultural and ethnic factors, and the groups' educational needs, the content and tools suitable to the training are selected, and the educational planning is executed. 

5. Conclusion
Study findings show that applying non-pharmaceutical interventions effectively controls and prevents type 2 diabetes complications. The interventions, such as lifestyle correction, suitable diet, social support, application of treatment devices, traditional treatment, and education, all have a role in treating type-2 diabetes. However, depending on the patient’s condition, these interventions may need to be accompanied by medication. Most studies are in line with a low-carbohydrate diet. Still, this study demonstrated that in addition to the low glucose and high protein diet, consuming some foodstuffs, including brown rice, DAK beverages, β-carotene contained foods, and low-fat diets could decrease HbA1c levels. Structured physical activity, family support through their participation in the care programs, application of telemonitoring devices, and diabetes self-management education are all effective methods in controlling diabetes and preventing its complications. However, some of these components need further investigation to confirm a rigorous and consistent program. In addition, it seems that the most important issue is education because using all of the above methods requires patient education, so proper patient education should not be neglected.

Study limitations
We attempted to minimize the limitations of this study. We used several strategies to identify studies to limit publication bias's possible effect. The Inclusion criteria were chosen to increase the possibility that high-quality studies would be selected. However, there are many limitations. Firstly, a literature search was conducted in major electronic databases, Medline, Science Direct, Embase, Scopus, Cochrane Library, and the Google Scholar search engine. Still, no other databases were searched (gray literature). Therefore, some relevant studies are probably missing. Secondly, based on the search strategy in the study, we included all studies with available full text in English and Persian languages that investigated the non-pharmacological interventions in the control and treatment of type 2 diabetes with “clinical trial,” “treatment,” “type-2 diabetes,” ‘control,” and its equivalents in MeSH, namely “NIDDM” and “diabetes mellitus.” However, other interventions for treating this disease can be investigated in other studies, but due to the small number of them, they were not included in this study, and only the main interventions were used. Third, we excluded articles published in preprint databases due to a lack of peer review.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Sabzevar University of Medical Sciences (Code: IR.MEDSAB.REC.1399.145) and informed consent was obtained from every participant.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Writing–review and editing: Fatemeh Ghardashi and Roghayeh Zardosht; Data collection and writing–original draft: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank Sabzevar University of Medical Sciences for their support.


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