Running head: DECREASING HEMOGLOBIN A1C LEVELS

Decreasing Hemoglobin A1c Levels

Danielle Giaritelli
University of South Florida

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Abstract
Clinical Problem: Patients with Type Two Diabetes who have an uncontrolled hemoglobin A1c
level, >6.5%, are at an increased risk of serious complications including renal failure, blindness,
and increasing their chance of developing cardiovascular disease. Lifestyle modifications,
including diet, exercise, and following a structured medication regimen are the gold standards for
controlling the hemoglobin A1c in diabetic patients (Misa et al., 2013).
Objective: To determine if structured patient education about lifestyle changes will impact
hemoglobin A1c in a one-year time span compared to patients who did not receive education.
The hemoglobin A1c levels were compared in both groups at the end of the one year with the
baseline. The key words used when searching for studies on PubMed and CINHAL were
decreasing hemoglobin A1c, patient education, type two diabetes, and education for type two
diabetes.
Results: Results in all three studies concluded that patient education has a positive outcome in
decreasing hemoglobin A1c levels. Guo et al. (2013) demonstrated that insulin therapy along
with education related to diabetes allowed for a greater reduction in hemoglobin A1c, as
compared to those who only received insulin therapy (p=0.004). Misa et al. (2013) confirmed
patient education caused a decrease in hemoglobin A1c levels by implementing education
specific to each patient using the individual-based lifestyle education (SILE) program compared
to no education (p=0.003). Mohamed, Al-Lenjawi, Amuna, Zotor, & Elmahdi (2013) showed that

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educating patients with a program based on education and a patients attitude about type two
diabetes decreased hemoglobin A1c levels compared to no education (p=0.012).
Conclusion: The studies validate that additional education about diet and exercise along with
medications will result in decreased and controlled hemoglobin A1c levels.
Decreasing Hemoglobin A1c Levels
Type Two Diabetes is a complicated and debilitating disease affecting over 1 billion
people worldwide and is steadily increasing. Because of the complex nature of diabetes, it poses
risks for serious complications resulting in disabilities and decreased quality of life, while
increasing economic costs (Mohamed, Al-Lenjawi, Amuna, Zotor, & Elmahdi, 2013). Because of
the increasing prevalence of patients with type two diabetes, it is important to start educating
patients about changes they can make that will help prevent life-altering complications. Several
clinical studies utilized evidenced based practices in an effort to educate patients on ways to keep
their hemoglobin A1c level controlled, therefore decreasing their chance of developing further
complications. The method of choice in the three randomized controlled trials was implementing
patient educational sessions about what he or she can do to lower their hemoglobin A1c. Any
health care provider will be the infrastructure support needed to help implement this change. The
three randomized controlled trials as well as one guideline from the National Guideline
Clearinghouse by the Academy of Nutrition and Dietetics (2014) have been assessed to
determine if this method if effective in the clinical setting. In patients with Type 2 Diabetes, how
does patient education on lifestyle modifications (diet, exercise, medications) compared to no
education affect Hemoglobin A1c levels within one year?
Literature Search

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The search engines used to find randomized controlled trials and a guideline related to the
PICOT question were PubMed, CINHAL, and the National Guideline Clearing House. The key
search terms used were type two diabetes, decreasing hemoglobin A1c levels, patient education,
and decreasing hemoglobin A1c levels with patient education.
Literature Review
There were three randomized controlled trials and a guideline relevant to the PICOT
question that were utilized in order to confirm whether or not patient education will have a
positive outcome in decreasing hemoglobin A1c levels. Guo et al. (2013) conducted a study in
China because they were finding patients were not following their medication plan because of
lack of education. The study revealed 9.7% of their population over the age of 20 suffered from
diabetes and 95% of those people had a confirmed diagnosis of Type Two Diabetes. Because of
the information the study yielded, the Organization Program of DiabEtes INsulIN ManaGement
(OPENING), a randomized controlled study, began. The desired outcome of this study was to
determine if patients were educated about their medications and their diagnosis involved with
insulin administration would be effective in reducing Hemoglobin A1c.
The method used to conduct the study consisted of two groups and a total of 1289
patients with Type 2 Diabetes, a randomized education group and a control group, which is
shown in Table 1. The education group received insulin therapy along with additional education
related to diabetes while the control group received only insulin therapy. There were two
different types of medications given-Insulin, a subcutaneous injection and Biguanides-an oral
drug. At the end of the study, the results were compared and although similar there was a greater
reduction in the hemoglobin A1c in the education group (2.16% vs 2.08%; P<0.05). A larger

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percentage of patients in the education group obtained the target HbA1c (<6.5%). The study
seemed to prove that providing education and a strict medication regimen would result in bettercontrolled diabetes. The strength of this study was the groups were randomized and the outcomes
were obtainable. It was unbiased and allowed for accurate results. The evidence supported in this
study is valid for the paper because it demonstrated that the use of structured education has an
effect on maintaining Hemoglobin A1c and the P was less than 0.05 validating the results.
Misa et al. (2013) conducted a study that was tailored to diabetic patients specific needs.
Because of the prevalence of Type 2 diabetes and serious complications that can occur with it,
this study was conducted to evaluate if a structured individual-based lifestyle education (SILE)
program would have a positive effect with lowering hemoglobin A1c (HbA1c) levels. Lifestyle
modification is believed to be the most effective treatment for people with type two diabetes.
This randomized study led by health care professionals was conducted over a six-month time
span.
The method used for the trial, as seen in table 1, enrolled twenty general practitioners in
different clinics in Kanagawa prefecture, Japan. The participants were a total of 193 men and
women ranging from 20 to 79 years of age with type 2 diabetes and HbA1c concentrations of
6.5% (NGSP) or higher. Another requirement in order to participate in the study was that their
primary health care provider was currently treating them. Four sessions of structured individualbased lifestyle education (SILE) were implemented to see if there was a change in the
hemoglobin A1c. After concluding the study, the results were compared with those of a control
group who received their original care and no additional education. The goal of the study was to
assess the change in HbA1c levels at six months from baseline for both groups and see if there

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was a difference. The data they looked at were plasma glucose, lipid profile, blood pressure,
HgA1c levels, BMI, energy, and nutrient intake. The average change six months later in HbA1c
was a 0.7% reduction in the intervention group (n = 100) and a 0.2% reduction in the control
group (n = 93) (difference 0.5%, 95%CI: -0.2% to 0.8%, p = 0.004). The study was helpful in
confirming that the outcome of improvement in HbA1c levels was greater in those who were
additionally educated over those who received their usual care. Strengths in this study is it was
randomized trial and that it was unique to each to better fit their needs using the individual-based
lifestyle education (SILE) program. This study suggests that education and diet modification are
a vital part in decreasing HbA1c levels in patients with Type 2 Diabetes with the P value less
than 0.05 validating the effectiveness of this trial.
Mohamed et al. (2013) conducted a similar study to those explained in table 1 also
choosing too implement diabetes education to evaluate whether or not it had an impact in
decreasing patients hemoglobin A1c levels. Aside from using only diabetes education, this study
also looked at enhancing a patients attitude toward this disease and how it will positively affect
them to set goals. This method of how this study was conducted was on a total of 420 patients
with type 2 diabetes living in Doha, Qatar. The patients were picked at random for intervention
(n=215) or a control group (n=215). They gathered a baseline for each patient and also measured
the patients hemoglobin A1c and lipid profile at intervals of every three months. The
interventions used for the intervention group were four different education sessions of ten to 20
patients per session lasting three to four hours. The four different topics each session covered
were diabetes pathophysiology and complications, maintaining a healthy life style, exercise
benefits and goal setting, and lastly, concentrating on enhancing attitude and practice using

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counseling techniques. They assessed the outcomes for each patient comparing the control group
and intervention group with each baseline and the final level 12 months later after intervention .
When comparing the outcome of both groups, results showed a significant decrease in the
Hemoglobin A1c (P=0.012) and improvement in diabetes knowledge (p=0.0001) in the
intervention group. The strengths in this study are that it was randomized and utilized
informational resources to educate the patient on how they can control their diabetes through
methods other than strictly medications. These studies have the evidence to show that structured
patient education on diabetes and promoting a healthy life style can significantly reduce
hemoglobin A1c and ways to do so with a resulting value of P of 0.012 in decreasing hemoglobin
A1c validating this study.
The guideline used from the National Guideline Clearinghouse by the Academy of
Nutrition and Dietetics (2014) specified several different evidence based practices in the
approach to reduce hemoglobin A1c in diabetic patients. The guideline has very similar results as
the studies listed in Table 1, placing emphasis on patient education about lifestyle changes (i.e.
diet and exercise). The guideline gave a nutritional intervention providing foods that are
recommended for supporting weight loss. It also recommended nutritional counseling along with
goal setting and practicing new behaviors. The guideline proposed the same interventions as the
randomized controlled trials about the importance of patient education in order to decrease
hemoglobin A1c levels.
Synthesis
Guo et al. (2013) showed that providing diabetic patients with information about their
medications and diagnosis would contribute towards lowering hemoglobin A1c (P<0.05). Misa et

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al. (2013) demonstrated that providing education to diabetic patients in four different educational
sessions, which were specific to that patients needs allowed for a significant reduction in
hemoglobin A1C levels (P=0.004). Mohamed et al. (2013) confirmed that providing patients
with additional education along with encouraging goal setting and a better attitude would allow
for a decrease in hemoglobin A1c (P=0.012). The Academy of Nutrition and Dietetics (2014)
also high recommends nutritional therapy, goal setting, and social support to help reduce
hemoglobin A1c levels (2014).
Evidence of the studies show that there is a significant reduction in hemoglobin A1c in
those who receive education compared to those who do not. However, it is unknown if a patient
will seek out a resource to receive education or if health care providers will provide it. Because
of this gap, further research is still needed to evaluate what can be done to encourage patients to
look for resources that can provide them with education and also the motivation to do so.
Another gap is these studies were conducted on specific ethnicities; therefore these results may
not be valid for other populations that have not had a study done yet. Further research will need
to be done for this potential problem, because education may not be as effective in some cultures
as it is in others.
Proposed Practice Change
Providing diabetic patients with education about their disease and simple changes that
can reduce their risk of complications has evidence supporting that it can reduce hemoglobin
A1c. Because it is unknown whether or not a patient chooses to look for this education, it is
imperative health care providers start implementing this education in their clinical settings. The
amount of sufficient evidence supporting this should allow for this practice to become evidence

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based in all health care areas because there a significant impact on enhancing a patients quality
of life.
Change Strategy
An important strategy that would promote staff engagement is emphasizing patient care
and encouraging staff to educate their diabetic patients about lifestyle changes to prevent
complications because of the positive impact it will have on their patients life. Reminding staff
about patients quality of life and the importance placed on this in clinical setting should enable
them to have more of a desire to educate their patients because they want the best outcome. Also,
holding a team meeting and presenting this evidence could be a key factor in promoting staff
engagement because it shows education has a significant impact on decreasing hemoglobin A1c.
The Model for Evidence-Based Practice Change
It is vital to diabetic patient outcomes that health care providers recognize the importance
of patient education and the affect it has on hemoglobin A1c and the need to conform practice
into an evidenced-based solution. In order to implement these changes, there needs to be
structured educational sessions provided by health care teams based on current evidence. The
Model for Evidence-Based Practice Change can be utilized for implementing this proposal into
the clinical setting.
Roll Out Plan
Steps

Description of Steps

Timeframe For Rollout

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Step 1

Assess the need for change in practice at diabetes

Complete January, 2015
institute and health care organizations with diabetic
patients
Include stakeholders at the hospital and other
heath care organizations
Collect internal data about current practice and if
there is information given to diabetic patients
Compare external data with internal data
Identify problem which is the lack of patient
education about diabetes causing uncontrolled
hemoglobin A1c levels
Link problem, interventions, and outcomes by
presenting previously researched randomized
controlled trials and the evidence supporting the
research

Step 2

Locate the best evidence through researching different

Complete February, 2015
randomized controlled trials and using the best studies
Identify types and sources of evidence
Review research concepts through websites such
as CINHAL, PubMed, and the National
Guideline Clearinghouse
Plan the search and conduct the search

Step 3

Critically analyze the evidence

Critically appraise and weigh the evidence
Synthesize the best evidence by reviewing the
randomized controlled trials and deciding which
methods used were most effective
Assess feasibility, benefits, and risks of new
practice

Complete February, 2015

Step 4

Design practice change

Define proposed change by sharing evidence
found and the support for practice change
Identify needed resources by deciding where
education sessions can take place and times
available to best fit patients needs
Design the evaluation of the pilot
Design the implementation plan by planning
with health care providers how they can most
efficiently deliver diabetes education that will
benefit the patient

Complete March, 2015

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Step 5

Step 6

Implement and evaluate change in practice

Implement pilot study
Evaluate processes, outcomes, and costs by
discussing with health care team and providers
and figuring out the most efficient and cost
effective way to implement the practice change
Develop conclusions and recommendations

Communicate recommended change to

stakeholders
Integrate into standards of practice after the
study is complete and the change was proven to
be effective in decreasing patients hemoglobin
A1c levels
Monitor process and outcomes periodically by
checking patients hemoglobin A1c levels every
three months through follow up appointments to
see if the education is continuing to help them
control their hemoglobin A1c levels
Celebrate and disseminate results of project by
having a party to celebrate the teams success
and efforts

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Implement: May, 2015
Evaluate: May, 2016

May, 2016

Model of evidence-based practice change (Melnyk & Fineout-Overholt, 2011, p. 286).

Project Evaluation
At the start of May, 2015, all diabetic patients will receive education about diabetes and
dates of four educational seminars that will discuss the pathophysiology of diabetes, goal setting,
nutritional information to promote weight loss or maintaining a healthy lifestyle, and exercise.
The specific data planned to be collected are hemoglobin A1c levels to evaluate whether or not
these changes are reducing the levels prior to education. If the hemoglobin A1c level has a
significant decrease and is less than or equal to 6.5% at the end of the study compared to the
baseline, then it will indicate a success. Because each hemoglobin A1c level is patient specific,
the percent needed to decrease in order to be successful will depend on each patient, therefore it
is determined successful if the level is below or equal to 6.5%. The test will be done every three

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months over a one year time span to determine if patients continue following the lifestyle
changes are they are educated.
Dissemination of EBP
There are several ways this project can be disseminated both locally and regionally.
Letters and emails can be written to inform stakeholders and health care providers of the change
in policy and reminding them they need to be providing patients with education and telling them
about the seminars that will be occurring. A team meeting for each floor in a clinical setting
would be critical to success, so there are uniform guidelines of what to educate each patient
about and how to do so. This can be presented with a PowerPoint, poster, or handouts. Last,
establishing a leadership team that can conduct small focus group meetings and involving
clinical EBP experts who can act as mentors will allow for engaged clinical support. Gaining
administrative support through these actions will enable the project to be successful. Explaining
the reason for this proposal and the evidence behind can help disseminate the project. Another
method is publishing a paper in a scientific journal that hospitals can read and see the impact this
proposal can have on patient outcomes. Promoting patient education in clinical settings
everywhere for diabetic patients will improve the overall health of these patients, reduce risks of
complications, and decrease hospital stays.

References
Academy of Nutrition and Dietetics. (2014). Prevention of type 2 diabetes evidence-based
nutrition practice guideline. Chicago (IL): Academy of Nutrition and Dietetics
Guo, X., Ji, L., Lu, J., Liu, J., Lou, Q., Liu, J., & ... Gu, M. (2013). Efficacy of structured

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education in patients with type 2 diabetes mellitus receiving insulin treatment. Journal of
Diabetes, 6(4), 290-297. doi:10.1111/1753-0407.12100
Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing &
Healthcare (2nd ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams &
Williams.
Misa, A., Kazue, Y., Mariko, W., Masako, N., Itsuro, K., Eisuke, H., & Toshiro, T. (2013).
Effects of lifestyle education program for type 2 diabetes patients in clinics: A cluster
randomized controlled trial. BMC Public Health, 13(1), 1-14. doi:10.1186/1471-2458-13467
Mohamed, H., Al-Lenjawi, B., Amuna, P., Zotor, F., & Elmahdi, H. (2013). Culturally sensitive
patient-centered educational programme for self-management of type
2 diabetes: A randomized controlled trial. Primary Care Diabetes, 7,199-206.
doi:10.1016/j.pcd.2013.05.002

Table 1
Literature Review

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Reference

Aims

Design and
Measures

Sample

Outcomes /
statistics

Guo, X., Ji, L., Lu, J.,

Liu, J., Lou, Q., Liu, J.,
& ... Gu, M. (2013).
Efficacy of structured
education in patients with
type 2 diabetes mellitus
receiving insulin
treatment. Journal of
Diabetes, 6(4), 290-297.
Doi:
10.1111/1753-0407.1210
0.

To determine
if education
about insulin
therapy and
additional
education in
diabetic
patients is
effective in
lowering
hemoglobin
A1c levels.

Randomized
trial comparison
in a one year
time period.
This study
measured that
patient
education has a
significant
impact on
decreasing
hemoglobin
A1c levels.

A total of 1,289
patients with
type two
diabetes were
split into a
control group
and a
randomized
education group.

Patient
education
significantly
reduced
hemoglobin
A1c levels in
the
randomized
education
group
(P=<0.05).

Misa, A., Kazue, Y.,

Mariko, W., Masako, N.,
Itsuro, K., Eisuke, H., &
Toshiro, T. (2013).
Effects of lifestyle
education program for
type 2 diabetes patients
in clinics: A cluster
randomized controlled
trial. BMC Public Health,
13(1), 1-14. doi:
10.1186/1471-2458-13-4
67

To determine
if using a
structured
individualbased
lifestyle
education
program
specific to
each patient
is effective in
lowering
hemoglobin
A1c levels.

Randomized
control trial
done in Japan
over a six
month time
period. This
study measured
if four sessions
of structured
individual
lifestyle-based
education has a
significant
impact on
decreasing
hemoglobin
A1c levels.

A total of 193
men and women
with ages
ranging from 20
to 79 with type
two diabetes and
a hemoglobin
A1c level >6.5%
were in the
study. A
requirement in
order to
participate was
they were
currently being
treated for
diabetes.

The four
educational
sessions had a
positive
impact and
contributed
too reducing
patients
hemoglobin
A1c levels
(P=0.004).

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Mohamed, H., AlLenjawi, B., Amuna, P.,
Zotor, F., & Elmahdi, H.
(2013). Culturally
sensitive
patient-centered
educational programme
for self management of
type
2 diabetes: A
randomized controlled
trial. Primary Care
Diabetes, 7,199-206.doi:
10.1016/j.pcd.
2013.05.002

To determine
the
effectiveness
of a
structured
education
program
based on
knowledge,
attitude, and
practice
measures in
patients with
type two
diabetes and
the effects it
had on
hemoglobin
A1c levels.

Randomized
control trial
conducted in
Qatar over a
one year time
period. It
measured if
providing
patients with
education;
knowledge,
encouraging
goal setting and
a positive
attitude would
affect
hemoglobin
A1c levels.

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A total of 420
patients were
picked at random
for an
intervention
group and a
control group.
They put
together a
baseline of
measurements
and also
measured the
hemoglobin A1c
level every three
months.

The study
showed that
providing
patients with
education and
also giving
them advice
on setting
goals to lose
weight and
having a
positive
attitude about
maintaining
a healthy
lifestyle is a
key part of
reducing
hemoglobin
A1c levels
(P=0.012).

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