1. The Effect of Reduced Carbohydrate Diet Education on Hemoglobin A1c
in Patients with Type 2 Diabetes
Lauren C. Parker, BSN, RN
Valparaiso University DNP Student
Significance
Synthesis of the Evidence
Evaluation of Changes
Demographic data: Age; sex; race; marital status; years with type 2 diabetes; income; degree of education; and perception of diabetes control
Primary Outcomes: Hemoglobin A1c
Secondary Outcomes: Weight; body mass index; waist circumference; lipid levels; blood pressure; knowledge; comorbidities; anti-glycemic medications; and diet compliance
Knowledge was assessed via pre- and post-tests created by the project manager over a 3-month period
Attrition: Chi-square and independent t-tests revealed no differences in participants’ hemoglobin A1c and demographic variables lost to attrition (n = 5) compared to those who followed up at 3 months
Globally, 387 million people are living with type 2 diabetes (T2D), with an estimated increase of 205 million people affected by 2035 (International Diabetes Federation, 2014)
There has been a 50% increase in the rate of T2D in Indiana from 1994 to 2012 (Centers for Disease Control and Prevention, 2012)
T2D leads to many diseases including HTN, stroke, MI, CAD, CKD, and non-traumatic amputation (American Diabetes Association, 2014)
Although many guidelines exist, there remains a great debate as to the appropriate carbohydrate intake to manage T2D
Samples: Quantitative and descriptive studies
Outcomes: The critically appraised literature evaluated macronutrient composition, specifically low carbohydrate intake, as a means to manage T2D
Appraisal of Evidence
Level: Rating System for Hierarchy of Evidence
(Melnyk & Fineout-Overholt, 2005)
Quality: Johns Hopkins Nursing Evidence-Based Practice
Research and Non-Research Evidence Appraisal Tools
PICOT Question
Evidence
In patients with type 2 diabetes, what is the effect of reduced carbohydrate diet education, compared to usual care, on hemoglobin A1c over a 3-month period?
Level of
Evidence
Included
Designs of Evidence
Quality Grade
Level I 2
Systematic reviews
A (2)
Level II 4
Randomized controlled trials
B (2)
Level III 1
Controlled trial without randomization A
Level IV
Single arm intervention studies
A (1)
B (3)
Project Outcomes
Hemoglobin A1c: p = HDL: p = .033
Weight: p = Triglycerides: p = .174
Body mass index: p = Systolic blood pressure: p = .017
Waist circumference: p = Diastolic blood pressure: p = .013
Total cholesterol: p = Knowledge: p = .001
LDL: p = .830
Review of the Literature
Key Terms: Type 2 diabetes; type 2 diabetes mellitus; diabetes mellitus, type 2; low carbohydrate diet; carbohydrate, restricted; ketogenic diet; low-carbohydrate; hemoglobin A1c; glycated hemoglobin; glycosylated hemoglobin; and glycemic index
Inclusion Criteria: (a) Peer reviewed; (b) published between ; (c) written in English; and (d) abstract available
Exclusion Criteria: (a) Conducted in an in-patient setting;
(b) included a diagnosis of type 1 diabetes only; (c) utilized animal
subjects; (d) included pregnant or breast feeding women;
(e) diagnosis of gestational diabetes; (f) major focus on physical
activity; and (g) assessed the synergistic effect of diet and newly
prescribed oral anti-glycemic medications
Pre- and Post-Intervention Mean Hemoglobin A1c
Decision to Change Practice
Best Practice Recommendation:
Carbohydrate intake of <45% of daily caloric intake
Sample meal plans
Structured nurse-to-patient educational session
Self-reported food records
Implementation
Results of Literature Search
Sample: Patients with type 2 diabetes aged years seeking routine medical care (n = 24)
Pre-test (n = 24); post-test (n = 19)
Setting: Private family practice
Design: Pre-test, post-test design
Program intervention included:
15-minute student-led individual educational session
Easy-to-read handouts comprised of sample meal plans, sample grocery lists, a reduced carbohydrate food pyramid, examples of various carbohydrate-counts and corresponding measurements in common foods, and self-reported food records adapted with permission from Atkins Nutritionals, Inc.®
4- and 8-week follow-up phone calls to reinforce education
Theoretical Framework: Health promotion model (Pender, 1982)
Evidence-Based Practice Model: Iowa model of evidence-based practice (Titler et al., 2001)
Time: 3 months
Conclusions
Databases
Searched
Number of
Articles Found
Duplicate
Articles
Reviewed
Articles Analyzed
Proquest
280 21 5
MEDLINE 51 9 17
CINAHL 6 8
Health Source 2 4
Health & Wellness 10 3
Cochrane Library
Joanna Briggs Institute
Citation Search 1
This EBP project demonstrated significant improvements in patients’ hemoglobin A1c, weight, body mass index, waist circumference, systolic and diastolic blood pressure, HDL, and knowledge of a reduced carbohydrate diet
The findings from this project can help to initiate policy change for the management of patients with T2D within a family practice setting, as a means to enhance the provision of chronic care
Recommendations
Research: Greater research is warranted utilizing larger sample sizes and longitudinal designs to evaluate dietary compliance and effect long term
Practice: Continued implementation at project site via nurse practitioner and physician staff
Education: Continue to educate physicians, staff, and patients regarding the benefits of encouraging and following a reduced carbohydrate diet
Acknowledgements
Endless thanks to my advisor Dr. Munden, DNP, RN, FNP-BC
Also, thank you to the physician and staff who made this project possible