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VOLUME 4: NO. 1 JANUARY 2007
The Healthy Diabetes Plate
COMMUNITY CASE STUDY
Suggested citation for this article: Raidl M, Spain K,
Lanting R, Lockard M, Johnson S, Spencer M, et al. The
healthy diabetes plate. Prev Chronic Dis [serial online]
2007 Jan [date cited]. Available from: http://www.cdc.gov
/pcd/issues/2007/jan/06_0050.htm.
PEER REVIEWED
Abstract
Background
Diabetes education presents two major challenges to the
U.S. Cooperative Extension System. The first is that the
majority of diabetes education services are provided in
more populated areas, resulting in large nonurban areas
being underserved. The second is that many individuals
with diabetes find the meal-planning component of dia-
betes education confusing.
Context
The University of Idaho, a land-grant institution,
includes teaching, research, and extension as part of its
mission. Extension means “reaching out,” and in Idaho,
the Extension Service provides research-based programs
on agricultural, natural resources, youth, family, commu-
nity, and environmental issues in 42 of Idaho’s 44 counties,
making it accessible to most Idahoans.
Methods
The University of Idaho Extension Service collaborated
with dietitians and certified diabetes educators to develop
and test materials that simplify the meal-planning compo-
nent of diabetes education. The result was a four-lesson
curriculum, The Healthy Diabetes Plate, which used the
plate format to teach individuals about the type and
amount of foods they should consume at each meal. In
2004, the four-lesson curriculum was taught in three
urban and five rural counties. Surveys, hands-on activi-
ties, and note-taking of participants’ comments were used
to collect data on participants’ characteristics, their ability
to plan meals, and changes in eating habits.
Consequences
Participants were able to correctly plan breakfast, lunch,
and dinner meals and improved their intake of fruit and
vegetables.
Interpretation
Quantitative and qualitative evaluation information
gathered from class participants helped identify which
components of The Healthy Diabetes Plate curriculum
were effective.
Background
Approximately 21 million Americans, or 7% of the
American population, have been told by a doctor or other
health care professional that they have diabetes (1). But
how well do people with diabetes manage their disease? A
survey conducted by the American Association of Clinical
Endocrinologists on 157,000 individuals with type 2 dia-
betes found that approximately two thirds did not have
their diabetes under control and were more likely to expe-
rience blindness and limb loss or die prematurely from
myocardial infarction, kidney failure, or a stroke (2).
Diabetes education is recommended to help individuals
control their diabetes, but to be effective diabetes educa-
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
www.cdc.gov/pcd/issues/2007/jan/06_0050.htm • Centers for Disease Control and Prevention 1
Martha Raidl, PhD, RD, Kristina Spain, MS, RD, Rhea Lanting, MS, Marsha Lockard, MS, Shelly Johnson,
MS, Marnie Spencer, MS, RD, Laura Sant, MS, RD, Julia Welch, Audrey Liddil, MS, Mimi Hartman-
Cunningham, MA, RD, CDE
VOLUME 4: NO. 1
JANUARY 2007
tion must be accessible and understandable. Currently,
most diabetes educators are located in health care organi-
zations in urban areas (3), and most diabetes information
provided in nutrition therapy classes is poorly understood
by participants (4). In Idaho, the solution to both problems
was to have the University of Idaho (UI) Extension Service
deliver diabetes education. The extension service is acces-
sible to rural and urban clientele, having offices in 42 of 44
counties in Idaho. To make nutrition therapy classes
understandable to participants, materials were developed
using a visual format, the Idaho Plate Method (IPM). A
group of Idaho dietitians modified the Swedish Plate
Method, which has been used successfully since 1987 to
teach meal planning to individuals with type 2 diabetes
(5-7). The IPM follows the nutritional guidelines of the
American Diabetes Association and the American
Dietetic Association (8).
Studies show that participants gain and retain more
knowledge about diabetes when attending more than one
lesson (9). Although the IPM has been used as a tool to
plan meals, no multi-lesson diabetes curriculum had been
developed for using the IPM as part of the meal-planning
process. Therefore, a curriculum was developed that
focused on using the IPM to plan meals in many settings.
The resulting four-lesson curriculum was called The
Healthy Diabetes Plate (10), and its target audience was
defined as adults with type 2 diabetes or their caregivers.
The purpose of this project was to develop, test, and evalu-
ate The Healthy Diabetes Plate curriculum that could be
taught by extension educators to underserved populations.
Context
The incidence of diabetes in Idaho has increased from 4%
in 1997 to 6.2% in 2004 (11). In 2005, more than 61% of the
state’s area or population was designated as medically
underserved (12). The UI Extension System can help reach
this underserved population. UI faculty members who
teach extension programs in the community are called
extension educators, and those that teach nutrition and
health programs are called Family and Consumer Sciences
(FCS) extension educators. The extension nutrition educa-
tion specialist at UI provides research-based information
and program development for FCS extension educators.
The increased incidence in diabetes in Idaho has created
greater interest and demand for diabetes education mate-
rials among FCS extension educators. In 2000, the UI
extension nutrition education specialist conducted a needs
assessment with 24 UI FCS extension educators. The
number one request among the extension educators was
for new materials on nutrition for diabetes education. The
request was based on input from advisory boards and res-
idents in their local communities. The UI FCS extension
educators requested that any diabetes education materials
developed include basic information on diabetes but focus
mainly on meal planning in a variety of settings. The UI
College of Agricultural and Life Sciences provided a $3000
grant to develop and test diabetes materials that could be
used by UI FCS extension faculty.
It was also important that materials used by extension
faculty be technically accurate. The program manager for
the Idaho Diabetes Prevention and Control Program pro-
moted The Healthy Diabetes Plate curriculum in Idaho
and other states by reviewing materials and facilitating
collaboration between local registered dietitians, certified
diabetes educators, and FCS extension educators.
The resulting four-lesson curriculum was developed and
piloted during 3 years in three states (Idaho, Oregon, and
Colorado) and reviewed by 10 extension educators, three
extension nutrition specialists, and three certified diabetes
educators. Numerous revisions were made on the content,
activities, and evaluation tools. The final peer-reviewed
curriculum, called The Healthy Diabetes Plate, was pub-
lished in January 2003 (10). Eight UI extension faculty
members received a copy of the final curriculum in October
2003 and were trained on the materials, activities, evalua-
tion tools, and research protocol. Testing of The Healthy
Diabetes Plate was conducted during 2003 and 2004.
Methods
Program and activities
The Healthy Diabetes Plate curriculum contains four
lessons; participants met weekly either in a classroom or
supermarket. Each lesson focused on teaching participants
how to plan meals correctly using the IPM (Figure 1). The
program was designed to reach an audience of people with
diabetes and individuals who are caregivers of people with
diabetes. Because individuals aged 45 years and older
have an increased risk of developing diabetes, the program
participants were divided into two age groups: individuals
2 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2007/jan/06_0050.htm
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
aged less than 45 years and individuals aged 45 years or
older (13).
Lesson 1 covered basic information on diabetes (signs
and symptoms) and an introduction to the IPM.
Information about the five food groups (vegetables,
starches, meats and other proteins, fruits, and dairy)
and how they fit on the plate was discussed. In this class,
participants were divided into three groups and instruct-
ed to plan a breakfast, lunch, or dinner meal using a
meal-planning sheet (Figure 2). In lessons 2, 3, and 4,
participants learned how to plan meals in three different
settings. The first setting was in the home, using foods
they typically ate at home; the second setting was in the
supermarket, using new foods introduced during the
supermarket tour; the third setting was in a restaurant or
fast-food establishment. The meal-planning lessons not
only reinforced the five food groups but also helped partic-
ipants visually plan meals; participants were able to visu-
alize the types and amounts of foods allowed and how the
foods formed a balanced and nutritious meal.
Recruitment of participants
Adult participants were recruited through the county
extension newsletter and selected through nonrandom
sampling. Extension faculty found that registration for the
classes filled up quickly, and many potential participants
were placed on a waiting list for the next set of classes.
Participants were recruited from five rural and three
urban counties. When participants residing in an urban
area called to register for the class, several commented
that either they could not afford the cost of diabetes edu-
cation classes at their own local hospital or that they had
taken a class but did not understand most of it. Residents
in rural counties commented that this was the first time
diabetes classes had been offered in their county. The UI
Human Assurances Committee approved this study, and
each participant signed a subject consent form.
Program evaluation
The Healthy Diabetes Plate program was evaluated
using pre- and postcurriculum surveys and meal-planning
activities. A precurriculum survey was filled out during
lesson 1 and contained questions on demographics and dia-
betes history. The precurriculum survey also included a
four-question semiquantitative food frequency survey.
Questions in the food frequency survey were related to
foods promoted in the IPM — whole grains, fruits, vegeta-
bles, and milk — that are known to affect blood glucose lev-
els (15-17). The postcurriculum survey was completed at
the end of lesson 4; it included the same four-question
semiquantitative food frequency survey as well as a com-
ments section. In lessons 2, 3, and 4, a meal-planning
activity was used to determine participants’ abilities to
plan meals correctly using the IPM. Each participant
planned breakfast, lunch, and dinner meals in three dif-
ferent settings (i.e., home, supermarket, and eating out).
The breakfast, lunch, and dinner meals were combined
within each setting and analyzed. For each setting, the
percentage of correct responses for each of the five food
groups was calculated.
VOLUME 4: NO. 1
JANUARY 2007
www.cdc.gov/pcd/issues/2007/jan/06_0050.htm • Centers for Disease Control and Prevention 3
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
Figure 1. The Idaho Plate Method for meal planning, reproduced by permis-
sion from Idaho Plate Method, LLC (14).
Figure 2: Example of a meal-planning form from The Healthy Diabetes
Plate curriculum, Idaho Plate Method.
VOLUME 4: NO. 1
JANUARY 2007
Statistical analysis
Data were gathered on participant demographic charac-
teristics, the reasons given by participants for taking the
class, food consumption frequency, and the ability of par-
ticipants to plan meals correctly in three settings. Pre- and
postcurriculum food frequency questions were analyzed
using t tests; participants served as their own control.
Consequences
Demographic and diabetes characteristics
Table 1 shows participants’ age, sex, racial and ethnic
characteristics, and reasons for taking the class. One hun-
dred and thirty five individuals started the project, and
117 (87%) completed all four lessons. Most of the partici-
pants (88%) were aged 45 years or older. Ages ranged from
26 years to 83 years. Of the 117 participants who complet-
ed the lessons, 83% were female and 17% were male.
Table 1 also shows that 113 (96.6%) were white, and the
rest of the participants were evenly divided into Hispanic,
African American, Asian American, and American Indian
groups. In Idaho, the most recent census data (2004) indi-
cated that approximately 91% of the population of Idaho is
white, followed by 8% Hispanics, 1.4% American Indian
and Alaska Native, 1% Asian, and less than 0.5% African
American, Native Hawaiian and Other Pacific Islander.
While Hispanic participation in the program was low, the
rest of the research population was similar to the most
recent census data on Idaho (18).
Reasons why participants took the classes were divided
into three categories: 1) 48% had been diagnosed with type
2 diabetes; 2) 46% did not have diabetes and were care-
givers of individuals who had diabetes; and 3) 6% were not
sure if they had diabetes but were interested in learning
more about diabetes. The results indicate that the target
population was reached.
Eating habits
Table 2 shows that there were no significant changes in
daily whole grain or milk consumption, but there were sig-
nificant increases in daily fruit (P = .02) and vegetable con-
sumption (P = .01).
Ability to plan meals correctly
Table 3 shows that a high percentage of participants
were able to plan their meals correctly: 86% to 97% of par-
ticipants in the home setting; 88% to 96% in the super-
market setting; and 90% to 99% in the restaurant and
fast-food setting. In all three settings, the dairy group had
the lowest percentage of correct responses. Comments
from the instructors and participants indicated that some
participants forgot that with the IPM, cheese was grouped
with meat and other protein and not with dairy.
Interpretation
The results from the study indicate that having FCS
extension educators teach The Healthy Diabetes Plate
curriculum solves two problems encountered in diabetes
education — understandability and accessibility. The IPM
was easy for participants to understand; a high percent-
age of participants planned meals correctly in three dif-
ferent settings. Because extension faculty members are
located in urban and rural counties, diabetes education
became accessible to the underserved population. Also,
participants in our study indicated that they preferred
attending extension classes rather than visiting their
physician or attending hospital classes. We speculate that
extension educators may be viewed as less threatening
than health professionals, and a greater level of comfort
among participants may help to explain the low attrition
rate in this study.
The IPM focused on meal planning and showed partici-
pants how to include all foods in their meal planning. A
focus on meal planning provided an opportunity to rein-
force basic information at each lesson. Exposing partici-
pants to a variety of settings helped them plan their meals
accordingly. Planning meals in supermarkets and restau-
rants made the lessons more applicable and interesting
and sparked discussions on how participants could eat out
at their favorite restaurant and still adhere to the guide-
lines of the IPM.
Most Americans do not consume the recommended five
to nine daily servings of fruits and vegetables. The super-
market tour lesson provided an excellent opportunity for
participants to learn about new fruits and vegetables and
how to incorporate them in their meal plan. The signifi-
cant increase in fruit and vegetable consumption indicat-
4 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2007/jan/06_0050.htm
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
ed that participants were making some of these changes
in their diet.
The Healthy Diabetes Plate curriculum became a start-
ing point for diabetes education for many participants. One
outcome was that many participants wanted to continue to
meet on a monthly or bimonthly basis as a support group
to help one another follow the IPM. Participants also had
questions about diabetes that were outside the expertise of
the extension educator (e.g., questions about insulin, foot
care, and matching insulin to food). The extension educa-
tors invited health care professionals such as pharmacists,
podiatrists, and certified diabetes educators to answer
questions at meetings. One topic not covered in The
Healthy Diabetes Plate curriculum was physical activity.
Many participants expressed an interest in being more
physically active and starting a walking program.
One of the best ways to learn about the effectiveness of a
lesson is to listen to comments made by participants.
Participants made the following comments: “This is so easy
to understand,” “I’ll be able to follow this forever,” “Now I
know how to fit all foods into my diet,” and “I don’t have to
give up cookies forever.”
Future projects include adding a physical activity com-
ponent to the study and making The Healthy Diabetes
Plate more culturally appropriate to the Hispanic popula-
tion. Based on research indicating that diet and physical
activity may help control and prevent type 2 diabetes, a
walking program and resistance activity component are
being piloted along with The Healthy Diabetes Plate les-
sons. One of the fastest-growing population groups in
Idaho is the Hispanic population. A separate curriculum
written for the Hispanic population needs to be developed.
By participating in this project, the UI Extension Service
strengthened its ties with the residents in the community,
health care professionals, and the Idaho Diabetes
Prevention and Control Program. These diabetes educa-
tion classes are now offered on a regular basis (3 to 4 times
per year) in various counties to meet the needs of their
clientele. Many extension faculty members serve on local
diabetes advisory councils, and some health care profes-
sionals regularly refer their clients with diabetes to these
classes. Finally, the manager of the Idaho Diabetes
Prevention and Control Program is currently providing
expertise and resources for a new diabetes pedometer proj-
ect conducted by the UI Extension Service.
Acknowledgments
The authors thank Dr Lou Riesenberg, UI Department
of Agricultural and Extension Education, for his input in
planning this project and his assistance in calculating fre-
quencies on the demographic characteristics and the UI
College of Agricultural and Life Sciences for providing
funding to develop and test The Healthy Diabetes Plate.
Author Information
Corresponding Author: Martha Raidl, PhD, RD,
University of Idaho, 322 E Front St, Suite 180, Boise, ID
83702. Telephone: 208-364-4056. E-mail: mraidl@uida-
ho.edu.
Author Affiliations: Kristina Spain, Bureau of Clinical
and Preventive Services, Idaho Department of Health and
Welfare, Boise, Idaho; Mimi Hartman-Cunningham, Idaho
Diabetes Prevention and Control Program, Idaho
Department of Health and Welfare, Boise, Idaho; Rhea
Lanting, University of Idaho (UI), Twin Falls, Idaho;
Marsha Lockard, UI, Marsing, Idaho; Shelly Johnson, UI,
Coeur d’Alene, Idaho; Marnie Spencer, UI, Blackfoot,
Idaho; Laura Sant, UI, Preston, Idaho; Julia Welch, UI,
Grangeville, Idaho; Audrey Liddil, UI, Pocatello, Idaho.
Ms. Welch is now affiliated with Schweitzer Engineering,
Pullman, Wash.
References
1. National diabetes fact sheet: total prevalence of dia-
betes in the United States, all ages, 2005. Atlanta
(GA): Centers for Disease Control and
Prevention;[updated 2005 Nov 16]. Available from:
http://www.cdc.gov/diabetes/pubs/estimates05.htm#pr
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2. American Association of Clinical Endocrinologists.
State of diabetes in America. Jacksonville (FL):
American Association of Clinical Endocrinologists;
2005. Available from: http://www.aace.com
/public/awareness/stateofdiabetes/DiabetesAmericaRe
port.pdf
3. Lorig K, Gonzalez VM. Community-based diabetes
self-management education: definition and case study.
Diabetes Spectr 2000;13(4):234-42.
4. Maryniuk MD. The new shape of medical nutrition
VOLUME 4: NO. 1
JANUARY 2007
www.cdc.gov/pcd/issues/2007/jan/06_0050.htm • Centers for Disease Control and Prevention 5
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
VOLUME 4: NO. 1
JANUARY 2007
therapy. Diabetes Spectr 2000;13(3):122-4.
5. Camelon KM, Hadell K, Jamsen PT, Ketonen KJ,
Kohtamaki HM, Makimatilla S, et al. The Plate Model:
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6. Rizor HM, Richards S. All our patients need to know
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8. Rizor H, Smith M, Thomas K, Harker J, Rich M.
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9. Noel PH, Larme AC, Meyer J, Marsh G, Correa A,
Pugh JA. Patient choice in diabetes education curricu-
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diabetes. Diabetes Care 1998;2(16):896-901.
10. Raidl M. The Healthy Diabetes Plate. Moscow:
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11. Idaho Department of Health and Welfare. Idaho
Behavioral Risk Factors: results from the 2004
Behavioral Risk Factor Surveillance System. Boise
(ID): Division of Health, Bureau of Health Policy and
Vital Statistics; 2005.
12. Salant P, Porter A. Profile of rural Idaho: a look at eco-
nomic and social trends affecting rural Idaho. Boise:
Idaho Commerce & Labor, Division of Commerce;
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RuralIdaho/tabid/204/Default.aspx.
13. National Diabetes Information Clearinghouse. Am I at
risk for type 2 diabetes? Taking steps to lower your
risk of getting diabetes. Bethesda (MD): National
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14. Idaho plate method [homepage on the Internet].
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PF. Whole-grain intake is favorably associated with
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Tables
Table 1. Participant Characteristics (N = 117), The Healthy
Diabetes Plate Curriculum, Five Rural and Three Urban
Counties in Idaho
Age, y
<45 (range, 26-44) 14 (12.0)
>
45 (range, 45-83) 103 (88.0)
Sex
Male 20 (17.1)
Female 97 (82.9)
Race and ethnicity
White 113 (96.6)
Hispanic 1 (0.8)
African American 1 (0.8)
Asian American 1 (0.8)
American Indian 1 (0.8)
Reason for taking class
Diagnosed with type 2 diabetes 56 (47.9)
Not diagnosed with diabetes, but are 54 (46.2)
caregivers of individuals with diabetes
Not sure if they had diabetes, but are 7 (6.0)
interested in learning about diabetes
6 Centers for Disease Control and Prevention • www.cdc.gov/pcd/issues/2007/jan/06_0050.htm
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
Characteristic No. of Participants (%)
Table 2. Results of Pre- and Postcurriculum Food Frequency Surveys (N = 117), The Healthy Diabetes Plate Curriculum, Five
Rural and Three Urban Counties in Idaho
Fruits 1.8 (0.9) 3.2 (0.4) .02
Milk 1.8 (1.0) 2.2 (0.8) .20
Vegetables 1.3 (0.7) 4.1 (0.6) .01
Whole grains 1.0 (0.4) 1.3 (0.8) .54
Table 3. Percentage of Correct Responses on Food Choices, by Food Group and Meal Setting, The Healthy Diabetes Plate
Curriculum, Five Rural and Three Urban Counties in Idaho
Bread, starch, whole grains 92 96 99
Dairy 86 88 90
Fruits 94 90 98
Meat or other protein 97 94 99
Vegetables 93 90 99
VOLUME 4: NO. 1
JANUARY 2007
www.cdc.gov/pcd/issues/2007/jan/06_0050.htm • Centers for Disease Control and Prevention 7
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
Precurriculum Postcurriculum t Test
Food Group Mean No. of Servings per Day (SD) No. of Servings per Day (SD) P Value
Meal Setting
Food Group Home Supermarket Restaurant or Fast Food