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The Healthy Diabetes Plate

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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 diabetes education confusing. 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, community, and environmental issues in 42 of Idaho's 44 counties, making it accessible to most Idahoans. The University of Idaho Extension Service collaborated with dietitians and certified diabetes educators to develop and test materials that simplify the meal-planning component 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 activities, and note-taking of participants' comments were used to collect data on participants' characteristics, their ability to plan meals, and changes in eating habits. Participants were able to correctly plan breakfast, lunch, and dinner meals and improved their intake of fruit and vegetables. Quantitative and qualitative evaluation information gathered from class participants helped identify which components of The Healthy Diabetes Plate curriculum were effective.
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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
ev3
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:
a visual method of teaching meal planning. DAIS
Project Group. Diabetes Atherosclerosis Intervention
Study. J Am Diet Assoc 1998;98(10):1155-8.
6. Rizor HM, Richards S. All our patients need to know
about intensified diabetes management they learned
in fourth grade. Diabetes Educ 2000;26(3):392-
4,396,400-2.
7. Brown MD, Lackey HD, Miller TK, Priest D.
Controlling calories — the simple approach. Diabetes
Spectr 2001;14(2):110-2.
8. Rizor H, Smith M, Thomas K, Harker J, Rich M.
Practical nutrition: the Idaho Plate Method. Practical
Diabetology 1998;17:42-5.
9. Noel PH, Larme AC, Meyer J, Marsh G, Correa A,
Pugh JA. Patient choice in diabetes education curricu-
lum: nutritional versus standard content for type 2
diabetes. Diabetes Care 1998;2(16):896-901.
10. Raidl M. The Healthy Diabetes Plate. Moscow:
University of Idaho Educational Publications; 2003.
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;
2005. Available at: http://irp.idaho.gov/Profileof
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
Institute of Diabetes and Digestive and Kidney
Diseases, National Institutes of Health; 2004. Chapter
4, Should I be tested for diabetes?; p. 4. Available from:
http://diabetes.niddk.nih.gov/dm/pubs/riskfortype2/ris
k.pdf.
14. Idaho plate method [homepage on the Internet].
Rexburg (ID): Idaho Plate Method. Available from:
http://platemethod.com.
15. McKeown NM, Meigs JB, Liu S, Wilson PW, Jacques
PF. Whole-grain intake is favorably associated with
metabolic risk factors for type 2 diabetes and cardio-
vascular disease in the Framingham Offspring Study.
Am J Clin Nutr 2002;76(2):390-8.
16. Ford ES, Mokdad AH. Fruit and vegetable consump-
tion and diabetes mellitus incidence among U.S.
adults. Prev Med 2001;32(1):33-9.
17. Choi HK, Willett WC, Stampfer MJ, Rimm E, Hu FB.
Dairy consumption and risk of type 2 diabetes mellitus
in men: a prospective study. Arch Intern Med
2005;165(9):997-1003.
18. U.S. Census Bureau. State and county QuickFacts:
Idaho. Washington (DC): U.S. Census Bureau;[updat-
ed 2006 Jan 12]. Available from: http://quickfacts.cen-
sus.gov/qfd/states/16000.html
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
... A nurse of each participating healthcare center, who were previously trained for the study and unconnected to the other activities of the study, gave the standardized individual brief advice about healthy lifestyles before randomization to the study groups. The advice regarding diet was based on the plate method [29] to attain a more balanced diet, where the plate is divided into 4 parts: half of the plate for salad or vegetables, a quarter for carbohydrates and the other quarter for proteins (preferably white meats). Moreover, it is recommended to add a medium-sized piece of fruit and a low-fat dairy product, which can be consumed as a dessert. ...
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Background Mobile health (mHealth) is currently among the supporting elements that may contribute to an improvement in health markers by helping people adopt healthier lifestyles. mHealth interventions have been widely reported to achieve greater weight loss than other approaches, but their effect on body composition remains unclear. Objective This study aimed to assess the short-term (3 months) effectiveness of a mobile app and a smart band for losing weight and changing body composition in sedentary Spanish adults who are overweight or obese. Methods A randomized controlled, multicenter clinical trial was conducted involving the participation of 440 subjects from primary care centers, with 231 subjects in the intervention group (IG; counselling with smartphone app and smart band) and 209 in the control group (CG; counselling only). Both groups were counselled about healthy diet and physical activity. For the 3-month intervention period, the IG was trained to use a smartphone app that involved self-monitoring and tailored feedback, as well as a smart band that recorded daily physical activity (Mi Band 2, Xiaomi). Body composition was measured using the InBody 230 bioimpedance device (InBody Co., Ltd), and physical activity was measured using the International Physical Activity Questionnaire. Results The mHealth intervention produced a greater loss of body weight (–1.97 kg, 95% CI –2.39 to –1.54) relative to standard counselling at 3 months (–1.13 kg, 95% CI –1.56 to –0.69). Comparing groups, the IG achieved a weight loss of 0.84 kg more than the CG at 3 months. The IG showed a decrease in body fat mass (BFM; –1.84 kg, 95% CI –2.48 to –1.20), percentage of body fat (PBF; –1.22%, 95% CI –1.82% to 0.62%), and BMI (–0.77 kg/m2, 95% CI –0.96 to 0.57). No significant changes were observed in any of these parameters in men; among women, there was a significant decrease in BMI in the IG compared with the CG. When subjects were grouped according to baseline BMI, the overweight group experienced a change in BFM of –1.18 kg (95% CI –2.30 to –0.06) and BMI of –0.47 kg/m2 (95% CI –0.80 to –0.13), whereas the obese group only experienced a change in BMI of –0.53 kg/m2 (95% CI –0.86 to –0.19). When the data were analyzed according to physical activity, the moderate-vigorous physical activity group showed significant changes in BFM of –1.03 kg (95% CI –1.74 to –0.33), PBF of –0.76% (95% CI –1.32% to –0.20%), and BMI of –0.5 kg/m2 (95% CI –0.83 to –0.19). Conclusions The results from this multicenter, randomized controlled clinical trial study show that compared with standard counselling alone, adding a self-reported app and a smart band obtained beneficial results in terms of weight loss and a reduction in BFM and PBF in female subjects with a BMI less than 30 kg/m2 and a moderate-vigorous physical activity level. Nevertheless, further studies are needed to ensure that this profile benefits more than others from this intervention and to investigate modifications of this intervention to achieve a global effect. Trial Registration Clinicaltrials.gov NCT03175614; https://clinicaltrials.gov/ct2/show/NCT03175614. International Registered Report Identifier (IRRID) RR2-10.1097/MD.0000000000009633
... This component was designed to progressively increase the knowledge and abilities of participants to improve their metabolic control through healthier eating. Nutrition education was based on "the smart plate": a plate method with modifications for T2D (18)(19)(20)(21). Activities around the plate method allowed participants to identify foods and beverages high in carbohydrates (both simple and complex), and to build knowledge around how to combine them with other foods for balanced meals. ...
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Abstract Background Type 2 diabetes (T2D) is a worldwide epidemic and a leading cause of death in Mexico, with a prevalence of 15.9%, and >70% of diagnosed adults have poor glycemic control [glycated hemoglobin (HbA1c) >7.5%]. We developed a diabetes self-management education program contextualized to the study population, including dietary preferences, health literacy, and health system. Objectives We aimed to evaluate the efficacy of a self-management + text message program (¡Sí, Yo Puedo Vivir Sano con Diabetes!) on primary (HbA1c), and secondary behavioral (self-management), clinical, and psychosocial outcomes in adults with T2D in Mexico City. Methods Participants were recruited at public primary healthcare centers (Seguro Popular), and randomly allocated to treatment (n = 26) or wait-list control groups (n = 21) with data collected at 3 and 6 mo. The program included 7 weekly sessions and 6 mo of daily text/picture messages. Descriptive statistics and a generalized linear mixed model with intent-to-treat analysis were calculated. Results Participants were 55.5 ± 8.8 y of age (mean ± SD), 68% female, 88.6% overweight/obese, and 57% lived in food-insecure households. Mean ± SD T2D duration was 11.9 ± 7.8 y and HbA1c was 9.2% ± 1.5%. There was 89% attendance at sessions and 6.4% attrition across both groups at 6 mo. Group-by-time effects were seen in self-monitoring of blood glucose (P < 0.01) and diabetes self-efficacy (P < 0.04); and a trend for lower HbA1c was seen in the intervention group at 6 mo (P = 0.11). Significant improvements in dietary behavior (P < 0.01) were demonstrated in the intervention group over time, but this did not reach statistical significance compared with the control group. Conclusions The program was associated with clinically significant improvements in T2D self-management, self-efficacy, and HbA1c over time. Thus, T2D self-management skills, including diet, were improved in a vulnerable metropolitan population. This trial was registered at clinicaltrials.gov as NCT03159299.
... This is a good method if you are taking multiple dosages of rapid-acting insulin so you can modify the amount accordingly. But if you are on fixed or biphasic insulin regimen you need to be consistent with the quantity of carbohydrate, glycemic index and starch on a day-to-day basis 22 . ...
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Medical Nutritional Therapy MNT is considered one ofthe pillars in managing DM either through preventing diabetes in highly risk people (primary prevention, or by treating existing diabetes(secondary prevention) and finally by preventing or delaying diabetes complication (tertiary prevention) all through improving g]ycemic control. The goal is to concentrate on losing weight& address the increasing prevalence of cardiovascular risk factors (HTN, dyslipidemia & obesity) as the majority of T2DM are obese. Individualized hypocaloric diet & modest weight loss of about 7% usually result in rapid & dramatic glucose decline in individuals with newly diagnosed T2DM. Primarily fruits, vegetables, fiber-rich & low fat food all lead to improved g]ycemic control, weight loss and reduce insulin resistance. The purpose of this review is to highlight the important Medical Nutritional Therapy guidelines in newly diagnosed Type 2DM and those with advance complications. Key words: Medical Nutritional Therapy, Type2 DM, Meal planning
... The health benefits of physical activity and the recommendation to complete at least 30 minutes of moderate activity 5 days a week, or 20 minutes of vigorous activity 3 days a week, will be explained. Counselling on food will be in compliance with the plate method, [59] in which a plate is divided into 4 parts: half the plate for salad or vegetables, one fourth for proteins (white meat preferred over red meat), and the final fourth for carbohydrates. In addition, a medium-sized piece of fruit and a skimmed dairy product should be consumed for dessert. ...
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Introduction: Mobile technology, when included within multicomponent interventions, could contribute to more effective weight loss. The objective of this project is to assess the impact of adding the use of the EVIDENT 3 application, designed to promote healthy living habits, to traditional modification strategies employed for weight loss. Other targeted behaviors (walking, caloric-intake, sitting time) and outcomes (quality of life, inflammatory markers, measurements of arterial aging) will also be evaluated. Methods: Randomized, multicentre clinical trial with 2 parallel groups. The study will be conducted in the primary care setting and will include 700 subjects 20 to 65 years, with a body mass index (27.5-40 kg/m), who are clinically classified as sedentary. The primary outcome will be weight loss. Secondary outcomes will include change in walking (steps/d), sitting time (min/wk), caloric intake (kcal/d), quality of life, arterial aging (augmentation index), and pro-inflammatory marker levels. Outcomes will be measured at baseline, after 3 months, and after 1 year. Participants will be randomly assigned to either the intervention group (IG) or the control group (CG). Both groups will receive the traditional primary care lifestyle counseling prior to randomization. The subjects in the IG will be lent a smartphone and a smartband for a 3-month period, corresponding to the length of the intervention. The EVIDENT 3 application integrates the information collected by the smartband on physical activity and the self-reported information by participants on daily food intake. Using this information, the application generates recommendations and personalized goals for weight loss. Discussion: There is a great diversity in the applications used obtaining different results on lifestyle improvement and weight loss. The populations studied are not homogeneous and generate different results. The results of this study will help our understanding of the efficacy of new technologies, combined with traditional counseling, towards reducing obesity and enabling healthier lifestyles. Ethics and dissemination: The study was approved by the Clinical Research Ethics Committee of the Health Area of Salamanca ("CREC of Health Area of Salamanca") on April 2016. A SPIRIT checklist is available for this protocol. The trial was registered in ClinicalTrials.gov provided by the US National Library of Medicine-number NCT03175614.
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Background: Glycemic index (GI) measures postprandial blood sugar after consumption of carbohydrate-rich foodstuff. Kenya is yet to fully embrace this concept in prevention and management of diabetes mellitus. Objective: To review and tabulate GIs of locally consumed foods in order to improve dietary management of diabetes mellitus. Methodology: A literature search was conducted using Google scholar and PubMed databases which identified 7 articles on glycemic index values of Kenyan foods published between 2002 and 2020. Two articles failed to meet the inclusion criteria and five proceeded for review. Key search words used included GI, glycemic load and glycemic response combined with Kenya. The data was reported depending on whether the testing involved healthy individuals or patients suffering from diabetes mellitus. Results: Nine individual foods and 7 mixed meals were identified. Low GI foods included beans and whole maize ugali consumed alongside cowpea leaves. High GI foods included whole maize ugali eaten with beef, boiled rice, boiled cassava and cassava-sorghum ugali eaten with silver fish. Conclusion: Proper meal mixing is important in diabetes management. Cowpea leaves and beans possess GI lowering potential. This information can be used to improve guidance on food choices for diabetes patients.
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While classically linked to memory, the hippocampus is also a feeding behavior modulator due to its multiple interconnected pathways with other brain regions and expression of receptor for metabolic hormones. Here we tested whether variations in insulin sensitivity would be correlated with differential brain activation following exposure to palatable food cues, as well as with variations in implicit food memory in a cohort of healthy adolescents, some of whom were born small for gestational age (SGA). Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) was positively correlated with activation in the cuneus, and negatively correlated with activation in the middle frontal lobe, superior frontal gyrus and precuneus when presented with palatable food images versus non-food images in healthy adolescents. Additionally, HOMA-IR and insulinemia were higher in participants with impaired food memory. SGA individuals had higher snack caloric density and greater chance for impaired food memory. There was also an interaction between the HOMA-IR and birth weight ratio influencing external eating behavior. We suggest that diminished insulin sensitivity correlates with activation in visual attention areas and inactivation in inhibitory control areas in healthy adolescents. Insulin resistance also associated with less consistency in implicit memory for a consumed meal, which may suggest lower ability to establish a dietary pattern, and can contribute to obesity. Differences in feeding behavior in SGA individuals were associated with insulin sensitivity and hippocampal alterations, suggesting that cognition and hormonal regulation are important components involved in food intake modifications throughout life.
Article
Background & aims The study aimed to evaluate the effectiveness of the Simplified Diabetes Nutrition Education (SDNE) on glycemic control and other diabetes-related outcomes in patients with type 2 diabetes mellitus (T2DM). Methods This a randomized controlled trial (RCT) randomized 208 patients with T2DM [mean age = 48.8 ± 11.8 years, Glycated Hemoglobin (HbA1c) = 9.5 ± 2.4%, and Body Mass Index = 28.0 ± 5.6 kg/m²] to intervention group (n = 104) or control group (n = 104). Participants in the intervention group received a weekly diabetes nutrition module based on the health belief model for 12 weeks in addition to the usual care whereas the control participants were given the usual care. We evaluated HbA1c and diabetes-related outcomes (metabolic parameters, dietary intake, and physical activity level) at baseline, 12 weeks, and 22 weeks. Health beliefs, diabetes knowledge, and health literacy were also evaluated. Results After 22 weeks, HbA1c improved significantly in the intervention group (−1.7%) from the baseline value, compared to the control group (+0.01%) (p < 0.001). Furthermore, the intervention group also showed better improvement in metabolic parameters than the control group (p < 0.05). Besides, dietary intake and physical activity levels improved significantly among the intervention group compared to the control group (p < 0.05). Likewise, health beliefs, diabetes knowledge, and health literacy also improved significantly in the intervention group compared to the control group (p < 0.05). Conclusion SDNE improves glycemic control and other diabetes-related outcomes among the intervention group compared to the control group. Trial registration ClinicalTrials.gov with ID: NCT04433598. Registered on 16 June 2020 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04433598.
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Medical nutrition therapy (MNT) is the bedrock for the management of gestational diabetes mellitus (GDM). Several different types of dietary approaches are used globally, and there is no consensus among the various professional groups as to what constitutes an ideal approach. The conventional approach of limiting carbohydrates at the cost of increasing energy from the fat source may not be most optimal. Instead, allowing higher levels of complex, low-to-medium glycaemic index carbohydrates and adequate fibre through higher consumption of vegetables and fruits seems more beneficial. No particular diet or dietary protocol is superior to another as shown in several comparative studies. However, in each of these studies, one thing was common – the intervention arm included more intensive diet counselling and more frequent visits to the dieticians. For MNT to work, it is imperative that diet advice and nutrition counselling is provided by a dietician, which is easy to understand and use and includes healthy food options, cooking methods, and practical guidance that empower and motivate to make changes towards a healthy eating pattern. Various simple tools to achieve these objectives are available, and in the absence of qualified dieticians, they can be used to train other health care professionals to provide nutrition counselling to women with GDM. Given the impact of GDM on the future health of the mother and offspring, dietary and lifestyle behaviour changes during pregnancy in women with GDM are not only relevant for immediate pregnancy outcomes, but continued adherence is also important for future health.
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To examine the effects of patient choice between two education curriculums that emphasized either the standard or nutritional management of type 2 diabetes on class attendance and other outcomes among a mostly Hispanic patient population. A total of 596 patients with type 2 diabetes were randomly assigned to either a choice or no choice condition. Patients in the choice condition were allowed to choose their curriculum, while patients in the no choice condition were randomly assigned to one of the two curriculums. Outcomes were assessed at baseline and at a 6-month follow-up. When given a choice, patients chose the nutrition curriculum almost four times more frequently than the standard curriculum. Contrary to our hypothesis, however, patients who had a choice did not significantly increase their attendance rates or demonstrate improvements in other diabetes outcomes compared with patients who were randomly assigned to the two curriculums. Patients in the nutrition curriculum had significantly lower serum cholesterol at a 6-month follow-up, whereas patients in the standard curriculum had significant improvements in glycemic control. Of the randomized patients, 30% never attended any classes; the most frequently cited reasons for nonattendance were socioeconomic. Hispanic patients, however, were just as likely as non-Hispanic patients to attend classes and participate at the follow-up. Patients who attended all five classes of either curriculum significantly increased their diabetes knowledge, gained less weight, and reported improved physical functioning compared with patients who did not attend any classes. Although providing patients with a choice in curriculums at the introductory level did not improve outcomes, differential improvements were noted between patients who attended curriculums with different content emphasis. We suggest that diabetes education programs should provide the opportunity for long-term, repetitive contacts to expand on the modest gains achieved at the introductory level, as well as provide more options to match individual needs and interests and to address socioeconomic barriers to participation.
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The influence of whole grains on cardiovascular disease risk may be mediated through multiple pathways, eg, a reduction in blood lipids and blood pressure, an enhancement of insulin sensitivity, and an improvement in blood glucose control. The objective was to examine the association between diets rich in whole- or refined-grain foods and several metabolic markers of disease risk in the Framingham Offspring Study cohort. Whole-grain intake and metabolic risk markers were assessed in a cross-sectional study of 2941 subjects. After adjustment for potential confounding factors, whole-grain intake was inversely associated with body mass index (: 26.9 in the lowest and 26.4 in the highest quintile of intake; P for trend = 0.06), waist-to-hip ratio (0.92 and 0.91, respectively; P for trend = 0.005), total cholesterol (5.20 and 5.09 mmol/L, respectively; P for trend = 0.06), LDL cholesterol (3.16 and 3.04 mmol/L, respectively; P for trend = 0.02), and fasting insulin (205 and 199 pmol/L, respectively; P for trend = 0.03). There were no significant trends in metabolic risk factor concentrations across quintile categories of refined-grain intake. The inverse association between whole-grain intake and fasting insulin was most striking among overweight participants. The association between whole-grain intake and fasting insulin was attenuated after adjustment for dietary fiber and magnesium. Increased intakes of whole grains may reduce disease risk by means of favorable effects on metabolic risk factors.
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Dietitians from Canada, Finland, France, and Sweden have explored methods of teaching meal planning to persons with diabetes and dyslipidemia in the Diabetes Atherosclerosis Intervention Study. The Plate Model, a method commonly used in Europe, is a simple alternative to the traditional exchange-based method for teaching meal planning. In this visual method, a dinner plate serves as a pie chart to show proportions of the plate that should be covered by various food groups. Portions of foods and appropriate food choices can be depicted for meals and snacks in assorted forms of the model. Methods of presenting the model range from professional photography to hand-drawn sketches and displays of food replicas. Benefits of the model for adult learners include enhancement of the connection between dietary theory and practice, promotion of memory retention and understanding through visual messages, and experience of a positive approach to nutrition counseling. Various cuisines and festive foods can be incorporated into the model. The Plate Model offers a meal planning approach that is simple and versatile. The effectiveness of the model and its applications to other populations need to be evaluated.
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It may be feasible for some patients using simplified meal-planning approaches and short-acting insulin regimens to use an insulin pump instead of 2 daily injections of 70/30 insulin. Although this approach may not be possible for everyone, the methods discussed in this article open the door for some individuals whose main stumbling blocks are calculating insulin dosing and grams of CHO. In our practice, we have seen repeatedly that simplified approaches for counting CHO intake and calculating insulin dose can work successfully even with intensive insulin management. It is our challenge as diabetes health professionals to continually search for creative ways to help our patients simplify their daily diabetes management tasks. In many cases, the patient is more likely to commit to healthful changes when the meal plan is simpler and more visual. It is not possible, however, to make patients proficient in CHO counting and insulin dosing in one visit. Referral to a registered dietitian who specializes in diabetes allows a tailored plan to be developed with each individual based on health parameters, treatment goals, lifestyle, and cognitive skills.
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Adequate fruit and vegetable intake may lower the risk of several chronic diseases, but little is known about how it affects the risk of diabetes mellitus. We examined whether fruit and vegetable consumption was associated with diabetes incidence in a cohort of U. S. adults aged 25-74 years who were followed for about 20 years. In the analytic sample of 9,665 participants, 1,018 developed diabetes mellitus. The mean daily intake of fruits and vegetables as well as the percentage of participants consuming five or more fruits and vegetables per day was lower among persons who developed diabetes than among persons who remained free of this disease (P < 0.001). After adjustments for age, race or ethnicity, cigarette smoking, systolic blood pressure, use of antihypertensive medication, serum cholesterol concentration, body mass index, recreational exercise, nonrecreational exercise, and alcohol consumption, the hazard ratio for participants consuming five or more servings of fruits and vegetables per day compared with those consuming none was 0.73 (95% confidence interval (CI), 0.54-0.98) for all participants, 0.54 (95% CI, 0.36-0.81) for women, and 1.09 (95% CI, 0.63-1.87) for men. Adding education to the model changed the hazard ratios to 0.79 (95% CI, 0.59-1.06) for all participants, 0.61 (95% CI, 0.42-0.88) for women, and 1.14 (95% CI, 0.67-1.93) for men. Fruit and vegetable intake may be inversely associated with diabetes incidence particularly among women. Education may explain partly this association.
Article
Diet and lifestyle modifications can substantially reduce the risk of type 2 diabetes. While a strong inverse association has been reported between dairy consumption and the insulin resistance syndrome among young obese adults, the relation between dairy intake and type 2 diabetes is unknown. We prospectively examined the relation between dairy intake and incident cases of type 2 diabetes in 41,254 male participants with no history of diabetes, cardiovascular disease, and cancer at baseline in the Health Professionals Follow-up Study. During 12 years of follow-up, we documented 1243 incident cases of type 2 diabetes. Dairy intake was associated with a modestly lower risk of type 2 diabetes. After adjusting for potential confounders, including body mass index, physical activity, and dietary factors, the relative risk for type 2 diabetes in men in the top quintile of dairy intake was 0.77 (95% confidence interval [CI], 0.62-0.95; P for trend, .003) compared with those in the lowest quintile. Each serving-per-day increase in total dairy intake was associated with a 9% lower risk for type 2 diabetes (multivariate relative risk, 0.91; 95% CI, 0.85-0.97). The corresponding relative risk was 0.88 (95% CI, 0.81-0.94) for low-fat dairy intake and 0.99 (95% CI, 0.91-1.07) for high-fat dairy intake. The association did not vary significantly according to body mass index (< 25 vs > or = 25 kg/m(2); P for interaction, .57). Dietary patterns characterized by higher dairy intake, especially low-fat dairy intake, may lower the risk of type 2 diabetes in men.
Practical nutrition: the Idaho Plate Method
  • H Rizor
  • M Smith
  • K Thomas
  • J Harker
  • M Rich
Rizor H, Smith M, Thomas K, Harker J, Rich M. Practical nutrition: the Idaho Plate Method. Practical Diabetology 1998;17:42-5.
The Healthy Diabetes Plate. Moscow: University of Idaho Educational Publications
  • M Raidl
Raidl M. The Healthy Diabetes Plate. Moscow: University of Idaho Educational Publications; 2003.