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June 25, 2003


Emory Study Finds That A Simple Meal Plan Emphasizing Healthy Food Choices Is As Effective as an Exchange-Based Meal Plan for African-Americans With Type 2 Diabetes

ATLANTA -- Choosing healthy, low-fat foods is as effective for helping urban African-Americans with Type 2 diabetes maintain proper glucose control as the traditional "exchange-based" meal plan approach, according to published findings of a study conducted at the Grady Health System Diabetes Clinic.

In the exchange-based plan, patients were given materials from the American Diabetes Association, Inc. and the American Dietetic Association modified to improve readability and were instructed in both food exchanges and portion sizes. The plan emphasized weight loss, and if followed properly, would result in participants losing one pound per week.

The findings are published in the June issue of Diabetes Care by lead author and endocrinologist David C. Ziemer, MD, assistant professor of medicine in the Division of Endocrinology and Metabolism at the Emory University School of Medicine and physician at the Diabetes Clinic, and conclude that simple meal plans that include healthy food choices improved HDL ("good" cholesterol) and triglycerides and resulted in comparable weight loss to that of the traditional exchange based meal plan.

The paper, co-authored by several nurses, registered dieticians and Emory physicians practicing at the Grady Diabetes Clinic, suggests that medical nutrition therapy is primarily effective in urban African Americans with Type 2 diabetes, and that either a meal plan emphasizing guidelines for healthy food choices or a low literacy exchange method is equally effective as a meal planning approach.

The study also suggests that because a healthy food choice meal plan may be simpler to teach and is easier for patients to understand, it may be preferable for low-literacy patient populations to follow. Researchers hypothesized that the exchange based plan is tedious because of the amount of computation and classification of foods into groups that is necessary. Keeping track of these classifications, Dr. Ziemer said, typically requires referring to lists of foods, which can be a barrier for low literacy populations. And while those in the healthy food choice group were given the same educational material as the exchange group, all content related to quantity of food was removed and replaced with the FDA Food Guide Pyramid, which was modified to group high-starch and high-protein foods as recommended for persons with diabetes.

The modified food guide pyramid, in turn, was glossy and in full color with line drawings of food. Patients were instructed to limit use of sweets and fats, particularly saturated fat. Although food models were used, portion sizes were not discussed and weight loss was not emphasized.

The conclusions are based on findings from a study between August 1994 and August 1995 and analyzed data in 1997 among 648 patients with initial visits to the Grady Diabetes Clinic. Participants, who were categorized as obese because each weighed 20 percent over their ideal body weight, were randomized in two groups: 359 in the meal exchange group, which emphasized weight loss through low-literacy materials, and 289 among the healthy food choices group, which simply encouraged participants to make good food choices by eating less sugary and fatty foods. Each participant was followed for six months.

For those in both groups who returned for their appointments over the six-month period, Dr. Ziemer and other researchers discovered no significant differences. Both groups decreased the number of sugary and fatty foods they ate to an equal degree; their hemoglobin counts improved; 53.2 percent of people in the exchange group lost some amount of weight compared to 53 percent of those in the healthy food choices group who lost weight; and both groups improved their good cholesterol levels a bit, and decreased their triglyceride levels.

"There was no difference between the two groups," Dr. Ziemer said. "What this says is that youíve got the same results regardless of how you taught the diet, whether you tried to do the complicated approach that emphasized weight loss, or the diet that emphasized healthy food choices. Despite the fact that the participants in the healthy food choices group werenít given any instructions on weight loss, about half of them lost weight."

The American Diabetes Association Meal Exchange Plan has long been considered the gold standard in managing diabetes for several years. Dr. Ziemer said the plan can become complicated, however, when it comes to figuring out the number of bread and meat exchanges diabetics must make. Rather than only emphasize the exchange approach, Dr. Ziemer and his colleagues figured that emphasis on choosing healthy foods could be just as important.

"Itís not 100 percent clear exactly if the most important thing about diet is losing weight or eating the right foods," Dr. Ziemer noted. "There are data that indicate losing a little bit of weight might be all it takes."

Dr. Ziemer was not surprised by the findings.

"The exchange plan was so hard to follow that we figured the healthy food choices approach would work just as well, especially in our patient population," he said. "Also, if you look at actual weight loss studies, the percentage of people who actually decide to lose weight and maintain their weight loss a year or two later, is very small. So, we didnít actually think that making weight loss a goal was really going to change patientsí outcomes in other areas."

Overall, Dr. Ziemer said the study was a success.

"The bottom line is that you can teach diet in a simpler manner and still get good results," he said.

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