diabetes meal management

8/8/2019 Diabetes Meal Management

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DIABETES MEAL MANAGEMENTby

MARY ELLEN HISE PENTURF, B.S. in H.EA T H E S I S

INFOOD AND NUTRITION

Submitted to the Graduate Facultyof Texas Tech University inPartial Fulfillment ofthe Requirements forthe Degree ofMASTER OF SCIENCE

INHOME ECONOMICS

Approved

Accepted

December, 1987


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s

A C K N O W L E D G M E N T Sm i^ o f " ^ I w o u l d l i k e t o e x p r e s s m y s i n c e r e a p p r e c i a t i o n t o D r . M a r a a r e t t e

H a r d e n f o r h e r g u i d a n c e , e n c o u r a g e m e n t , s u p p o r t a n d p a t i e n c et h r o u g h o u t t h e c o u r s e o f m y g r a d u a t e p r o g r a m . I a l s o w i s h t o t h a n kD r . M a l l o r y B o y l a n a n d D r . Ei S o o n C h o f o r t h e i r a d v i c e a n d g u i d a n c ea s m e m b e r s o f m y r e s e a r c h c o m m i t t e e .

I w o u l d a l s o l i k e t o t h a n k L i s a M c K e e f o r h e r t e c h n i c a la s s i s t a n c e a n d G a y R i g g a n f o r h e r c o o p e r a t i v e e f f o r t i n t h ep r e p a r a t i o n o f t h e m a n u s c r i p t .

A d e e p a p p r e c i a t i o n i s e x t e n d e d t o m y h u s b a n d , C h a r l i e , f o r h i sm o r a l s u p p o r t , p a t i e n c e a n d l o v e t h r o u g h o u t m y g r a d u a t e s t u d i e s .

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C O N T E N T S

A C K N O W L E D G M E N T S i iA B S T R A C T vL I S T O F T A B L E S v iL I S T O F F I G U R E S v i i

I . I N T R O D U C T I O N 1I I . R E V I E W O F L I T E R A T U R E 3

I n c i d e n c e a n d R i s k F a c t o r s f o r N o n - I n s u l i n -D e p e n d e n t D i a b e t e s M e l l i t u s 3D i a b e t i c D i e t I n s t r u c t i o n f o r N o n - I n s u l i n -D e p e n d e n t D i a b e t e s M e l 1 i t u s 5C o n t i n u i n a E d u c a t i o n f o r D i e t a r v P e r s o n n e l 7E d u c a t i o n a l T o o l s a n d T e c h n i q u e s f o r D i a b e t i c

D i e t s 8I I I . M E T H O D S A N D P R O C E D U R E S 1 1

V i d e o c a s s e t t e P r o d u c t i o n 1 1S u b j e c t s 1 3D e m o g r a p h i c D a t a S h e e t 1 3T h e D i a b e t i c E x c h a n g e L i s t Q u e s t i o n n a i r e 1 3N u t r i t i o n G a m e S h e e t 1 4P r o g r a m E v a l u a t i o n F o r m 1 4D a t a C o l l e c t i o n ''or t h e D i a b e t i c E x c h a n g e L i s t

Q u e s t i o n n a i r e 1 4C o l l e c t i o n o f C a l o r i e a n d E x c h a n g e E s t i m a t i o n

G a m e D a t a 1 5S t a t i s t i c a l T r e a t m e n t 1 5

I V . R E S U L T S A N D D I S C U S S I O N 1 7

C a l o r i e a n d E x c h a n g e E s t i m a t i o n S c o r e s 2 3i i i


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A n a l y s i s o f t h e D i a b e t i c E x c h a n g e L i s tQ u e s t i o n n a i r e ? 6

P r o g r a m E v a l u a t i o n S c o r e s 2 9V . C O N C L U S I O N S A N D R E C O M M E N D A T I O N S 3 2

C o n c l u s i o n s 3 2R e c o m m e n d a t i o n s 3 2

R E F E R E N C E S 3 4A P P E N D I C E S

A . S C R I P T : D I A B E T E S M E A L M A N A G E M E N T 3 7B . A D D I T I O N A L M A T E R I A L S 5 2

IV


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A B S T R A C T

The pur pose of this study was to develop a diabetic mealmanage ment instructional videotape to enhance and improvecomprehension of the diabetic e xchange system by food personn el.Subjects wer e assigned to three groups according to occupational andeducational leve l. Sample size for the groups was 30 , each havino atreatment and control subgrou p. Group 1 was composed primarily ofregistered or consulting die tit ian s. Group 2 was composed of foodservice s uper viso rs, and Group 3 was primarily dietary managers andhead cook s. Knowledge was measured by a pre- and post-test instrumentafter viewing the 16-minute videot ape. A significant interaction wasfound betwee n vi deo and gro up, with group 3 havino a mean increase of12 points post- video t reatm ent. This group had the lowest level ofeducat ion and pre-test sco res , and thus was aided the greatest byviewing the video prog ram. A volun tary game for subjects was used toevaluate Cal orie and exchange estima tions for two mea ls , varying inCalorie level. Subjects generally underestimated Calorie and numberof exchanges prior to viewing the videocassette program and raisedtheir scores sli ghtly aft er the video trea tmen t. This video tape v/illbe a useful tool for improving the serving of diabetic diets by foodservi ce personnel as well as for enhanci ng diet ary compli ance of newlydiagnosed diabetic individuals.


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LIST OF TABLES

1. Calor ie and Diabeti c Exchanges for Meal A 16?. Calorie and Diabetic Exchanges for Meal P 163. Demographic Characteristics of Subjects 184 . Employment and Educational Characte ristics of Subjects 195. Mean Calor ie Estimation Scores for Meal A ?36. Mean Exchange Estimation Scores of Meal A ?47 . Calorie Estimation Scores for Meal B ?58. Mean Exchanqe Estimation Scores of Meal P 26

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L I S T O F F I G U R E S

1 . D i s t r i b u t i o n o f d i a b e t i c r e l a t i v e s r e p o r t e d b y s u b j e c t s 1 7 .2 . M e a n p r e - a n d p o s t - t e s t s c o r e s o f c o n t r o l g r o u p s ? 73 . M e a n p r e - a n d p o s t - t e s t s c o r e s o f v i d e o t r e a t m e n t g r o u p s 2 84 . M e a n d i f f e r e n c e s b e t w e e n p r e - a n d p o s t - t e s t s c o r e s f o r

v i d e o t r e a t m e n t a n d c o n t r o l g r o u p s 3 05 . S e l e c t e d C o m m e n t s f r o m P r o g r a m E v a l u a t i o n F o r m 3 1

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CHAPTER IINTRODUCTION

Non-ins ulin-de penden t diabetes mellitus (NIDDM) is one of themost common chronic diseases in the United Sta tes . Approximately 90 ^of individuals diagnosed as having diabetes have NIDDM and anadditional 4-5 mill ion pe ople meet the diagno stic cri teria for NIDDMbut have not yet been diagnosed ( 1 - 3 ) .

Risk factors for NIDDM can be determine d by measur ing incid ence,which is the number of new cases of illness occurring in a specifiedpopula tion at risk per unit of tim e. Determi ning that a certainattribute is a "risk factor" can be accomplished by documenting ahigher incidence rate in persons with the factor than in those withoutit (? ) . Incidence rates are highest in the United States for Black s,Mexican Amer ica ns, and American Ind ians. Socioeconomic status andurban or rural habitation may also influence incidence rates. Themost impor tant risk factors for develo pment of NIDDM are increasinga g e , h e r e d i t y , a n d o b e s i t y ( 2 , 4 ) .

Diet ary man agem ent is essential in all therapy for indi vidualswith NIDDM . The Exchange Lists are the most wide ly used tool fordietary planning and meal management ( 5) . Unfortu nately, pastnutritional educationa l met hods for diabetic persons have resulted inpoor comprehension levels and decreased compliance ( 6 - 9 ) . Dietarycompliance is further complicated by the over and underestimation offood portion size in diet manag ement .


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Innovative teaching methods are needed to enhance dietinstruction and provide for alternate learning styles for NIDDMper sons . Sli des , programmed instruct ion, and videocassette programsmay be used in a variety of instructional form ats. All of thesemethods allow material to be reinforced by repetition and alsoallevia te the problem of time deficie ncy. Studies have shown thatsimpler diet instruction using videocassette programs have beeneffective in producing changes in knowledge and behavior for diabeticindividuals (10, 11 ) . Of the many teaching m.ethods, videocassettescould be accessible in hospital and nursing home "facilities.

In many rural hospi tals and nursing h ome s, diet instruction isoften given by a food service supervisor or dietary manag er. This isdue primarily to the scarcity of dietitians in these facili ties. Forthese employees, adequate knowledge about the diabetic exchange systemis neces sary, although actual knowledge about diabetic treatment maybe limited. For food service supervi sors, dietary man age rs, and otherfood service emplo yees , continuing education is often required toincrease knowledge about current nutritional methods andrecomm endat ions. On-the-j ob training is the most common method ofcontinuing education (12, 1 3 ) . It is in this format that audiovisualprograms may be used effectively.

The complexities of the diabetic exchange system may be difficultnot only for the NIDDM individual, but also for the food serviceemployee unfamiliar with the six exchange lists and varying portions i z e s . The development of a basic, easy to understand videocassetteprogram would enable supplementation of the traditional form ofteachi ng, while promoting better comprehension of the exchanoe system.


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CHAPTER IIREVIEW OF LITERATURE

Diabetes mel lit us, a chronic health problem in the United State s,is a primary cause of blindness, kidney failure and limb amputation.Dial ysis treatm ent for kidney f ailure -^rom diabe tes a lone costs morethan one billio n doll ars an nua lly , and this ficure is expected tod o u b l e d u r i n g t h e n e xt f e w y e a r s ( 1 , 4 ) .

Incidence and Risk Factors for Non-Insulin-Dependent Diabetes Mellitus

Non-insul in-depend ent diabetes mellitus ( N I D D M ) , also calledadult-onset or type II diabete s, affects about ten million middle-ageor older Americans, or approximately 9 0 % of all people diagnosed ashaving diabet es. The incidence of NIDDM has been escalating since1935 for all age gr oup s. National sur veys comprised of annualphysician interviews showed that approximately 32 new cases per tenthousand po pulati on, ages 20 years and older, were reported annually.This is illustrated by the five-fold increase in diabete s during thepast 45 ye ar s. Approximately 500,000 new cases of NIDDM are diagnosedeach year in persons over 2 5, yet half of the persons who have NIDDMare undetected or undiagnosed (2).

Major risk factors associated with the onset of NIDDM areincreasing age , heredity and obesity. Risk factors for NIDPM aredetermined by documenting a higher incidence rate in persons with thef a c t o r t h a n t h o s e w i t h o u t it ( 2 , 4 ) .


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Strong evidence supports the genetic component for thedevelopmen t of NIDDM. Data from the National Health Interview Survey(NHIS) ( 1 9 7 9 - 1 9 8 1 ) , indicated that both obesity and aging influencedthe develo pment of the disease in susceptible individ uals, and thatthe incidence of NIDDM steadily increased after the fourth decade ofl i fe ( 14 ) . N o n - i n s u l i n - d e p e n d e n t d i a b e t e s m e l l i t u s is h i g hl vcorrelated with obesity. Approxim ately 8 0% of people with NIDDM haveexcess body fat or adipos ity. Both the National Health InterviewSurvey and Health and Nutrition Examination Survey 11 (HANES II)indicated that the prevalence of NIDDM increased with increasinga m o u n t s o f b o d y f a t ( 14, 1 5 ) .

Stud ies by Ha rris et al_. illustrated the suscept ibilit y ofdifferent races to the development of NIDDM ( 16 ). In the UnitedStates between 1966 and 1 981 , the prevalence of diabetes increased120% in blacks but only 60% in whites (1 6) . The HANES II studyalso showed that blacks had a 50 % greater prevalence of diabetes thanw h i te s ( 1 5 ) .

The greatest prevalence for diabetes occurs among the PimaIndians ( 17 ). Full heritage Pima Indians have almost a two-foldgreater incidence rate of NIDDM than Pimas with Caucasian admixture .Stein (18) and Drevets (19) also reported a greater prevalence ofNIDDM in full-heritage Cherokee Indians as compared withm i x e d - h e r i t a g e C h e r o k e e a n d C h o c t o w I n d i a n s .

Gardn er and co-workers (20) reported that Mexican Americans inSan Ant oni o, Texas had a higher preva lence of NIDDM than non-Hispanic


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instruction is the lack of understandin g about the dietary regimewhich results in poor patient complia nce. Haynes (24) definedcompl iance as the extent to which a person's behavi or (in terms oftaking med icat ion , following die ts, or altering lifesty le) coincideswith medical or health advice . Studies have shown that the majorityof diab etic individua ls have a low level of compli ance with diet aryrecommendations (6-9, 25 , 2 6 ) . Williams e^ al^. (?7) compared at homefood intakes of diabetic patien ts to the diabeti c exchan ge li sts , andfound that 7 5% of those studied had significa nt defic its in thedistri bution of their food choices half of the time, and 50 % haddefic ienci es all the tim e. Food items most frequently deleted werefrui ts, non-starchy ve getab les, and mea ts. Also , dietary compliancedata collected in 1984 indicated that 80 % of known diabeticindivid uals said that they had received a written diet, but only 53%followed the prescribed diet plan (8 ).

Diet ary compl iance is further complicated by difficul ty inestima tion of food portion size. Lansky and Browne!1 (?8) found aclinically sionificant pattern of overestimation of food quantitiesand Caloric content by obese females. These researchers hypothesizedthat lack of skill in estimati ng portion sizes may have contributed tothe poor evaluation of Caloric value in commonly eaten foods .

Rapp and co-work ers f?9) reported that in an outpatie nt cli nic,diabet ic su bjects un derest imate d the size of chicken portions by anaverage of 4 5 . 7 % , while overesti mating margarine by an averaoe of 30 %to 40 %. These researchers also reported infrequent use of foodquantity measuring devices by subjects.


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Continuing Education for Dietary PersonnelDue prima rily to the scarci ty of dietitians in many rural

hospitals end nursing hom es, an adequate degree of knowledge aboutdiabet ic tre atmen t is essential for all personnel who prepare foods orwho may give dietary instruction to patients or reside nts. Foodservice supervisors, dietary managers, and other food serviceemployees may give dietary counseling and also supervise preparationof meals for NIDDM patient s. Continuing education for these employeesvaries due to available teaching resources, and to the degree ofcontinuing education required (3 0) .

Continuing education for food service employees may beaccomplishe d by inservic e train ing, enrollment in short coursesconducted away from the work se tting , or by on-the-job trainin g.Vid eot ape s, sl id es, and programm.ed instruction have all been usedeffectively to increase knowledge about nutritional methods andrecommend ations. Most of the continuing education in nursing homesand hospitals has been found to be on-the-job type with no one personresponsible for the training (12, 13, 3 0 ) .

The size of a hospital often dictates the type of educationaltraining that is avail able to the food service wo rk er s. An AmericanHospital Assoc iatio n survey showed that the number of dietary trainingprograms decreased as the number of hospital beds decreased (31).This survey also reported that fewer dietary inservice trainingprograms existed in the south central United States than in otherregions of the nation. The lower percentage was probably due to theexistence of fewer large hospitals.


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8Educational Tools and Techniques forDiabetic Diets

A serious inadequacy exists in the area of effectiveinstructional programs for persons with diabetes mel litu s. Thedevelopment of innovative videocassette p rogr ams, bookle ts, slides,and programmed instruc tion could enable dietary informa tion to betransmitted by methods that allow for reinforcement by repetition( 1 0 , 32 , 3 3 ) . These approaches could also alleviate the problem oftime deficiency and allow for indepth patient instruction.

Audiovisu al instruction may be used in a wide variety of dietaryprograms depending upon the objectives and the learning format.Video casse ttes, used in instru ction, can convey basic information in aform that is appeali ng and instruct ional . Studies have shown thatvideocassette programs and alternate teaching methods d re effective inproduci ng changes in knowledge and behavior (10, 11 , 32- 341 . Hasseland Medved (34) reported that significantly higher post-test scoreswere achieved when diabetic patients received group diet instructionusing the audiovisual format than those who were taught in thetraditional bedside mann er.

Pace et al_. (10) studied the effects of implementing diet therapyvide ocas sett e instructi on in diet therapy during the 5th yea r o ^ theCorona ry Prim ary Preven tion Trial (CPPT) at the Lipid Research Clinic( L C R ) , Baylor College of Medi cine . The objective of the studv was toimprove adherence to the prescribed diet. The videocassette programdefined the desirable behavior for the participants after viewing theprogram.


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Results showed that attitudes relating to eating breakfast werenot significantl y d ifferent during the pre-instruction period, orafte r the one week or two month post ins truction test period. Itshould be noted that individ uals in this study had been in the Trialat least four years and would have had reasonabl e knowledge of thepurpose and composition of the Trial diet .

McCu lloc h et al^. (11) studied the effects of three teachingmethods on know ledge , compli ance, and glycemic control. Subjects werepoorly controlled insulin-dependent diabetic patient s. Glycemiccontrol was measured by glycosylated hemoglobin levels. Teachingmethods used were conventional diet sheet instruction (group 1 ) ,practical lunchtime demonstrations (group 2 ) , and videotaped education(group 3 ) . Dietary knowledge determined by an initial guestionnairewas poor in all thre e gro up s. Only 52 % gave an ansv/er on the num berof carb ohyd rate exchang es consumed daily and less than one-third ofthese answers were correct when compared with their seven day foodre co rd s. McC ull och et al_. (11) also reported that patient s -found itmuch easier to understand the concept of carbohydrate exchanges whenshown real food quantiti es of 10 grams of carboh ydrate as compared toonly the reading of conventional diet sheet s. After six mont hs offol low -up , no improvement was observed for group 1, but in groups 2and 3, both knowledge and compliance improved significantl y. Thu s,this study illustrated that simpler diet instruction resulted inimproved compliance and unders tanding . Since many studies have shownthat dietary compliance by diabetic patients was low, the primaryobjec tive for this project was to develo p a basic easy to understand


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10videocassette which would promote better comprehension of the complexExchange System. Specific objectives wer e:

1. To develop a videoca ssette program on diabetes mealm a n a g e m e n t .

2 . To determine the effectiveness of the videocassette programon increased knowledge and understanding of the diabeticexchanges by food service personnel.


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CHAPTER IIIMETHODS AND PROCEDURES

Videocassette ProductionA sixteen minute videocassette program entitled Diabetes Meal

Manageme nt was produced in cooperation with the KTXT-TV station. MarkSlusher, a KTXT full-time employee, served as the technical director.

A script for narration of the videocassette program was primarilyadapted from the Exchange List for Meal Planning booklet (2?.) . Thescript was designed for the seventh to eighth grade reading levelusing the SMOG Index . The SMOG Index , developed in 1969 by G. HarryMcLaughin, is a readability test designed to determine the approximategrade level required in order to understand writt en material (35 ).

The script was analyzed and critiqued by both university facultyand the technical director of the program for content and foradap tabi lity to video taping. Afte r editing and revision of thescri pt, a storybo ard was develo ped for use in all taping se ssi ons.The stor yboard w as the writ ten doc ument which served as an exactstep -by- step guide for recording the entire program. The left handcolumn of the storyboard contained the exact script (Appendix A ) ,while the right hand column described the visual scene.

Visual ai ds wer e planned and developed sim ultaneo usly with thestoryb oard. Fifte en, eight by eleven poster s, drawn bv a graphicarti st, were designed to attract interest and simplify information.Cartoons, symbols, and other information that would be difficult tovideo tape were designed and illustrated on the poster boards. The

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12Exch ange List for Meal Plann ing booklet was used throughout theprogram to vis uali ze and emphasi ze the six exchanoe lists and topromote continuity of the program.

Remot e taping sessions wer e conducted at the Texas Tech StudentRecreational Cent er, the South Plains Mali of Lubbock, Texas, and theHome Econo mics Tower at Texas Tech Univ ersi ty. Prior approval byadministrative personnel was reouired before taping sessions werepermitted at the Recreational Center and the South Plains Mall.Individ uals at the Student Recreational Center were taped toillustr ate a variet y of different sport and exercise ac tivi ties .Filming of people participating in racquetball, basketball , exercisebiki ng, and swimming was used to show different forms of exercise fordiabetes man age men t. The South Plains Mall served as an ideallocation fo r filming ind ividuals who illustrated obesi ty, age, andother risk factors associated with diabetes.

All food items shown on the videota pe were cooked and preparedthe day of the taping in a laboratory in the Home Economics FoodScience Tower. For the taping session, a variety of table cloth s,plac emats , silve rware , and dishes were used. Clear standardizedmeas uring cups were used to better illustra te food portion sizes. Astationary camer a, moni tor , and high wattage lighting were used forstill shots of the food items displayed against a black bac kdrop .Each food item was taped for approximat ely 60 sec ond s.

Approximate ly 180 minutes of video were taped. Editing of thevideo footage was conducted at the KTXT-TV station. Approximately onehour of editing was n ecess ary to produ ce one minute of video on the


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13master ta pe. Background music from tapes and the narrated script wererecorde d, edited, and matched with the video footage. The voice usedin the narration was that of Mark Slush er, the producer. A charactergenerator was employed to produce the title, visual text, and credits.

SubjectsIndividuals in this study were participants of the Annual White

Swan Food and Nutrition Seminar conducted May 19-20, 1987.Participants attended this seminar from primarily rural hospitals,nursing hom es, and other establishments (churches, senior citizenscenter s) where dietary services were utilized. Continuing educationcredits were available for dietary managers and registered dietitians.

Demographic Data SheetA three paoe demograp hic questi ornai re (Appendix B ) was mailed to

all registran ts prior to the semi nar. Completed questionnaire s wer ecollected on the first day of the semi nar. Demographic data included:occupation, age, race, place and length of employment, education, anddiabetic and resident census.

The Diabetic Exchange List QuestionnaireThe Diabe tic Exc hange List Quest ionna ire (Appendix P^ was adapted

from the Diabetes Educational Profile (3 5) . The questionnair e,composed of twelve multiple choice ques tions , was used to assessknowl edge con cernin g food groups and portion sizes in the six exchangel i s t s . Participants were asked to circle the correct response to eachq u e s t i o n .


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14Nutrition Game Sheet

The Nutri tion Game Sheet (Appendix B ) was developed to assessknowledge of portion sizes (as explained by the diabetic exchangel i s t s ) , and to evaluate Calorie and exchange estimation of food items.Space (on the game she et) was provided for exchanges and Calorieestimati ons for both me al s. Meal A represented all of the exchangegroups with the exception of the milk excha nge. Meal P representedall of the exchange groups with the exception of the vegetableexc hang e. Particip ants were asked to sum the total Calories in eachm e a l , and to i de nti fy the level of fat in a mea t "-'f pre sen t in them e a l ) .

Program Evaluation FormA daily Program Evaluation Form was designed to rate each

presentation, and allow for specific comments about speakers,m a t e r i a l s , a n d t h e q u a l i t y , o r c o n t en t o f t h e p r e s e n t a t i o n s .Assessment was rated on a scale of excellent to poor.

Data Collection for the Diabetic ExchangeList Questionnaire'The Diabetic Exchange List Question naire (Appendix B) was mailed

to all registra nts prior to the seminar. On day one of the seminar,completed questionnai res were collec ted. The subjects were randomlyassigned to control or treatment gr ouD. On day two of the seminar,the treatment group viewed the Diabetic Meal Managem ent vi deocas sette.Approximately four hours after viewino the videotaped program, bothtreatment and control groups were again administered the Diabetes


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15E x c h a n g e L i s t Q u e s t i o n n a i r e ( A pp e nd i x B ) . T h e q u e s t i o n n a i r e ,identical in content for both day s, was arranged in a differents e q u e n c e .

Collec tion of Calori e and Fxchange Estimation~~~ Game D a HThe Calorie and excha nge estima tion game was developed for use

before and after viewing the vide ocass ette program . Participation inthe game was volu ntar y. Two meals (Tables 1 and 2) with varyingCalorie and excha nge contents were used in the gam e. Identical mealswere used both days of the seminar . The meals were placed on a tableoutside of the auditorium doors and participants we re asked to maketheir estimatio ns on the Nutrition Game Sheet (Appendix B ) . On dayone, prior to viewing the videoca ssette, forty-five participantsestimated the number of Calories and exchanges in the two me als .After viewing the videocassette on the second day, thirty-eightparti cipan ts e stimated the Calories and number of exchanges for bothme al s. Four prizes were awarded to those individuals having thecloses t estim ation for total Calories for meals A and B for both days .Prizes were display ed to encourage pa rticipati on in the game .

Statistical TreatmentA three by two factorial design was used to examin e the pre- and

post-test score s for the video treatment and control grou ps. Studentt-tests were used to evalu ate esti mation scores for Calorie anddiabe tic excha noes bef ore and after viewing the program. A .05 levelof significanc e was used. The SAS Statistical Analysis System wasused for these analyses.


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16Table 1. Calorie and Diabetic Exchanges for Meal A

Food Item

Hamburger PattyRiceFruit CocktailHamburger BunM a y o n n a i s ePecansTomato J uiceLettuceDill PickleMustard

Amount

4 ounces2/3 cup] cup1 bun3 tsp4 halves1 cup2 leaves4" spear1 tsp

Exchange

MeatBreadFruitBreadFatFatVegetable,Free Food,Free Food-,Free Food'

Numbi

4222312000

Total

er

Cal

Calories

300160120160135A S50000

ories: 970

A Free Food contains less than 20 Calories per serving. Itemslisted may be eaten as desired on the Exchange List Meal Plans.Calories are negl igibl e and need not be counted on a meal p lan.

Tabl e 2. Calo rie and Diabetic Exchanges for Meal B

Food Item Amount Exchange Number Calories

Corn FlakesM i l k ( 2 % m i l k f a t )BananaPork Sausage Links

3/4 cup1 cup13 ounce

BreadMilkFruitMeat

1123

80120120300

Total Calo ries : 620


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CHAPTER IVRESULTS AND DISCUSSION

Of the ninety women who attended the annual seminar andparticipated in this study, 30 were food service superv isors, 16 weredietary man age rs, and 18 were dietitia ns. Head cooks , food servicea i d s , and other health care personnel concluded the sample (Table 3 ) .For the purpose of this study, the subjects were assigned to one ofthree groups accordi ng to occupati on and educational leve l. These twovariables were selected since they would influence test scores.Sample size for each group was thirty, each containing a treatment andcontrol sub gro up. Group 1 consisted primarily of registered orconsulting dietitians and other participants who had college orgraduate degr ees. Group 2 was composed of food service supervisors,and Group 3 was made up primarily of dietary manage rs and head co oks .Groups 2 and 3 had similar educational levels (Tables 3 and 4 ) .

Half of the total sample were in the 50 or above age category(Table 3 ) . When the total population was examined by group s, 47 % ofthe subjects in Group 1 were under 39 years , whereas 77 % of thesubjects in Group 3 were 50 or above. Eighty-four percent of ailsubjects were Cauc asian; Group 2 had the highest ethnic populationw i t h 3 3%.

A wide range of educational levels existed (Table 4 ) . Onepercent of the total sample had less than a high school deor ee, 74 %had obtained a high school equiv alen cy d egr ee, and 30 % held a collegedegr ee. Group 1 subjects had the highest percent of college degree s.

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21Subject s assigned to groups 2 and 3 had less than 1% college degree s.Although educational level varie d, all participants except twosubjects responded "yes" to having a thorough understanding of theplanning and serving of diabetic die ts.

Income level increased with years of education (Table 4 ) .Subje cts assig ned to group 1 reported incomes of greate r than $15.00an hou r. Subje cts in group 2 had a slightly higher average hourlyincome than those in group 3.

Thi rty- sev en percent of the total sample worked in nursing homes,while 3 7% were employed in a hospital dietary facility (Table 4 ) .Subjec ts in groups 2 and 3 were primarily employed in nursing homesand in dietary departments of hospi tals . Group 1 participants oftenreported no place of employment due to either consulting or referralw o r k f r o m p h y s i c i a n s .

Thir ty per cent of the subjects reported length of employment intheir present facility at 1-5 years (Table 4 ) . These data do notreflect the poss ible mobility of these subjects, nor their years ofprior employment in other facili ties.

Thirty-two percent of all the subjects participating in thisstudy had a relative with diabe tes. Four individuals, or 4.4% o^ thetotal sampl e reported that they had dia bet es. This percentage ishigher than that of the national avera ge for NIDDM of 2.35% (2, 3^.Although the subjects were not asked to report the kind of diabetes,this older population suggests that the type was NIDDM. Theincreasing age of the subjects may also be responsible for the higherincidence of the diabetes reported ( 2 ) . Distribution of diabeticrelatives reported by the participants is shown in Figure 1.


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22

30 To e 2 0 - -

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Selfy y Spoujs

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23Relatives were defined as family member (spouse, broth er, sister,c h i l d r e n , p a r e n t s , o r s e l f ) . T h e incidence o f diabetic family memberswas equal within t h e g r o u p s .

C a l o r i e and Exchanqe Estimation ScoresThe mean Calorie estimation score fo r meal A prior to seeing t he

video w a s 7 1 0 . 2 . T h e post-video Calorie mean w a s 763.2 (Table 5 ) .The actual Calorie value f o r meal A w a s 9 7 0 . Subjects underestimatedthe content by more than 2 0 0 Calor ies. This value w a s extremely highsince t h e m a j o r i t y o f t h e subjects worked in a dietary department, andsince they had reported a thorough knowledge of diabetic diets.Although scores were higher after seeing t h e video, this differencew as not s t a t i s t i c a l l y s i g n i f i c a n t .

T a b l e 5 . Mean Calorie Estimation Scores f o r Meal A

P r e - V i d e o

P o s t - V i d e o

N

45

3 8

M e a n

7 1 0 . 2

7 6 3 . 2

A c t u a l V a l u e

9 7 0

9 7 0

SD

186.3

1 8 7 . 8

Range

2 5 0 - 1 0 7 5

2 9 5 - 1 2 7 0

Mean exchange estimation scores f o r meal A (Table 6 ) wereunderestimated for all exchange groups f o r both p r e - a nd post-videop e r i o d s . Prior to seeing t h e v i d e o , t h e subjects underestimated them e a t and bread groups b y o n e exchange f or both categories. T h egreatest dif-^erence w a s f o r t h e f a t exchange with an estimation meanof 2.2 w h i l e th e actual value w a s 4 ( T ab l e 6 ) . T h i s d if f e r en c e m a v


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24T a b l e 6. Mean Exchange Estimation Scores o f Meal A

P r e - V i d e o

P o s t - V i d e o

E x c h a n g e

M e a tFatBreadF r u i tV e g e t a b l e

M e a tFatB r e a dFruitV e g e t a b l e

N

4343434343

3636363636

M e a n

3.02.23.01.61.3

2.92.23.31.81.8*

SD

1.00.20.80.70.1

1.00.10.70.70.1

R a n g e

1-51-7/-51-30-2

1-61-42-41-30.5-3

S i g n i f i c a n t ( p < . 0 5 ) .

have resulted because t he subjects did not consider t h e 4 pecan halves(1 f a t e x c h a n g e ) u se d to garnish t h e fruit cocktail. After viewingthe video , mean estimation scores increased slightly f o r bread, andfor fruit, bu t these data were not significantly different whencompared with pre-video scores. T h e vegetable exchanoe estimationmean increased from 1.3 to 1.8 after viewing t h e videocassette. Thisincrease w a s s i g n i f i c a n t . L e t t u c e , p i c kl e s (1 dill s p e a r ) , andmustard were displayed with t h e m e a l , but were considered a "freefood." A "free food" is defined a s o n e containing less than 2 0Calories p e r serving. Items in the "free food" category m a y b e eatenas desired o n t h e Exchange List Meal Plans ( 2 2 ) .

Mean Calorie estimation scores f o r meal B were much closer to theactual value f o r both p r e - a nd post-video periods than were t h e scoresfor meal A . Estimation means were 529.6 and 550.4 (Table 7 ^ fo r t he


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25Tabl e 7. Calor ie Estimation Scores for Meal B

P r e - V i d e o

P o s t - V i d e o

N

45

3 8

M e a n

529.6

550.4

Actual Value

62 0

620

SD

180.3

108.7

Range

220-980

325-700

p r e - and post-vid eo periods r espectivel y, with the actual value being620 Calo rie s. The c loser estimation s may be because m.eal B wassmaller and less complicated than meal A.

Both pre- and post-video viewing mean exchange estimation scoresfor meal B (Table 8) were both underestimated and overestimated. MealB had no fat exch ange s, yet the mean estimation score for fat was 1.17(pre-vi deo) and .69 (post-video) (Table 8 ) . Meat estimation scoreswere 2.0 and 2.4 for p re- and p ost-v ideo, respectively, while theactual va lue was 3.0 . The meat served in the meal consisted of 3 (1oz.) pork link s. Seventy-se ven percent of the subjects indicated thatpork links were included in the list as a high fat me at. This couldhave attributed to the confusion about the number of fat exchanges.

Due to the Calor ie and Excha nge Estimation Game being on avoluntary bas is, the sample size was decreased to 45 subjects thefirst day and 38 subjects the second day. Fewer oarticipantsattempted the estimation game on the second day probably due to theduplici ty of the meals on both days. Sixty percent and 53% of Group 1a nd 2 s u b j e c t s , r e s p e c t i v e l y , r e s po n d ed t o t h e o a m e ; w h e r e a s , f ro mGroup 3 only 30% of the participa nts resp onded. The lower educational


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26T a b l e 8 . Mean Exchange Estimation Scores o f Meal B

Pre-Video

Post-Video

Exchange

MeatFatBreadFruitVegetable

MeatFatBreadFruitVegetable

N

434343A 343

3636363636

Mean

2.01.171.11.91.11

2.40.691.01.931.06

SD

1.21.70.50.570.43

0.91.090.20.240.23

Range

0-30-61-3.51-A0-2

0-30-41-21-21-2

level a n d limited prior knowledge about t h e exchange system m a y haveinhibited t h e subjects assigned t o Group 3 .

Analysis o f t h e Diabetic ExchangeList Questionnair'e ^The Diabetic Exchange List Questionnaire (Appendix B ) , used a s

the pre- a n d post-test instrument, w a s called a questionnaire in orderto lessen test anxiety o f t h e s u b j e c t s . P r e - a n d post-video mean testscores a r e shown in Figure 2 , f o r t he control group. A s expected,little difference existed between t h e p r e - a n d post-test scores f o rthe three control grou ps. Mean test scores d i d decrease more than 1 0points between g roup s, with subjects in Group 3 having t h e lowestavera ge. After video treatment (Figure 3 ) , pre- a n d post-test meanscores varied greatly between t h e individual in groups 7. a n d 3 .Scores f o r Group 1 subjects remained relatively unchanged indicating aprevious high level o f knowledge about t h e exchange lists. A


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2 7

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L C o n t r o l g r o u p 1 c o n s i s t e d p r i m a r i l y o f d i e t i t i a n s a n d o t h e rp a r t i c i p a n t s w h o h a d c o l l e g e d e c r e e s .C o n t r o l g r o u p 2 i s c o m p o s e d o f f o o d s e r v i c e s u p e r v i s o r s .C o n t r o l g r o u p 3 c o n s i s t e d p r i m a r i l y o f d i e t a r y m a n a g e r s a n d h e a dc o o k s .


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28

10 0 -19 0 -8 0 -

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Figure 3 . Mean pr$- an d post-test scores o f video treatmentg r o u p s .Video treatment group 1 consisted primarily o f dietitians and

other participants w h o h ad college degrees.Video treatment group 2 is composed o f food service supervisors.Video treatment group 3 consisted primarily o f dietary managers andhead cooks.


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29signi fican t interaction was found between group and video, with Group3 having a mean increase of 12 points post-video treatment. Thisgroup of subje cts had the lowest level of education , and pre-tests c o r e s , and thus were aided the greatest by viewing the video program.The decr ease between the pre- and post-video mean scores for those ingroup 2 (video treat ment ) may be partially explained by the fact thata few subjects may have souoht help from educational materialsconcerning the diabetic exchan ge system prior to the seminar . Thisallowed for pre-test scores to be relatively high when actuallyknowledge was low, which was reflected by low test scores when thet e st w a s r e a d m i n i s t e r e d .

The mean diffe rence between the pre- and post-test scores forcontrol and video treatm ent in each group is shown in Ficure 4. Thegraph illustrates the extreme range in mean test score differencesoccu rring in groups 2 and 3. Thes e data might not be so divergent ifa larger sample size had been used and more questions added to thetest instrument to reduce total points of each guestion.

Program Evaluation ScoresThe Program Evaluation Form (Appendix B) completed by the

participants for day two of the seminar showed that the "DiabeticInstruction for 1987" received the highest evaluation scores. Fortyof the 94 participants indicated that the presentation was excellent.In gen era l, comments were very support ive about using videocassettesfor dietary ins truct ion. Specific comments are shown in Figure 5.


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cID(D5- ^(DCDQ)UC(DL(Du.

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30rIIIIII

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F i g u r e 4 . Mean differences between p r e - a nd post-test scores f o rvideo treatment a n d control groups.


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31Figure 5. Selected Comments from Program Evaluation Form

--I liked the film on the food groups and the diabetics presented byM a r g a r e t t e H a r d e n . E n j o y e d the video on exchange lists very much--would be interestedin knowino about its availability.--The "Diabetic Instruction" for 1987 was very interesting.--Diabetic instruction f il m ve ry good, need to slow it down so thatan individual has time to comprehend it.--Tapes f or "Diabeti c In struct ion" could be very helpful for teachingin small f acili ties . " D i a b e t i c I n s t r u c ti o n " f il m w a s e x c e l l e n t g o o d t e ac h in g t o o l .


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CHAPTER VCONCLUSIONS AND RECOMMENDATIONS

ConclusionsThis study has demonstrated that the videotape program, "Diabetic

Meal Ma nag eme nt, " could be used as a viable tool for dietaryinstruc tion. Group 3 parti cipan ts, consisting primarily of head cooksand other dietary wo rk er s, had less formal training in diabetictreat ment, thus benefited the most from the program. A significantinter actio n was found between video and grou p. The subjects in thisstudy recommend ed use of the videocasse tte progr am in diabetic dietinstruction and in employee training progr ams.

The high degr ee of underes timat ion for meal A and B wassurprising due to the number of dietitians present at the seminar andthe majori ty of subjects reporting a thorough understanding ofdiabetic di ets . Scores were raised after viewing the video program,although the difference was not signifi cant. The importance ofaccurate food portion estimation was supported.

The importance of continuing education for those personnel whomay supe rvise the preparation of diabetic meals and give dietinstruction was demons trated.

RecommendationsVideocassette programs and alternate teaching methods in diabetic

diet managem ent need further development and implementation.Videot ape instruction for diabetes narrated in Spanish would helpallevi ate a deficiency in educational mater ials for Mexican Americans

32


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3 3r e s i d i n g i n t h e S o u t h w e s t . A l s o , f u r t h e r s t u d i e s s h o u l d c o n s i d e r t h eu s e o f v i d e o c a s s e t t e p r o g r a m s f o r i n s t r u c t i o n a b o u t p l a n n i n g r e n a l ,l o w s o d i u m , a n d l o w - f a t d i e t s .


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2 .

R E F E R E N C E S

1 . ^ ^ r r i s , M I . , a n d H a m m a n , R . F . : S u m m a r y . Iji H a r r i s , M . I . ,? ^ -*. D i a b e t e s i n A m e r i c a . U . S . D e p a r t m e n t o f H e a l t h an d H u m a nS e r v i c e s . N I H P u b li c a ti o n N o . 8 5 - 1 4 6 8 , A u g u s t , 1 9 8 5 .E v e r h a r t , J ., K n o w l e r , W . C , a nd B e n n e t t , P. H . : C h a p t e r I V.I n c i d e n c e a n d R i s k F a c t o r s f o r N o n i n s u l i n - D e p e n d e n t - D i a b e t e s . InH a r r i s , M . I . , e d . : D i a b e t e s in A m e r i c a . U . S . D e p a r t m e n t o f ~H e a l t h a nd H u m an S e r v i c e s . N l H P u b l i c a t i on N o . 8 5 - 1 4 6 8 , A u g u s t ,1 9 8 5 .

3 . H a r r i s , M . I . : T h e P r e v a l e n c e o f D i a g n o s ed D i a b e t e s , U n d i a cn o s e dD i a b e t e s a n d I G T . X H " Re li sh , J. S . , e d . : G e n e t i c - E n v i r o n m e n t a lI n t e r a c t i o n s in D i a b e t e s . A m s t e r d a m : E x c e rp t a M e d i c a , 1 9 8 2 .4 . G u s s l e r , J . D . : D i e t e t i c C u r r e n t s : C o n s e n s u s D e v e l o p m e n tC o n f e r e n c e o n D i e t a n d E x e r c i s e i n N o n - I n s u l i n - D e p e n d e n t D i a b e t e sM e l l i t u s . R o ss L a b o r a t o r i e s , V o l . 1 4 , N o . 4 , 1 9 8 7 .5 . F r a n z , M . J. , B a r r , P ., H o l l e r , H . , P o w e r s , M . A . , W h e e l e r ,

M . L . , a n d W y l i e - R o s e t t , J .: E x c h a n g e L i s t s : R e v is e d 1 9 8 6 . JA m D i e t A ss o c 8 7 : 2 8 - 3 4 , 1 9 8 7 .6 . W e s t , K . M . : D i e t t h e r a p y o f d i a b e t e s : A n a n a l y s i s o f f a i l u r e .A n n I n t e rn M ed 7 9 : 4 2 5 - 4 3 4 , 1 9 7 3 .7 . T u r n b r i d g e , R . E . , a nd W e t h e r i l l , J. H . : R e l i a b i l i t y a nd c o st o fd i a b e t i c d i e t s . B r M e d J 2 : 7 8 - 8 0 , 1 9 7 0 .8 . S a v a g e , P. J . , a nd K n o w l e r , W . C : D i e t t h e r a py fo r T y p e TId i a b e t e s m e l l i t u s : C a n n e w a p p r o a c h e s i mp r o ve t h e r a p e u t i cr e s u l t s ? N u t r A b s t R e v : R e v i e w s in C l in N u t r 5 4 :6 9 ( F e b . - M a r . ^1 9 8 4 .9 . C e r k o n e y , K . A . B . , a n d H a r t , L , K . : T h e r e l a t i o n s h i p b e t w e e nt h e h e a l t h b e l i e f m o d e l a n d c o m p l i a n c e o f p e r s o n s w i t h d i a b e t e sm e l l i t u s . D i a b e t e s C a r e 3 : 5 9 4 - 5 9 7 , 1 9 8 0 .

1 0 . P a c e , P . W . , H e n s k e , J . C , W h i t f i l l , B . J ., A n d r e w , S . M. ,R u s s e l l , M . L . , P r o b s t f i e l d , J . L . , an d I n s u l l , W . :V i d e o c a s s e t t e u s e i n d i e t i n s t r u c t i o n . 0 A m D i e t A s s o c8 3 : 1 6 6 - 1 6 9 , 1 9 8 3 .1 1 . M c C u l l o c h , D . M . , M i t c h e l l , R . D . , A m b l e r , J ., a n d T a t t e r s a l l ,R . B . : I n f l u e n c e of i m a g i n a t i v e t e a c h i n g o f d i e t o n c o m p l i a n c ea n d m e t a b o l i c c o n t r o l in i n s u l i n d e p e n d e n t d i a b e t e s . B r M e d J2 8 : 1 8 5 7 - 1 8 6 1 , 1 9 8 3 .

34


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35

'' Assoc'??;3S6.36^, m S " ' ' " ' ''' ''-''''''' '''''''''' ' '" ''''1 3 . M i e r , C . S . : In-service education practices in large hospitald e p a r t m e n t o f d i a b e t i c s . J A m Diet Assoc 77:303-306, 1980.1 4 . National Diabete s Data Grou p, National Institutes o f Health, fromdata o f t h e 1979-1981 United States National Health InterviewS u r v e y s , Public Health Service a n d National Center f o r HealthS t a t i s t i c s .1 5 . Second national health a n d nutrition examination survey,1 9 7 6 - 1 9 8 0 . National Center f o r Health Statistics, Department o fHealth a n d H u m a n S e r v i c e s . 1 9 8 4 .1 6 . H a r r i s , M . I . : National Diabetes Data Group. Unpublished datafrom t h e 1976 National Health Interview Survey, 1984a.1 7 . W e s t , K . M . : Diabetes in American Indians a n d other nativep o p u l a t i o n s o f t h e n e w w o r l d . D i a b e te s 2 3: 841 - 847 , 1 9 74.1 8 . S t e i n , J . H . , W e s t , K . M . , R o b e y , J . M . , T i r a d o r , D . F . , a n dM c D o n a l d , G . V'.: T h e high prevalence o f abnormal glucoset o l e r a n c e i n t h e Cherokee Indians o f North Carolin a. Arch InternM e d 1 1 6: 842 - 845 , 1 9 65 .1 9 . D r e v e t s , C . C : Diabetes mellitus in Choctow Indians. 0 OklaM e d A s s o c 5 8: 3 2 2 - 3 2 9 , 1 9 65 .2 0 . G a r d n e r , L . I . , S t e r n , M . P . , H a f f n e r , S . M . , G a s k i l l , S . P . ,H a z u d a , H . P . , a nd R e L e t h f o r d , J . H . : Prevalence o f diabetes inM e x i c a n A m e r i c a n s . D i a b e t e s 3 3: 8 6 - 9 2 , 1 9 84.2 1 . M a r t i n , D . B . , a nd Q u i n t , A . R . : Chapter XXIV, Therapy f o rD i a b e t e s . Ijn H a r r i s , M . I . , ed.: Diabetes in America. U . S .Department o f Health a n d H u m a n S e r v i c e s . N I H Publication N o .8 5 - 1 4 6 8 , A u g u s t , 1 9 85 .2 2 . American Diabe tes Asso ciat ion, American Dietetic Associat ion:Exchange Lists f o r Meal Planning. Chicag o: American Dietetic

A s s o c i a t i o n , 1 9 8 6 .2 3 . American Diabetes Association Task Force o n Nutrition a n dExchange Lis ts: Nutritional recommendations a n d principles f o ri n d i v i d u a l s w i t h d i a b e t e s m e l l i t u s: 1 9 8 6 . Submitted t o DiabetesC a r e f o r p u b l i c a t i o n .2 4 . H a y n e s , R . B . : A critical review o f t h e " d e t e r m i n a n t s " o fpatient compliance with therapeutic regim ens. Iji Sacke tt, D . L . ,a n d H a y n e s , R . B . , e d s .: T h e r a p e u t i c R e g i m e s . B a l t i m o r e: T h eJo h n s H o p k i n s U n i v e r s i t y P r e s s , 1 9 7 6 .


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APPENDIX ASCRIPT

DIABETES MEAL MANAGEMENT

37


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38SCRIPT

DIABETES MEAL MANAGEMENT

Do you have diabetes"?Does a friend?or a family member?

Tho usa nds of Americ ans do have diabet es and the number is growing eachyea r. Here are some statistics about diabe tes.- One in every 4 0 Americans has been told by a doctor that he or she

h a s d i a b e t e s .- 95% of these diabetic people are type II. Also called adult onset

o r n o n - i n s u l i n - d e p e n d e n t .- Half of those who develop diabetes after the age of 45 can control

it by diet alone.

This program was designed to provide information about diabetic mealmana geme nt. It will focus primarily on the type II diabetic person.The Exch ange List for Meal Planni ng Booklet produced by the AmericanDiabetes Associ ation and the American Dietetic Association mayaccompany this videotape or the videotape may be viewed alone .

The objectives of this program are:1. To defi ne: Diabetes

Meal Planning andExchange Lists


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392 . To list goals in nutrition for diabetes management

and3. To describe how to accomplish those goal s.

W h o G e t s D i a b e t e s?Anyo ne may get diabetes at any tim e, however , diabetes is found mostoften in three types of people:- People with relatives who have diabetes- Middl e-aged and older individuals- People who are overweight

What Is Diabetes?Diabet es is a condition in which the body cannot use foods properly.When food is digested, it breaks down into a sugar called glucose,

whi ch the body uses for ener gy. Insulin is a hormone produced by agland called the pan crea s. The pancreas releases insulin into thebloodstr eam when the blood glucose rises after eating. Insulin helpsthe glucose go from the blood into the body cells to be used forenergy or stored for future use.

People with type II diabetes make some insulin, but either it is notworking prope rly or there is not enough insulin produced. Peopleoften can control this type of diabetes by limiting the amount of foodthey eat and by increasing their exer cise . Oral hypoglycemic agents(diabetes p i U s ) help some people to make more insulin or to use theirown insulin better.


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40H o w I s D i a b e t e s M a n a g e d?- 11

T h e m a n a g e m e n t o f d i a be t e s h a s t h r e e p a r t s:- food- activity and- m e d i c a t i o n ( if n e e d e d )

Food raises blood- glucos e and blood-fat leve ls. Activity andmedica tions lower blood-g lucose and blood-fat level s. A balance ofthese three parts leads to good managem ent of diabet es.

There are three nutritional goals of diabetes management:- A p p r o p r i a t e b l o o d - g l u c o s e a n d b l o o d - f a t l e v e l s .- Reasona ble weigh t. It is important to eat the right amount of

Calories to help you reach and stay at a reasonable body weight.The 3rd Goal Is Good Nutr iti on. It is important to eat a varie ty of

food each day. Your body works better if you eat a balanced diet thati n c lu d e s t h e r i g h t a m o u n t s o f v i t a m i n s , m i n e r a l s , c a r b o h y d r a t e s ,p r o t e i n , a n d f a t .

Here are some principles of good nutrition:- Eat less fat. The average American adult eats too much fat. Eat

fewer high-fat foods such a baco n, nuts , gravy, marg ari ne, and solids h o r t e n i n r .

- E a t m o r e c a r b o h y d r a t e s , e s p e c i a l ly t h o s e h ig h i n f i b e r .Carboh ydrate foods are a good source of energy , vitam ins , andmi ner als . Fiber in foods may help to lower blood- glucos e andblood-fat leve ls. Foods that are high in fiber are noted in thpbooklet with a special symbol.


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41- Eat less suga r. All people should eat less sugar. Sugar has lots

of Calor ies and no vitamins or min era ls. Foods high in sugarinclu de: sugary breakfast foods , table sugar, honey, and syrup.One 12-ounce can of regular soft drink has nine teaspoons of sugar.

- Use less salt . Most of us eat too much salt. The sodium in saltcan cause the body to retain wat er , and in some people it may r aiseblood pr ess ure . Foods that are high in sodium are noted in thebooklet with a special symbol .

- Use alcohol in mode rati on. It's best to avoid alcohol altogeth er.

How Can A Person Accomplish These Goals?A dia bete s meal plan and the exchan ge lists will help you meet allt h e s e g o a l s .

What Is A Diabetes Meal Plan?A meal plan is a guide which shows you the number of food choi ces orexchanges you can eat at each meal and snack.

What Are Exchange Lists? - -

The six exchange lists help to make your meal plan wor k. Foods aregrouped toge ther on a list because they are ali ke. Every food on alist has about the same amount of carbohydrate, protein, fat, andCal ori es. In the amounts give n, all the choices on each list aree q u a l . An y foo d on a list can b e exch an ged or trad ed f'or any o the rfood on the same list.


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42T h e Si x Li s t s A r e: S t a r c h / B r e a d , M e a t a nd S u b s t i t u t e s , V e g e t a b l e s ,F r u i t , M i l k , a nd F a t .

Now , let's discuss each list individua lly. If you have the ExchangeLists Book let, turn to page 6 and follow along . The list shown firsti s S t a r c h / B r e a d .

Each item on this list contains approxi mately 80 Calorie s.

You can choose your starch exchanges from any of the items on thislist . If you want to eat a starch food that is not on this list, thegeneral rule is that:

- 1/2 cup of cereal, grain, or pasta is one servingor

- 1 ounce of a bread product is one serving .

Examples of one Starch/Bread exchange are:1/2 cup of cooked cereal such as Cream of Wheat or oat mea l.3/4 cup of ready-to-eat unsweet ened cereal such as Tot al.1/2 cup of cooked pasta or 1/3 cup white or brown rice.

Dried beans and peas are included in this list:1/3 cup cooked black eye peas or cooked beans eoual 1 excha nge.

Some examples of starchy vegetable s include 1/2 cup of corn or one 6inch long corn on the cob. A small baked potato is also one exc han oe.


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43Examples of breads incl ude:1/2 of a hotdog or hamburger bun1 small tortilla1 slice of white or wheat bread3 cups of popcornor6 sal tine-type crackers

All of these examples equal one Starch/Bread exchange.

The second list is the meat l ist. The meat list is divided into threeparts ba sed on the amount of fat and Calor ies : lean mea t, medium - atm e a t , a n d h i g h - f a t m e a t .

Before dis cussing each gro up, here are some important cooking TIPS tor e m e m b e r .

1. Ba ke, roast, broi l, grill or boil these foods rather than fryingthem with added fat.

2 . Use a nonstick pan spray or a nonstick pan to brown or -^ry thesef o o d s .

3. Trim off visible fat before and after cooking.4 . Do not add flou r, bread crum bs, coating mix es , or fat to these

foods when preparing them.5. Weigh meat after removing bones and fat, and after cooking.


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44Thre e ounces of cooked meat is about equal to 4 ounces of rawm e a t .Some examples of meat portions a re:2 ounces me at (2 meat excha nges) = 1 small chicken leg or thigh or

1/2 cup cottage cheese or tuna3 ounc es mea t (3 meat exc hange s) = 1 medium pork chop or 1 small

hamburge r or 1/2 of a whole chicken breast6. Resta urants usually serve prime cuts of mea t, which are high in

f a t a n d C a l o r i e s .

It is import ant to remember when looking at the meat list that oneexchange of meat is not to be confused with what one usually considersa portion or a standard serving.

(All examples of meat are standard servi ngs, not necessarily oneexcha nge.) Some examples of lean meats are:

Flank or skirt steakChicken and turkey without the skinTuna (canned in wat er)S a r d i n e sand any cottage cheese

Examples of medium fat meats a re:All ground beefPork chops or cutletsM o z z a r e l l a c h e e s e


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458 6 % f a t - f r e e l u n c h e o n m e a tand one egg

E x a m p l es o f h i g h - f a t m e a t s a r e:Pork sausageAny fried fish productAll regular cheeses such as American and cheddarPeanut butter

(High fat meats are high in saturated fa t, cholesterol and Calo ries,and should be used only three times per week.)

The third exchange list is the vegetable list. Each vegetable on thislist contains approx imately 25 Calo ries .

Unless otherwise noted, the serving size for one vegetable exchangei s :

1/2 cup of cooked vegetables or vegetable juice1 cup of raw vegetables

Examples of one vegetable exchange are:1/2 cup cooked green beans1 cup of onions1 cup of green peppersOne large tomatoor 1/2 cup of tomato juice


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46

Th e four th list is the fruit lis t. Each item on this list containsa b o u t 6 0 C a l o r i e s .

The car bohyd rate and Calorie content for a fruit serving are based onthe usual serving of the most commonly eaten fruit s. Use fresh fruitsor fruits frozen or canned without sugar added. Whole ^ruit is morefillin g than fruit juice and may be a better choi ce for tho se v/ho aretrying to lose wei ght . Unless otherwise noted, the serving size forone fruit serving is:

1/2 cup of fresh fruit or fruit juiceor 1/4 cup of dried fruit

Examples of one fruit exchange are:O n e a p p l e

1/2 banana1/2 cup fruit cocktail1/2 grapefruit1/2 cup of canned peaches1/3 cup of canned pineappleor 2 tangerines

One example of dried fruits would be:2 T b s p . o f r a i s i n s

And some examples of fruit juices would be:1/3 cup grape juice


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47or 1/2 cup orange juice

List num ber 5 is the milk list . The amount of fat in milk is measuredin perc ent (%) of but ter fat . The Calo ries vary, depending on whatkind of mil k you ch oo se. The list is divided into three parts basedon the amount of fat and Calories: skim/very lowfat milk , lowfatm i l k , a n d w h o l e m i l k .

Exampl es o f skim and very lowfat milk are :1/3 cup of dry nonfat milkor 1 cup skim milk

Examples of lowfat milk are:1 cup of 2 % milkor 8 oz . of plain lowfat yogurt

An example of the last group:1 cup of whole milk

The last list is the fat lis t. Each serv ing on the -"at list conta insabout 45 Ca lo ri es . The foods on the fat list contain mostly fat ,alth ough some items may also contain a small amount of prote in. Allfats are high in Calo ries and should be carefully mea sure d.

Examples of one unsaturated fat exchange are:1 t s p . m a r g a r i n e


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481 t s p . m a y o n n a i s e2 whole pecans1 tsp. oil10 small o livesor2 tsp. salad dressing of the mayonnaise variety

Examples of one saturated fat exchange are:1 slice bacon2 Tbsp. sour creamor 1 Tbs p. cream cheese

Two special categ ories are included in diabetes meal manageme nt, "^heyare free foods and combination foods.

A free food is any food or drink that contains less than 79 Caloriesper serv ing . You can eat as much as you want of those items that haveno serving size spec ifie d. You may eat two or three servings per dayor those items that have a specific servina size.

Examples of drinks included under the free food list are:BouillonSugar-free carbonated drinks1 Tbs p. unsweetened cocoa powderc o f f e eand tea


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50Combina tion foods do not fit into only one exchanqe list. It can bequite hard to tell what is in a certain casserole dish or baked fooditem.

The combination foods presented here represent a tvpical meal of manvwh o l iv e in the Sou thw est. Rememb er that these fo ods mu st be cou ntedas containing multiple exchances.

One Ench il ada = 1 med. meat1 bread/starch2 fat

One Tamal e = 1/2 med. meat1/4 bread/starch2 fat

Meat Tac o = 2 med. meat1 bread/starch1 fat

Cooked beans (1/3 cup) = 1 bread/starch

In this p ro gr am we have defined di abetes, meal planning and theEx ch ange Lists. Th e Fx ch ange Lists in conjunction wi th app ro pr iatemeal plans are one of the necessary tools for controlling the diabeticco nditi on. Th e six exch ange lists pro vid e a diabetic p erson with a


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51wi de vari ety 0"^ food cho ic es . This selection of food provides forgood nutrition while allowing reasonable weight to be obtained.

For more information about diabetes ask vour doctor or contact:

The American Diabetes Association1660 Duke StreetA l e x a n d r i a , V i r g i ni a 2 2 3 14

orThe American Dietetic Association430 North Michigan AvenueChi cag o, Illinois 60611

Good luck and good eating!


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A P P E N D I X BA D D I T I O N A L M A T E R I A L S

5 2


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53NUTRITION GAME SHEET

N a m e DateS o c ia l S e c . N o .Meal A "

Exchanges KcalsBread/StarchMeat and SubstitutesV e g e t a b l eFruitM i l kFatEstimation of Total Kcals:Type of Meat (if present in meal) lean

medium-fathigh-fat

Meal BExchanges Kcals

B r e a d / S t a r c hM e a t and S u b s t i t u t e sV e g e t a b l eFruitMilkFatE s t i m a t i o n of Total K c a l s:

Type of Meat (if present in mea l)lean

medium-fathigh-fat


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557 . NUMBER OF FULL-TIME EMPLOYEES IN DIETARY DEPARTMENT

A. Less than 5B . 5 to 10C. 10 to 15D . 15 to 20E . More than 208. APPR OXI MAT E AVERAGE DAILY PATIENT OR RESIDENT CFN


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561 4 . THE MENU S F OLLOW ED IN THE FACILITY WHE RE YOU WORK ARE PLANNED BYT HE

A . S u p e r v i s o rB . D i e t i t i a nC. Other (Identify )D . I don't know1 5 . WHEN DIET INSTRUCT ION IS NEE DED , IT IS GIVEN BY THEA . S u p e r v i s o rB . D i e t i t i a nC. Other (Identify )

D . I don't know1 6 . DO YOU FEEL THAT YOU HAVE A THORO UGH UNHER STANDING OF PLANNINGAND SERVING DIABETIC DIETS?A . Y e sB. No1 7 . WHA T IS THE AVERAGE NUMBER OF DIABETIC PATIENTS SERVED DAILY ?A. Less than 2B . 2 to 5C. 5 to 10D . More than 101 8 . DO YOU FEEL THAT YOU CORRECTLY USE THE FOOD EXCHANGE LISTS FORPLANNING WEIG HT CONTRO L, SODIUM AND FAT CONTROL, AND DIABETICM E N U S ?A. Yes

B . No1 9 . THE EXCHANG E LIST USED FOR MEAL PLANNING IN YOUR FACILITY WAS

PUBLISHED INA. 1976B . 1986C. I have no idea20 DO YOU USE THE WORK BOOK S PROVIDED AT THE WHITE SWAN SEMINARS FOR

INSERVICE TRAINING AFTER YOU RETURN HOME?A. YesB . NoC. This is my first time to attend

2 1 . IF YOU ARE A MEMBER OF DIETARY MANAGERS, HAVE YOU TAKEN THEEXAMINATION?A. YesB . NoC. I am not a memb er

? 2 . DID YOU PASS THE DIETARY MANAGERS EXAM?A. YesB. NoC. I have not taken it


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5 72 3 . I S A M E M B E R O F Y O U R F A M I L Y O N A D I A B E T I C D I E T ?

A . Y e sB . N o

2 4 . I F A N S W E R I S " Y E S " T O Q U E S T I O N 2 3 , W H A T R E L A T I O N S H I P I S T H I SP E R S O N T O Y O U ?

T H A N K Y O U .N O T E : P l e a s e t u r n t h i s p a g e o v e r a n d q u i c k l y c i r c l e y o u r i m m e d i a t er e s p o n s e t o e a c h i t e m .


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58DIABETES EXCHANGE LIST QUESTIONNAIRE

1. An examp le of one fat exchang e isa. 3 tbs p. of salad dressingb . 1 1/2 slices of crisp baconc. 1 tbs p. of safflo wer oild. 1 tsp. of margarinee. 3 tsp. of butter2 . An exampl e of one meat exchan ge isa. 3 oz . of chicken breastb . 1 slice of baconc. 1 oz . of flank steakd. 3 oz . of chickene . 3/4 c. of tuna3. Which food is not a member of the meat exchance group?a. eggb . baconc. chickend. tunae. cottage cheese4. Whic h of the following would not be included in the fat exchangelists?a . m a y o n n a i s e

b . salad dressingc. eggsd. lb small oliv ese . m a r g a r i n e

5. An example of one milk exchange isa. 2 tbs p. of sour creamb . 1/2 c. of ice creamc. 1 c. of skim milkd. 2 tbsp . of heavy creame. 1/4 c. of ice cream6. An example of one bread exchange isa. 1 c. of green beansb . 1/2 ear of cornc. 12 salti nesd. 1 c. macaro nie. 1/2 c. of spaghetti


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597 . Which of the following pairs of food items cannot be exchangedfor each other?

a. 1 c. 2% fat mil k; 1 c. yogu rt, lowfatb . 1/2 of a 9 in. banana; 1 small applec. 1 egg; 1 slice 86 % fat free luncheon meatd. 1 c. orange juice; 1/2 med. grapefruit8. Whi ch of the followin g is not correct for examples of meatp o r t i o n s?

a. 2 o z. of meat (2 meat e xcha nge s) = 1 sm. chicken thighb . 3 oz . of meat (3 meat exchang es) = 1 med. pork chopc. 2 oz. of meat (2 meat ex chan ges) = 1/4 c. tunad. 3 oz . of meat (3 meat ex chan ges) = 1 sm. hamburger9. Whic h food is not a memb er of the vegetable exchance group?a. carrotsb . a s p a r a g u s

c. broccolid. string beanse . potato1 0 . All but one of the following foods can be used in any amountexcepta. bouillonb . skim milkc. coffeed. unswe etene d dill picklese . diet soft drinks1 1 . An example of one fruit exchange isa. 1 c. of peachesb . 6 plumsc. 1/2 c. of fruit cocktaild. 4 pear halvese . 1 c. of orange juice1 2 . Each item on the fruit list contai ns appro x. Calories

a. 40b . 50c. 60d. 70


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6 0D I A B E T E S E X C H A N G E L I S T Q U E S T I O N N A I R E

N a m e D a t eS o c i a l S e c u r i t y N o .P l e a s e c i r c l e t h e c o r r e c t r e s p o n s e t o e a c h o f t h e f o l l o w i n g :1 . E a c h i t e m o n t h e f r u i t l i s t c o n t a i n s a p p r o x . C a l o r i e s

a . 4 0b . 5 0c . 6 0d . 7 0

2 . A n e x a m p l e o f o n e m i l k e x c h a n q e i sa . 2 t b s p . o f s o u r c r e a mb . 1 / 2 c . o f i c e c r e a mc . 1 c . o f s k i m m i l kd . 2 t b s p . o f h e a v y c r e a me . 1 / 4 c . o f i c e c r e a m

3 . W h i c h f o o d i s n o t a m e m b e r o f t h e v e g e t a b l e e x c h a n c e g r o u p ?a . c a r r o t sb . a s p a r a g u sc . b r o c c o l id . s t r i n g b e a n se . p o t a t oA . W h i c h o f t h e f o l l o w i n g p a i r s o f f o o d i t e m s c a n n o t b e e x c h a n g e df o r e a c h o t h e r ?a . 1 c . 2 % f a t m i l k : 1 c . y o g u r t , l o w f a tb . 1 / 2 o f a 9 i n . b a n a n a ; 1 s m a l l a p p l ec . 1 e g g ; 1 s l i c e 8 6 % f a t f r e e l u n c h e o n m e a td . 1 c . o r a n g e j u i c e ; 1 / 2 m e d . g r a p e f r u i t5 . A n e x a m p l e o f o n e f a t e x c h a n g e isa . 3 t b s p . o f s a l a d d r e s s i n gb . 1 1/ 2 s l i c e s o f c r i s p b a c o nc . 1 t b s p . o f s a f f l o w e r oi l

d . 1 t s p . o f m a r g a r i n ee . 3 t s p . o f b u t t e r

6 . W h i c h o f t h e f o l l o w i n g i s n o t c o r r e c t f o r e x a m p l e s o f m e a tp o r t i o n s ?a . 2 o z . o f m e a t ( 7 m e a t e x c h a n g e s ) = 1 s m . c h i c k e n t h i g hb . 3 o z . o f m e a t ( 3 m e a t e x c h a n g e s ) = 1 m e d . p o r k c h o pc . 2 o z . o f m e a t ( 2 m e a t e x c h a n g e s ) = 1 /4 c . t u n ad . 3 o z . o f m e a t ( 3 m e a t e x c h a n g e s ) = 1 s m . h a m b u r g e r


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617 . Whi ch food is not a membe r of the meat exchang e group?

a. eggb . baconc. chickend. tunae. cottage cheese8. An exampl e of one meat exchange isa. 3 oz . of chicken breastb . 1 slice of baconc. 1 oz . of flank steakd. 3 oz . of chickene . 3/4 c. of tuna9. All but one of the foll owing foods can be used in any amountexcepta. bouillon

b . skim milkc. coffeed. unsweet ened dill picklese. diet soft drinks1 0 . Whic h of the following would not be included in the fat exchange

lists?a . m a y o n n a i s eb . salad dressingc. eggsd. 10 small oliv ese . m a r g a r i n e

1 1 . An example of one bread exchange isa. 1 c. of green beansb . 1/2 ear of cornc. 12 saltinesd. 1 c. macaronie. 1/2 c. of spaghetti

1 2 . An example of one fruit exchange isa. 1 c. of peachesb . 6 plumsc. 1/2 c. of fruit cocktaild. 4 pear halvese . 1 c. of orange juice


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62WHIT E SWAN FOOD AND NUTRITION SEMINARPROGRAM EVALUATION FORM(Dav 2)May 2 0, 1987

s o a c f I n L - J ^ ^ p r e se n t at i o n b y p l ac i ng a c he ck in t he a p pr o pr i at es p a c e . Specif ic comments will be helpfu l.

+>ccu1 O)uXLU

cuCDms_cu>oJZlCDrai .cC2OrcuCO

s-ooQ-

1. Diabet ic Instruction for 19872 . Bacteria in the News3. Salt Substit utes, Sugar Substitutesand anti-oxidants4 . Gastri c Surgery for Obesit y: DietaryManagement5. Toda y's Health Care Industry6. Plan ning , Purchasing and Management7 . Helping Hands for Special Needs8. Feeding People

403426

40

3026

J 4

424436

37

282525

121832

17

284023

24 31 32Specific comments regarding quality of program, mate rials , discussionl e a d e r s , and/or speakers

Future Program Sug gest ions : I wish I knew more about


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PERMISSION TO COPY

In pr esenting this thesis in partial fu lf il lm ent of therequi rem ents f or a master's degr ee at Texas Tech Univ ersity, I agreethat the Library and my major department shall make it freely available for researc h pu rp oses. Perm issio n to copy this thesis forscholarly purposes may be granted by the Director of the Library ormy majo r pr of essor. It is understood that any copyi ng or pub li catio nof this thesis for financial gain shall not be allowed without myfurther written permission and that any user may be liable for copyright infringement.

Disagr ee (Perm issio n not gr anted) Ag ree (Perm issio n gr anted)

. ,. . . . / / ^Student's sig natur e Stud ent's signatur e

Date Date- / / . i . i^ -C//'


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diabetes meal management

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