DIABETES MEAL MANAGEMENT

by
MARY ELLEN HISE PENTURF, B.S. in H.E

A THESIS

IN

FOOD AND NUTRITION

Submitted to the Graduate Faculty

of Texas Tech University in
Partial Fulfillment of
the Requirements for
the Degree of
MASTER OF SCIENCE

IN
HOME ECONOMICS

Approved

Accepted

December, 1987
 s

mi
ACKNOWLEDGMENTS

^of"^ I would like to express my sincere appreciation to Dr. Maraarette

Harden for her guidance, encouragement, support and patience
throughout the course of my graduate program. I also wish to thank
Dr. Mallory Boylan and Dr. Ei Soon Cho for their advice and guidance
as members of my research committee.
I would also like to thank Lisa McKee for her technical
assistance and Gay Riggan for her cooperative effort in the
preparation of the manuscript.
A deep appreciation is extended to my husband, Charlie, for his
moral support, patience and love throughout my graduate studies.

n
 CONTENTS

ACKNOWLEDGMENTS ii

ABSTRACT v

LIST OF TABLES vi

LIST OF FIGURES vii

I. INTRODUCTION 1

II. REVIEW OF LITERATURE 3

Incidence and Risk Factors for Non-Insulin-
Dependent Diabetes Mellitus 3
Diabetic Diet Instruction for Non-Insulin-
Dependent Diabetes Mel 1 itus 5
Continuina Education for Dietarv Personnel 7
Educational Tools and Techniques for Diabetic
Di ets 8
III. METHODS AND PROCEDURES 11
Videocassette Production 11
Subjects 13
Demographic Data Sheet 13
The Diabetic Exchange List Questionnaire 13
Nutrition Game Sheet 14
Program Evaluation Form 14
Data Collection •''or the Diabetic Exchange List
Questionnaire 14
Collection of Calorie and Exchange Estimation
Game Data 15
Statistical Treatment 15
IV. RESULTS AND DISCUSSION 17
Calorie and Exchange Estimation Scores 23
iii
 Analysis of the Diabetic Exchange List
Questionnaire ?6
Program Eval uati on Scores 29
V. CONCLUSIONS AND RECOMMENDATIONS 32
Conclusions 32
Recommendations 32
REFERENCES 34
APPENDICES
A. SCRIPT: DIABETES MEAL MANAGEMENT 37
B. ADDITIONAL MATERIALS 52

IV
 ABSTRACT

The purpose of this study was to develop a diabetic meal

management instructional videotape to enhance and improve

comprehension of the diabetic exchange system by food personnel.

Subjects were assigned to three groups according to occupational and

educational level. Sample size for the groups was 30, each havino a

treatment and control subgroup. Group 1 was composed primarily of

registered or consulting dietitians. Group 2 was composed of food

service supervisors, and Group 3 was primarily dietary managers and

head cooks. Knowledge was measured by a pre- and post-test instrument

after viewing the 16-minute videotape. A significant interaction was

found between video and group, with group 3 havino a mean increase of

12 points post-video treatment. This group had the lowest level of

education and pre-test scores, and thus was aided the greatest by

viewing the video program. A voluntary game for subjects was used to

evaluate Calorie and exchange estimations for two meals, varying in

Calorie level. Subjects generally underestimated Calorie and number

of exchanges prior to viewing the videocassette program and raised

their scores slightly after the video treatment. This videotape v/ill

be a useful tool for improving the serving of diabetic diets by food

service personnel as well as for enhancing dietary compliance of newly

diagnosed diabetic individuals.

 LIST OF TABLES

1. Calorie and Diabetic Exchanges for Meal A 16

?. Calorie and Diabetic Exchanges for Meal P 16

3. Demographic Characteristics of Subjects 18

4. Employment and Educational Characteristics of Subjects 19

5. Mean Calorie Estimation Scores for Meal A ?3

6. Mean Exchange Estimation Scores of Meal A ?4

7. Calorie Estimation Scores for Meal B ?5

8. Mean Exchanqe Estimation Scores of Meal P 26

VI
 LIST OF FIGURES

1. Distribution of diabetic relatives reported by subjects 17.

2. Mean pre- and post-test scores of control groups ?7
3. Mean pre- and post-test scores of video treatment groups 28
4. Mean differences between pre- and post-test scores for
video treatment and control groups 30
5. Selected Comments from Program Evaluation Form 31

vn
 CHAPTER I

INTRODUCTION

Non-insulin-dependent diabetes mellitus (NIDDM) is one of the

most common chronic diseases in the United States. Approximately 90^

of individuals diagnosed as having diabetes have NIDDM and an

additional 4-5 million people meet the diagnostic criteria for NIDDM

but have not yet been diagnosed (1-3).

Risk factors for NIDDM can be determined by measuring incidence,

which is the number of new cases of illness occurring in a specified
population at risk per unit of time. Determining that a certain
attribute is a "risk factor" can be accomplished by documenting a
higher incidence rate in persons with the factor than in those without
it (?). Incidence rates are highest in the United States for Blacks,
Mexican Americans, and American Indians. Socioeconomic status and
urban or rural habitation may also influence incidence rates. The
most important risk factors for development of NIDDM are increasing
age, heredity, and obesity (2, 4 ) .

Dietary management is essential in all therapy for individuals

with NIDDM. The Exchange Lists are the most widely used tool for
dietary planning and meal management (5). Unfortunately, past
nutritional educational methods for diabetic persons have resulted in
poor comprehension levels and decreased compliance (6-9). Dietary
compliance is further complicated by the over and underestimation of
food portion size in diet management.
 Innovative teaching methods are needed to enhance diet

instruction and provide for alternate learning styles for NIDDM

persons. Slides, programmed instruction, and videocassette programs

may be used in a variety of instructional formats. All of these

methods allow material to be reinforced by repetition and also

alleviate the problem of time deficiency. Studies have shown that

simpler diet instruction using videocassette programs have been

effective in producing changes in knowledge and behavior for diabetic

individuals (10, 11). Of the many teaching m.ethods, videocassettes

could be accessible in hospital and nursing home "facilities.

In many rural hospitals and nursing homes, diet instruction is

often given by a food service supervisor or dietary manager. This is

due primarily to the scarcity of dietitians in these facilities. For

these employees, adequate knowledge about the diabetic exchange system

is necessary, although actual knowledge about diabetic treatment may

be limited. For food service supervisors, dietary managers, and other

food service employees, continuing education is often required to

increase knowledge about current nutritional methods and

recommendations. On-the-job training is the most common method of

continuing education (12, 13). It is in this format that audiovisual

programs may be used effectively.

The complexities of the diabetic exchange system may be difficult

not only for the NIDDM individual, but also for the food service

employee unfamiliar with the six exchange lists and varying portion

sizes. The development of a basic, easy to understand videocassette

program would enable supplementation of the traditional form of

teaching, while promoting better comprehension of the exchanoe system.

 CHAPTER II

REVIEW OF LITERATURE

Diabetes mellitus, a chronic health problem in the United States,

is a primary cause of blindness, kidney failure and limb amputation.

Dialysis treatment for kidney failure -^rom diabetes alone costs more

than one billion dollars annually, and this ficure is expected to

double during the next few years (1, 4 ) .

Incidence and Risk Factors for Non-Insulin-

Dependent Diabetes Mellitus
Non-insulin-dependent diabetes mellitus (NIDDM), also called

adult-onset or type II diabetes, affects about ten million middle-age

or older Americans, or approximately 90% of all people diagnosed as

having diabetes. The incidence of NIDDM has been escalating since

1935 for all age groups. National surveys comprised of annual

physician interviews showed that approximately 32 new cases per ten

thousand population, ages 20 years and older, were reported annually.

This is illustrated by the five-fold increase in diabetes during the

past 45 years. Approximately 500,000 new cases of NIDDM are diagnosed

each year in persons over 25, yet half of the persons who have NIDDM

are undetected or undiagnosed (2).

Major risk factors associated with the onset of NIDDM are

increasing age, heredity and obesity. Risk factors for NIDPM are

determined by documenting a higher incidence rate in persons with the

factor than those without it (2, 4 ) .

 Strong evidence supports the genetic component for the

development of NIDDM. Data from the National Health Interview Survey

(NHIS) (1979-1981), indicated that both obesity and aging influenced

the development of the disease in susceptible individuals, and that

the incidence of NIDDM steadily increased after the fourth decade of

life (14). Non-insulin-dependent diabetes mellitus is highlv

correlated with obesity. Approximately 80% of people with NIDDM have

excess body fat or adiposity. Both the National Health Interview

Survey and Health and Nutrition Examination Survey 11 (HANES II)

indicated that the prevalence of NIDDM increased with increasing

amounts of body fat (14, 15).

Studies by Harris et al_. illustrated the susceptibility of

different races to the development of NIDDM (16). In the United

States between 1966 and 1981, the prevalence of diabetes increased

120% in blacks but only 60% in whites (16). The HANES II study

also showed that blacks had a 50% greater prevalence of diabetes than

whites (15).

The greatest prevalence for diabetes occurs among the Pima

Indians (17). Full heritage Pima Indians have almost a two-fold

greater incidence rate of NIDDM than Pimas with Caucasian admixture.

Stein (18) and Drevets (19) also reported a greater prevalence of

NIDDM in full-heritage Cherokee Indians as compared with

mixed-heritage Cherokee and Choctow Indians.

Gardner and co-workers (20) reported that Mexican Americans in

San Antonio, Texas had a higher prevalence of NIDDM than non-Hispanic

Caucasians. In this study, Mexican Americans had two to four times

higher NIDDM prevalence rates than their Anglo counterparts.

Diabetic Diet Instruction for Non-Insulin-

Dependent Diabetes MellituT

The backbone of therapy for patients with diabetes mellitus is

proper dietary management. In the United States, about 25% of people

having diabetes require insulin injections while 35% take oral

hypoglycemic medications. Three-fourths of these diabetic people also

follow a diet plan for control of their diabetes, while 15% use diet

alone. Diet is a crucial factor for maintenance and must be

individually tailored in terms of Caloric need, social and ethnic

background, and lifestyle of the diabetic individual f?l).

The Exchange Lists are the most widely used tool for dietary

planning and meal management by persons with NIDDM. This dietary

regime was developed to provide the diabetic person with practical

guidelines for the daily use of the food groups (22). In 1986, the

Exchange List for Meal Planning booklet was updated and revised by a

committee composed of members of the American Diabetes Association and

the American Dietetics Association. These changes reflected

nutritional recommendations for persons with diabetes as understood in

1986 (23). Major chanoes from the 1986 exchanoe list included

emphasizing a high carbohydrate, high-fiber diet; addino symbols to

foods high in fiber and sodium; changing nutritive values for the

starch/bread and fruit list; and adding lists of combination and free

foods.

Unfortunately, past attempts at nutrition education have resulted

in limited success (6-9). The major problem in diabetic diet

instruction is the lack of understanding about the dietary regime

which results in poor patient compliance. Haynes (24) defined

compliance as the extent to which a person's behavior (in terms of

taking medication, following diets, or altering lifestyle) coincides

with medical or health advice. Studies have shown that the majority

of diabetic individuals have a low level of compliance with dietary

recommendations (6-9, 25, 26). Williams e^ al^. (?7) compared at home

food intakes of diabetic patients to the diabetic exchange lists, and

found that 75% of those studied had significant deficits in the

distribution of their food choices half of the time, and 50% had

deficiencies all the time. Food items most frequently deleted were

fruits, non-starchy vegetables, and meats. Also, dietary compliance

data collected in 1984 indicated that 80% of known diabetic

individuals said that they had received a written diet, but only 53%

followed the prescribed diet plan (8).

Dietary compliance is further complicated by difficulty in

estimation of food portion size. Lansky and Browne!1 (?8) found a

clinically sionificant pattern of overestimation of food quantities

and Caloric content by obese females. These researchers hypothesized

that lack of skill in estimating portion sizes may have contributed to

the poor evaluation of Caloric value in commonly eaten foods.

Rapp and co-workers f?9) reported that in an outpatient clinic,

diabetic subjects underestimated the size of chicken portions by an

average of 45.7%, while overestimating margarine by an averaoe of 30%

to 40%. These researchers also reported infrequent use of food

quantity measuring devices by subjects.

 Continuing Education for Dietary Personnel

Due primarily to the scarcity of dietitians in many rural

hospitals end nursing homes, an adequate degree of knowledge about

diabetic treatment is essential for all personnel who prepare foods or

who may give dietary instruction to patients or residents. Food

service supervisors, dietary managers, and other food service

employees may give dietary counseling and also supervise preparation

of meals for NIDDM patients. Continuing education for these employees

varies due to available teaching resources, and to the degree of

continuing education required (30).

Continuing education for food service employees may be

accomplished by inservice training, enrollment in short courses

conducted away from the work setting, or by on-the-job training.

Videotapes, slides, and programm.ed instruction have all been used

effectively to increase knowledge about nutritional methods and

recommendations. Most of the continuing education in nursing homes

and hospitals has been found to be on-the-job type with no one person

responsible for the training (12, 13, 30).

The size of a hospital often dictates the type of educational

training that is available to the food service workers. An American

Hospital Association survey showed that the number of dietary training

programs decreased as the number of hospital beds decreased (31).

This survey also reported that fewer dietary inservice training

programs existed in the south central United States than in other

regions of the nation. The lower percentage was probably due to the

existence of fewer large hospitals.

 8

Educational Tools and Techniques for

Diabetic Diets

A serious inadequacy exists in the area of effective

instructional programs for persons with diabetes mellitus. The
development of innovative videocassette programs, booklets, slides,
and programmed instruction could enable dietary information to be
transmitted by methods that allow for reinforcement by repetition
(10, 32, 33). These approaches could also alleviate the problem of
time deficiency and allow for indepth patient instruction.

Audiovisual instruction may be used in a wide variety of dietary

programs depending upon the objectives and the learning format.
Videocassettes, used in instruction, can convey basic information in a
form that is appealing and instructional. Studies have shown that
videocassette programs and alternate teaching methods dre effective in
producing changes in knowledge and behavior (10, 11, 32-341. Hassel
and Medved (34) reported that significantly higher post-test scores
were achieved when diabetic patients received group diet instruction
using the audiovisual format than those who were taught in the
traditional bedside manner.
Pace et al_. (10) studied the effects of implementing diet therapy
videocassette instruction in diet therapy during the 5th year o^ the
Coronary Primary Prevention Trial (CPPT) at the Lipid Research Clinic
(LCR), Baylor College of Medicine. The objective of the studv was to
improve adherence to the prescribed diet. The videocassette program
defined the desirable behavior for the participants after viewing the
program.
 Results showed that attitudes relating to eating breakfast were
not significantly different during the pre-instruction period, or
after the one week or two month post instruction test period. It
should be noted that individuals in this study had been in the Trial
at least four years and would have had reasonable knowledge of the
purpose and composition of the Trial diet.

McCulloch et al^. (11) studied the effects of three teaching

methods on knowledge, compliance, and glycemic control. Subjects were
poorly controlled insulin-dependent diabetic patients. Glycemic
control was measured by glycosylated hemoglobin levels. Teaching
methods used were conventional diet sheet instruction (group 1),
practical lunchtime demonstrations (group 2 ) , and videotaped education
(group 3 ) . Dietary knowledge determined by an initial guestionnaire
was poor in all three groups. Only 52% gave an ansv/er on the number
of carbohydrate exchanges consumed daily and less than one-third of
these answers were correct when compared with their seven day food
records. McCulloch et al_. (11) also reported that patients -found it
much easier to understand the concept of carbohydrate exchanges when
shown real food quantities of 10 grams of carbohydrate as compared to
only the reading of conventional diet sheets. After six months of
follow-up, no improvement was observed for group 1, but in groups 2
and 3, both knowledge and compliance improved significantly. Thus,
this study illustrated that simpler diet instruction resulted in
improved compliance and understanding. Since many studies have shown
that dietary compliance by diabetic patients was low, the primary
objective for this project was to develop a basic easy to understand
 10

videocassette which would promote better comprehension of the complex

Exchange System. Specific objectives were:

1. To develop a videocassette program on diabetes meal

management.

2. To determine the effectiveness of the videocassette program

on increased knowledge and understanding of the diabetic

exchanges by food service personnel.

 CHAPTER III

METHODS AND PROCEDURES

Videocassette Production

A sixteen minute videocassette program entitled Diabetes Meal

Management was produced in cooperation with the KTXT-TV station. Mark
Slusher, a KTXT full-time employee, served as the technical director.

A script for narration of the videocassette program was primarily

adapted from the Exchange List for Meal Planning booklet (2?.). The
script was designed for the seventh to eighth grade reading level
using the SMOG Index. The SMOG Index, developed in 1969 by G. Harry
McLaughin, is a readability test designed to determine the approximate
grade level required in order to understand written material (35).
The script was analyzed and critiqued by both university faculty
and the technical director of the program for content and for
adaptability to video taping. After editing and revision of the
script, a storyboard was developed for use in all taping sessions.
The storyboard was the written document which served as an exact
step-by-step guide for recording the entire program. The left hand
column of the storyboard contained the exact script (Appendix A ) ,
while the right hand column described the visual scene.
Visual aids were planned and developed simultaneously with the
storyboard. Fifteen, eight by eleven posters, drawn bv a graphic
artist, were designed to attract interest and simplify information.
Cartoons, symbols, and other information that would be difficult to
video tape were designed and illustrated on the poster boards. The

11
 12

Exchange List for Meal Planning booklet was used throughout the
program to visualize and emphasize the six exchanoe lists and to
promote continuity of the program.

Remote taping sessions were conducted at the Texas Tech Student

Recreational Center, the South Plains Mali of Lubbock, Texas, and the
Home Economics Tower at Texas Tech University. Prior approval by
administrative personnel was reouired before taping sessions were
permitted at the Recreational Center and the South Plains Mall.
Individuals at the Student Recreational Center were taped to
illustrate a variety of different sport and exercise activities.
Filming of people participating in racquetball, basketball, exercise
biking, and swimming was used to show different forms of exercise for
diabetes management. The South Plains Mall served as an ideal
location for filming individuals who illustrated obesity, age, and
other risk factors associated with diabetes.
All food items shown on the videotape were cooked and prepared
the day of the taping in a laboratory in the Home Economics Food
Science Tower. For the taping session, a variety of table cloths,
placemats, silverware, and dishes were used. Clear standardized
measuring cups were used to better illustrate food portion sizes. A
stationary camera, monitor, and high wattage lighting were used for
still shots of the food items displayed against a black backdrop.
Each food item was taped for approximately 60 seconds.

Approximately 180 minutes of video were taped. Editing of the

video footage was conducted at the KTXT-TV station. Approximately one
hour of editing was necessary to produce one minute of video on the
 13

master tape. Background music from tapes and the narrated script were

recorded, edited, and matched with the video footage. The voice used

in the narration was that of Mark Slusher, the producer. A character

generator was employed to produce the title, visual text, and credits.

Subjects
Individuals 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 homes, and other establishments (churches, senior citizens
centers) where dietary services were utilized. Continuing education
credits were available for dietary managers and registered dietitians.

Demographic Data Sheet

A three paoe demographic questiornaire (Appendix B) was mailed to
all registrants prior to the seminar. Completed questionnaires were
collected on the first day of the seminar. Demographic data included:
occupation, age, race, place and length of employment, education, and
diabetic and resident census.

The Diabetic Exchange List Questionnaire

The Diabetic Exchange List Questionnaire (Appendix P^ was adapted

from the Diabetes Educational Profile (35). The questionnaire,

composed of twelve multiple choice questions, was used to assess

knowledge concerning food groups and portion sizes in the six exchange

lists. Participants were asked to circle the correct response to each

question.
 14

Nutrition Game Sheet

The Nutrition Game Sheet (Appendix B) was developed to assess

knowledge of portion sizes (as explained by the diabetic exchange

lists), and to evaluate Calorie and exchange estimation of food items.

Space (on the game sheet) was provided for exchanges and Calorie

estimations for both meals. Meal A represented all of the exchange

groups with the exception of the milk exchange. Meal P represented

all of the exchange groups with the exception of the vegetable

exchange. Participants were asked to sum the total Calories in each

meal, and to identify the level of fat in a meat ^"-'f present in the

meal).

Program Evaluation Form

A daily Program Evaluation Form was designed to rate each
presentation, and allow for specific comments about speakers,
materials, and the quality, or content of the presentations.
Assessment was rated on a scale of excellent to poor.

Data Collection for the Diabetic Exchange

List Questionnaire'

The Diabetic Exchange List Questionnaire (Appendix B) was mailed

to all registrants prior to the seminar. On day one of the seminar,

completed questionnaires were collected. The subjects were randomly

assigned to control or treatment grouD. On day two of the seminar,

the treatment group viewed the Diabetic Meal Management videocassette.

Approximately four hours after viewino the videotaped program, both

treatment and control groups were again administered the Diabetes

 15
Exchange List Questionnaire (Appendix B ) . The questionnaire,
identical in content for both days, was arranged in a different
sequence.

Collection of Calorie and Fxchange Estimation

~~~ Game D a H

The Calorie and exchange estimation game was developed for use

before and after viewing the videocassette program. Participation in

the game was voluntary. Two meals (Tables 1 and 2) with varying

Calorie and exchange contents were used in the game. Identical meals
were used both days of the seminar. The meals were placed on a table
outside of the auditorium doors and participants were asked to make
their estimations on the Nutrition Game Sheet (Appendix B ) . On day
one, prior to viewing the videocassette, forty-five participants
estimated the number of Calories and exchanges in the two meals.
After viewing the videocassette on the second day, thirty-eight
participants estimated the Calories and number of exchanges for both
meals. Four prizes were awarded to those individuals having the
closest estimation for total Calories for meals A and B for both days.

Prizes were displayed to encourage participation in the game.

Statistical Treatment

A three by two factorial design was used to examine the pre- and

post-test scores for the video treatment and control groups. Student

t-tests were used to evaluate estimation scores for Calorie and

diabetic exchanoes before and after viewing the program. A .05 level

of significance was used. The SAS Statistical Analysis System was

used for these analyses.

 16

Table 1. Calorie and Diabetic Exchanges for Meal A

Food Item Amount Exchange Numbier Calories

Hamburger Patty 4 ounces Meat 4 300

Rice 2/3 cup Bread 2 160
Fruit Cocktail ] cup Fruit 2 120
Hamburger Bun 1 bun Bread 2 160
Mayonnaise 3 tsp Fat 3 135
Pecans 4 halves Fat 1 AS
Tomato Juice 1 cup Vegetable, 2 50
Lettuce 2 leaves Free Food, 0 0
Dill Pickle 4" spear Free Food-, 0 0
Mustard 1 tsp Free Food' 0 0

Total Cal ories: 970

A Free Food contains less than 20 Calories per serving. Items

listed may be eaten as desired on the Exchange List Meal Plans.
Calories are negligible and need not be counted on a meal plan.

Table 2. Calorie and Diabetic Exchanges for Meal B

Food Item Amount Exchange Number Calories

Corn Flakes 3/4 cup Bread 1 80

Milk (2% milkfat) 1 cup Milk 1 120
Banana 1 Fruit 2 120
Pork Sausage Links 3 ounce Meat 3 300

Total Calories: 620

 CHAPTER IV

RESULTS AND DISCUSSION

Of the ninety women who attended the annual seminar and

participated in this study, 30 were food service supervisors, 16 were
dietary managers, and 18 were dietitians. Head cooks, food service
aids, and other health care personnel concluded the sample (Table 3 ) .
For the purpose of this study, the subjects were assigned to one of
three groups according to occupation and educational level. These two
variables were selected since they would influence test scores.
Sample size for each group was thirty, each containing a treatment and
control subgroup. Group 1 consisted primarily of registered or
consulting dietitians and other participants who had college or
graduate degrees. Group 2 was composed of food service supervisors,
and Group 3 was made up primarily of dietary managers and head cooks.
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 groups, 47% of

the subjects in Group 1 were under 39 years, whereas 77% of the

subjects in Group 3 were 50 or above. Eighty-four percent of ail

subjects were Caucasian; Group 2 had the highest ethnic population

with 33%.

A wide range of educational levels existed (Table 4 ) . One

percent of the total sample had less than a high school deoree, 74%

had obtained a high school equivalency degree, and 30% held a college

degree. Group 1 subjects had the highest percent of college degrees.

17
 18

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 21

Subjects assigned to groups 2 and 3 had less than 1% college degrees.

Although educational level varied, all participants except two
subjects responded "yes" to having a thorough understanding of the
planning and serving of diabetic diets.

Income level increased with years of education (Table 4 ) .

Subjects assigned to group 1 reported incomes of greater than $15.00
an hour. Subjects in group 2 had a slightly higher average hourly
income than those in group 3.

Thirty-seven percent of the total sample worked in nursing homes,

while 37% were employed in a hospital dietary facility (Table 4 ) .
Subjects in groups 2 and 3 were primarily employed in nursing homes
and in dietary departments of hospitals. Group 1 participants often
reported no place of employment due to either consulting or referral
work from physicians.

Thirty percent of the subjects reported length of employment in

their present facility at 1-5 years (Table 4 ) . These data do not

reflect the possible mobility of these subjects, nor their years of

prior employment in other facilities.

Thirty-two percent of all the subjects participating in this

study had a relative with diabetes. Four individuals, or 4.4% o^ the

total sample reported that they had diabetes. This percentage is

higher than that of the national average 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. The

increasing age of the subjects may also be responsible for the higher

incidence of the diabetes reported (2). Distribution of diabetic

relatives reported by the participants is shown in Figure 1.

 22

30
T

o^e 20 - -

(D
a
(0
c
ID 10
L
ID
QL

Self
yy Spoujs©

ChiIdnem

X Br^othen/Sister-

Par-enL

Figure 1. Distribution of diabetic relatives reported by

subjects.
 23

Relatives were defined as family member (spouse, brother, sister,

children, parents, or self). The incidence of diabetic family members

was equal within the groups.

Calorie and Exchanqe Estimation Scores

The mean Calorie estimation score for meal A prior to seeing the
video was 710.2. The post-video Calorie mean was 763.2 (Table 5 ) .
The actual Calorie value for meal A was 970. Subjects underestimated
the content by more than 200 Calories. This value was extremely high
since the majority of the subjects worked in a dietary department, and
since they had reported a thorough knowledge of diabetic diets.
Although scores were higher after seeing the video, this difference
was not statistically significant.

Table 5. Mean Calorie Estimation Scores for Meal A

N Mean Actual Value SD Range

Pre-Video 45 710.2 970 ±186.3 250-1075

Post-Video 38 763.2 970 ±187.8 295-1270

Mean exchange estimation scores for meal A (Table 6) were

underestimated for all exchange groups for both pre- and post-video

periods. Prior to seeing the video, the subjects underestimated the

meat and bread groups by one exchange for both categories. The

greatest dif-^erence was for the fat exchange with an estimation mean

of 2.2 while the actual value was 4 (Table 6 ) . This difference mav
 24

Table 6. Mean Exchange Estimation Scores of Meal A

Exchange N Mean SD Range

Meat 43 3.0 ±1.0 1-5

Fat 43 2.2 ±0.2 1-7
Pre-Video Bread 43 3.0 ±0.8 /-5
Fruit 43 1.6 ±0.7 1-3
Vegetable 43 1.3 ±0.1 0-2

Meat 36 2.9 ±1.0 1-6

Fat 36 2.2 ±0.1 1-4
Post-Video Bread 36 3.3 ±0.7 2-4
Fruit 36 1.8 ±0.7 1-3
Vegetable 36 1.8* ±0.1 0.5-3

•Significant (p<.05).

have resulted because the subjects did not consider the 4 pecan halves
(1 fat exchange) used to garnish the fruit cocktail. After viewing
the video, mean estimation scores increased slightly for bread, and
for fruit, but these data were not significantly different when
compared with pre-video scores. The vegetable exchanoe estimation
mean increased from 1.3 to 1.8 after viewing the videocassette. This
increase was significant. Lettuce, pickles (1 dill spear), and
mustard were displayed with the meal, but were considered a "free
food." A "free food" is defined as one containing less than 20
Calories per serving. Items in the "free food" category may be eaten
as desired on the Exchange List Meal Plans (22).

Mean Calorie estimation scores for meal B were much closer to the
actual value for both pre- and post-video periods than were the scores
for meal A. Estimation means were 529.6 and 550.4 (Table 7^^ for the
 25

Table 7. Calorie Estimation Scores for Meal B

N Mean Actual Value SD Range

Pre-Video 45 529.6 620 ±180.3 220-980

Post-Video 38 550.4 620 ±108.7 325-700

pre- and post-video periods respectively, with the actual value being
620 Calories. The closer estimations may be because m.eal B was
smaller and less complicated than meal A.
Both pre- and post-video viewing mean exchange estimation scores
for meal B (Table 8) were both underestimated and overestimated. Meal
B had no fat exchanges, yet the mean estimation score for fat was 1.17
(pre-video) and .69 (post-video) (Table 8 ) . Meat estimation scores
were 2.0 and 2.4 for pre- and post-video, respectively, while the
actual value was 3.0. The meat served in the meal consisted of 3 (1
oz.) pork links. Seventy-seven percent of the subjects indicated that
pork links were included in the list as a high fat meat. This could
have attributed to the confusion about the number of fat exchanges.
Due to the Calorie and Exchange Estimation Game being on a
voluntary basis, the sample size was decreased to 45 subjects the
first day and 38 subjects the second day. Fewer oarticipants
attempted the estimation game on the second day probably due to the
duplicity of the meals on both days. Sixty percent and 53% of Group 1
and 2 subjects, respectively, responded to the oame; whereas, from
Group 3 only 30% of the participants responded. The lower educational
 26

Table 8. Mean Exchange Estimation Scores of Meal B

Exchange N Mean SD Range

Meat 43 2.0 ±1.2 0-3

Fat 43 1.17 ±1.7 0-6
Pre-Video Bread 43 1.1 ±0.5 1-3.5
Fruit A3 1.9 ±0.57 1-A
Vegetable 43 1.11 ±0.43 0-2

Meat 36 2.4 ±0.9 0-3

Fat 36 0.69 ±1.09 0-4
Post-Video Bread 36 1.0 ±0.2 1-2
Fruit 36 1.93 ±0.24 1-2
Vegetable 36 1.06 ±0.23 1-2

level and limited prior knowledge about the exchange system may have

inhibited the subjects assigned to Group 3.

Analysis of the Diabetic Exchange

List Questionnair'e ^

The Diabetic Exchange List Questionnaire (Appendix B ) , used as

the pre- and post-test instrument, was called a questionnaire in order

to lessen test anxiety of the subjects. Pre- and post-video mean test
scores are shown in Figure 2, for the control group. As expected,

little difference existed between the pre- and post-test scores for

the three control groups. Mean test scores did decrease more than 10

points between groups, with subjects in Group 3 having the lowest

average. After video treatment (Figure 3 ) , pre- and post-test mean

scores varied greatly between the individual in groups 7. and 3.

Scores for Group 1 subjects remained relatively unchanged indicating a

previous high level of knowledge about the exchange lists. A

 27

00 -J
90 -

80 -
(fl 70 -
(D
L
0 60 -
U
CO
50 -
(0 40 -
Q)
30 -
20 -
10 -

2
GROUPS
Pne—LesL

S Pas-L~Le3-L

1
Figure 2 . Mean p r e - and post-test scores of control groups.

L Control group 1 consisted primarily o f dietitians and other

participants who had college d e c r e e s .
Control group 2 is composed of food service supervisors.
Control group 3 consisted primarily of dietary managers and head
cooks.
 28

100 -1

90 -
80 -

ID ^0 -
L
0 60 -
^ 50 -

ID ^0 -
30 -
20 -
10 -

2 "^

GROUPS
Pne—•Last.

3 Po=t-t==t

Figure 3. Mean pr$- and post-test scores of video treatment

groups.

Video treatment group 1 consisted primarily of dietitians and

other participants who had college degrees.
Video treatment group 2 is composed of food service supervisors.
Video treatment group 3 consisted primarily of dietary managers and
head cooks.
 29

significant interaction was found between group and video, with Group

3 having a mean increase of 12 points post-video treatment. This

group of subjects had the lowest level of education, and pre-test

scores, and thus were aided the greatest by viewing the video program.

The decrease between the pre- and post-video mean scores for those in

group 2 (video treatment) may be partially explained by the fact that

a few subjects may have souoht help from educational materials

concerning the diabetic exchange system prior to the seminar. This

allowed for pre-test scores to be relatively high when actually

knowledge was low, which was reflected by low test scores when the

test was readministered.

The mean difference between the pre- and post-test scores for

control and video treatment in each group is shown in Ficure 4. The

graph illustrates the extreme range in mean test score differences

occurring in groups 2 and 3. These data might not be so divergent if

a larger sample size had been used and more questions added to the

test instrument to reduce total points of each guestion.

Program Evaluation Scores

The Program Evaluation Form (Appendix B) completed by the

participants for day two of the seminar showed that the "Diabetic

Instruction for 1987" received the highest evaluation scores. Forty

of the 94 participants indicated that the presentation was excellent.

In general, comments were very supportive about using videocassettes

for dietary instruction. Specific comments are shown in Figure 5.

 16 - 30
15 -
14 -
r
13 -
I
c
(D
(D
12 - I
ID L 1I -
(D 0
5 U 10 - I
- ^ LO
(D
9 - I
CD -+J 8 -
Q) (D
01 7 - I
U -4J 6 -
C 1
(D -P
I
5 -
L 01
u.(D Q_0 4 -
U- 3 -
^4
TI 2 -
Q C
1 -
c ""
O I 0 -
(D (D
5^ L
-2-
-3 -
-4 -

V Gr-otjo i

LJ Gr-otjo 2

O Gr-OLJO 3
~" C o n t r - a l Gf~auos
"*"• V1 d e o TroQtmBrrL Gr-oi_ioJ

Figure 4. Mean differences between pre- and post-test scores for

video treatment and control groups.
 31

Figure 5. Selected Comments from Program Evaluation Form

--I liked the film on the food groups and the diabetics presented by
Margarette Harden.

—Enjoyed the video on exchange lists very much--would be interested

in knowino about its availability.

--The "Diabetic Instruction" for 1987 was very interesting.

--Diabetic instruction film—very good, need to slow it down so that
an individual has time to comprehend it.
--Tapes for "Diabetic Instruction" could be very helpful for teaching
in small facilities.
—"Diabetic Instruction" film was excellent—good teaching tool.
 CHAPTER V

CONCLUSIONS AND RECOMMENDATIONS

Conclusions
This study has demonstrated that the videotape program, "Diabetic
Meal Management," could be used as a viable tool for dietary
instruction. Group 3 participants, consisting primarily of head cooks
and other dietary workers, had less formal training in diabetic
treatment, thus benefited the most from the program. A significant
interaction was found between video and group. The subjects in this
study recommended use of the videocassette program in diabetic diet
instruction and in employee training programs.
The high degree of underestimation for meal A and B was
surprising due to the number of dietitians present at the seminar and
the majority of subjects reporting a thorough understanding of
diabetic diets. Scores were raised after viewing the video program,
although the difference was not significant. The importance of
accurate food portion estimation was supported.
The importance of continuing education for those personnel who
may supervise the preparation of diabetic meals and give diet
instruction was demonstrated.

Recommendations

Videocassette programs and alternate teaching methods in diabetic

diet management need further development and implementation.

Videotape instruction for diabetes narrated in Spanish would help

alleviate a deficiency in educational materials for Mexican Americans

32
 33
residing in the Southwest. Also, further studies should consider the
use of videocassette programs for instruction about planning renal,
low sodium, and low-fat diets.
 REFERENCES

1. ^^rris, M I., and Hamman, R. F.: Summary. Iji Harris, M. I.,

?^-*. Diabetes in America. U.S. Department of Health and Human
Services. N I H Publication No. 85-1468, August, 1985.
2. Everhart, J., Knowler, W. C , and Bennett, P. H.: Chapter IV.
Incidence and Risk Factors for Noninsulin-Dependent-Diabetes. In
Harris, M. I., ed.: Diabetes in America. U.S. Department of ~
Health and Human Services. NlH Publication No. 85-1468, August,
1985.

3. Harris, M. I.: The Prevalence of Diagnosed Diabetes, Undiacnosed

Diabetes and IGT. XH "Relish, J. S., ed.: Genetic-Environmental
Interactions in Diabetes. Amsterdam: Excerpta Medica, 1982.

4. Gussler, J. D.: Dietetic Currents: Consensus Development

Conference on Diet and Exercise in Non-Insulin-Dependent Diabetes
Mellitus. Ross Laboratories, Vol. 14, No. 4, 1987.

5. Franz, M. J., Barr, P., Holler, H., Powers, M. A., Wheeler,

M. L., and Wylie-Rosett, J.: Exchange Lists: Revised 1986. J
Am Diet Assoc 87:28-34, 1987.

6. West, K. M.: Diet therapy of diabetes: An analysis of failure.

Ann Intern Med 79:425-434, 1973.

7. Turnbridge, R. E., and Wetherill, J. H.: Reliability and cost of

diabetic diets. Br Med J 2:78-80, 1970.

8. Savage, P. J., and Knowler, W. C : Diet therapy for Type TI

diabetes mellitus: Can new approaches improve therapeutic
results? Nutr Abst Rev: Reviews in Clin Nutr 54:69 (Feb.-Mar.^
1984.

9. Cerkoney, K. A. B., and Hart, L, K.: The relationship between

the health belief model and compliance of persons with diabetes
mellitus. Diabetes Care 3:594-597, 1980.

10. Pace, P. W., Henske, J. C , Whitfill, B. J., Andrew, S. M.,

Russell, M. L., Probstfield, J. L., and Insull, W.:
Videocassette use in diet instruction. 0 Am Diet Assoc
83:166-169, 1983.

11. McCulloch, D. M., Mitchell, R. D., Ambler, J., and Tattersall,

R. B.: Influence of imaginative teaching of diet on compliance
and metabolic control in insulin dependent diabetes. Br Med J
28:1857-1861, 1983.

34
 35

''• Assoc'??;3S6.36^, mS"''"' ''' ''-''''''' '''''''''' ' '"^ ''''

13. Mier, C. S.: In-service education practices in large hospital

department of diabetics. J Am Diet Assoc 77:303-306, 1980.

14. National Diabetes Data Group, National Institutes of Health, from

data of the 1979-1981 United States National Health Interview
Surveys, Public Health Service and National Center for Health
Statistics.

15. Second national health and nutrition examination survey,

1976-1980. National Center for Health Statistics, Department of
Health and Human Services. 1984.

16. Harris, M. I.: National Diabetes Data Group. Unpublished data

from the 1976 National Health Interview Survey, 1984a.
17. West, K. M.: Diabetes in American Indians and other native
populations of the new world. Diabetes 23:841-847, 1974.
18. Stein, J. H., West, K. M., Robey, J. M., Tirador, D. F., and
McDonald, G. V'.: The high prevalence of abnormal glucose
tolerance in the Cherokee Indians of North Carolina. Arch Intern
Med 116:842-845, 1965.

19. Drevets, C. C : Diabetes mellitus in Choctow Indians. 0 Okla

Med Assoc 58:322-329, 1965.

20. Gardner, L. I., Stern, M. P., Haffner, S. M., Gaskill, S. P.,

Hazuda, H. P., and ReLethford, J. H.: Prevalence of diabetes in
Mexican Americans. Diabetes 33:86-92, 1984.

21. Martin, D. B., and Quint, A. R.: Chapter XXIV, Therapy for
Diabetes. Ijn Harris, M. I., ed.: Diabetes in America. U.S.
Department of Health and Human Services. NIH Publication No.
85-1468, August, 1985.

22. American Diabetes Association, American Dietetic Association:

Exchange Lists for Meal Planning. Chicago: American Dietetic
Association, 1986.

23. American Diabetes Association Task Force on Nutrition and

Exchange Lists: Nutritional recommendations and principles for
individuals with diabetes mellitus: 1986. Submitted to Diabetes
Care for publication.

24. Haynes, R. B.: A critical review of the "determinants" of

patient compliance with therapeutic regimens. Iji Sackett, D. L.,
and Haynes, R. B., eds.: Therapeutic Regimes. Baltimore: The
Johns Hopkins University Press, 1976.
 36

25. Ary, D. V., Toobert, D., Wilson, W., and Glasgow, P. E.: Patient
perspective on factors contributing to nonadherence to diabetes
regimen. Diabetes Care 9:168-172, 1986.

26. Glanz, K.: Dietitians' effectiveness and patient compliance with

dietary regimens. A pilot study. 0 Am Diet Assoc 75:631-636,
1979.

27. Williams, T. F., Anderson, E., Watkins, 0. D., and Coyle, V.:
Dietary errors made at home by patients with diabetes. J Am Diet
Assoc 61:19-25, 1967.

28. Lansky, D., and Brownell, K,. D.: Estimates of food quantity and
calories: Errors in self-reported among obese patients. Am 0
Clin Nutr 35:727-732, 1982.

29. Rapp, S. R., Dubbert, P. M., Burkett, P. A., and Buttress, Y.:
Food portion size estimation bv men with Type II diabetes. J Am
Diet Assoc 86:249-251, 1986.

30. Williams, C. R.: Dietetic assistant/technicians education. J Am

Diet Assoc 70:621-623, 1977.

31. Kralovec, P.: Survey shows increase in hospital training

programs. Hospitals, pp. 173-175, October, 1978.
32. Buller, A. C : Improving dietary education for patients with
hyperlipidemia. J Am Diet Assoc'72:277-281, 1978.

33. Lawson, V. K., Traylor, M. N., and Gram, M. R.: An audio-

tutorial aid for dietary instruction in renal dialysis. J Am
Diet Assoc 69:390-395, 1976.
34. Hassell, J., and Medved, E.: Group/audiovisual instruction for
patients with diabetes. J Am Diet Assoc 66:465-470, 1975.

35.' McLaughlin, G. H.: SMOG grading--a new readability formula. J

Reading 12:639-646, 1969.
36. Davis, W. K.: Diabetes Educational Profile. University of
Michigan, 1980.
 APPENDIX A
SCRIPT

DIABETES MEAL MANAGEMENT

37
 38

SCRIPT

DIABETES MEAL MANAGEMENT

Do you have diabetes"?

Does a friend?

or a family member?

Thousands of Americans do have diabetes and the number is growing each

year. Here are some statistics about diabetes.
- One in every 40 Americans has been told by a doctor that he or she
has diabetes.

- 95% of these diabetic people are type II. Also called adult onset
or non-insulin-dependent.

- 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 meal

management. It will focus primarily on the type II diabetic person.
The Exchange List for Meal Planning Booklet produced by the American
Diabetes Association and the American Dietetic Association may
accompany this videotape or the videotape may be viewed alone.

The objectives of this program are:

1. To define: Diabetes
Meal Planning and

Exchange Lists
 39

2. To list goals in nutrition for diabetes management

and

3. To describe how to accomplish those goals.

Who Gets Diabetes?

Anyone may get diabetes at any time, however, diabetes is found most
often in three types of people:

- People with relatives who have diabetes

- Middle-aged and older individuals
- People who are overweight

What Is Diabetes?

Diabetes is a condition in which the body cannot use foods properly.

When food is digested, it breaks down into a sugar called glucose,
which the body uses for energy. Insulin is a hormone produced by a
gland called the pancreas. The pancreas releases insulin into the
bloodstream when the blood glucose rises after eating. Insulin helps
the glucose go from the blood into the body cells to be used for
energy or stored for future use.

People with type II diabetes make some insulin, but either it is not

working properly or there is not enough insulin produced. People

often can control this type of diabetes by limiting the amount of food

they eat and by increasing their exercise. Oral hypoglycemic agents

(diabetes p i U s ) help some people to make more insulin or to use their

own insulin better.

 40

How Is Diabetes Managed?

- • 11

The management of diabetes has three parts:

- food

- activity and

- medication (if needed)

Food raises blood-glucose and blood-fat levels. Activity and

medications lower blood-glucose and blood-fat levels. A balance of

these three parts leads to good management of diabetes.

There are three nutritional goals of diabetes management:

- Appropriate blood-glucose and blood-fat levels.
- Reasonable weight. 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 Nutrition. It is important to eat a variety of
food each day. Your body works better if you eat a balanced diet that
includes the right amounts of vitamins, minerals, carbohydrates,
protein, and fat.

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 bacon, nuts, gravy, margarine, and solid
shorteninr.

- Eat more carbohydrates, especially those high in fiber.

Carbohydrate foods are a good source of energy, vitamins, and
minerals. Fiber in foods may help to lower blood-glucose and
blood-fat levels. Foods that are high in fiber are noted in thp
booklet with a special symbol.
 41

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

of Calories and no vitamins or minerals. Foods high in sugar

include: 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 salt

can cause the body to retain water, and in some people it may raise

blood pressure. Foods that are high in sodium are noted in the

booklet with a special symbol.

- Use alcohol in moderation. It's best to avoid alcohol altogether.

How Can A Person Accomplish These Goals?

A diabetes meal plan and the exchange lists will help you meet all

these goals.

What Is A Diabetes Meal Plan?

A meal plan is a guide which shows you the number of food choices or

exchanges you can eat at each meal and snack.

What Are Exchange Lists?

• - -

The six exchange lists help to make your meal plan work. Foods are

grouped together on a list because they are alike. Every food on a

list has about the same amount of carbohydrate, protein, fat, and

Calories. In the amounts given, all the choices on each list are

equal. Any food on a list can be exchanged or traded •f'or any other

food on the same list.

 42

The Six Lists Are: Starch/Bread, Meat and Substitutes, Vegetables,

Fruit, Milk, and Fat.

Now, let's discuss each list individually. If you have the Exchange
Lists Booklet, turn to page 6 and follow along. The list shown first
is Starch/Bread.

Each item on this list contains approximately 80 Calories.

You can choose your starch exchanges from any of the items on this
list. If you want to eat a starch food that is not on this list, the
general rule is that:
- 1/2 cup of cereal, grain, or pasta is one serving
or

- 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 oatmeal.

3/4 cup of ready-to-eat unsweetened cereal such as Total.

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 blackeye peas or cooked beans eoual 1 exchange.

Some examples of starchy vegetables include 1/2 cup of corn or one 6

inch long corn on the cob. A small baked potato is also one exchanoe.
 43

Examples of breads include:

1/2 of a hotdog or hamburger bun

1 small tortilla

1 slice of white or wheat bread

3 cups of popcorn

or

6 sal tine-type crackers

All of these examples equal one Starch/Bread exchange.

The second list is the meat list. The meat list is divided into three
parts based on the amount of fat and Calories: lean meat, medium -^at
meat, and high-fat meat.

Before discussing each group, here are some important cooking TIPS to

remember.

1. Bake, roast, broil, grill or boil these foods rather than frying

them with added fat.

2. Use a nonstick pan spray or a nonstick pan to brown or -^ry these

foods.

3. Trim off visible fat before and after cooking.

4. Do not add flour, bread crumbs, coating mixes, or fat to these

foods when preparing them.

5. Weigh meat after removing bones and fat, and after cooking.
 44

Three ounces of cooked meat is about equal to 4 ounces of raw

meat.

Some examples of meat portions are:

2 ounces meat (2 meat exchanges) = 1 small chicken leg or thigh or

1/2 cup cottage cheese or tuna

3 ounces meat (3 meat exchanges) = 1 medium pork chop or 1 small

hamburger or 1/2 of a whole chicken breast

6. Restaurants usually serve prime cuts of meat, which are high in

fat and Calories.

It is important to remember when looking at the meat list that one

exchange of meat is not to be confused with what one usually considers

a portion or a standard serving.

(All examples of meat are standard servings, not necessarily one

exchange.) Some examples of lean meats are:

Flank or skirt steak

Chicken and turkey without the skin

Tuna (canned in water)

Sardines
and any cottage cheese

Examples of medium fat meats are:

All ground beef
Pork chops or cutlets
Mozzarella cheese
 45

86% fat-free luncheon meat

and one egg

Examples of high-fat meats are:

Pork sausage

Any fried fish product

All regular cheeses such as American and cheddar

Peanut butter

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

The third exchange list is the vegetable list. Each vegetable on this
list contains approximately 25 Calories.

Unless otherwise noted, the serving size for one vegetable exchange
is:
1/2 cup of cooked vegetables or vegetable juice

1 cup of raw vegetables

Examples of one vegetable exchange are:

1/2 cup cooked green beans

1 cup of onions

1 cup of green peppers

One large tomato

or 1/2 cup of tomato juice

 46

The fourth list is the fruit list. Each item on this list contains

about 60 Calories.

The carbohydrate and Calorie content for a fruit serving are based on
the usual serving of the most commonly eaten fruits. Use fresh fruits
or fruits frozen or canned without sugar added. Whole ^ruit is more
filling than fruit juice and may be a better choice for those v/ho are
trying to lose weight. Unless otherwise noted, the serving size for
one fruit serving is:

1/2 cup of fresh fruit or fruit juice

or 1/4 cup of dried fruit

Examples of one fruit exchange are:

One apple

1/2 banana

1/2 cup fruit cocktail

1/2 grapefruit

1/2 cup of canned peaches

1/3 cup of canned pineapple

or 2 tangerines

One example of dried fruits would be:

2 Tbsp. of raisins

And some examples of fruit juices would be:

1/3 cup grape juice

 47

or 1/2 cup orange juice

List number 5 is the milk list. The amount of fat in milk is measured

in percent (%) of butterfat. The Calories vary, depending on what

kind of milk you choose. The list is divided into three parts based

on the amount of fat and Calories: skim/very lowfat milk, lowfat

milk, and whole milk.

Examples of skim and very lowfat milk are:

1/3 cup of dry nonfat milk
or 1 cup skim milk

Examples of lowfat milk are:

1 cup of 2% milk
or 8 oz. of plain lowfat yogurt

An example of the last group:

1 cup of whole milk

The last list is the fat list. Each serving on the -"at list contains

about 45 Calories. The foods on the fat list contain mostly fat,

although some items may also contain a small amount of protein. All

fats are high in Calories and should be carefully measured.

Examples of one unsaturated fat exchange are:

1 tsp. margarine
 48
1 tsp. mayonnaise

2 whole pecans

1 tsp. oil

10 small olives
or

2 tsp. salad dressing of the mayonnaise variety

Examples of one saturated fat exchange are:

1 slice bacon

2 Tbsp. sour cream

or 1 Tbsp. cream cheese

Two special categories are included in diabetes meal management, "^hey

are free foods and combination foods.

A free food is any food or drink that contains less than 79 Calories
per serving. You can eat as much as you want of those items that have
no serving size specified. You may eat two or three servings per day
or those items that have a specific servina size.

Examples of drinks included under the free food list are:

Bouillon

Sugar-free carbonated drinks

1 Tbsp. unsweetened cocoa powder

coffee

and tea
 49

Examples of vegetables that have a 1 cup specified serving size are:

Cabbage
Celery
Cucumbers
Green onions
and Radishes

Salad greens are unlimited.

Sweet substitutes such as sugar-free gelatin, sugar-free gum and sugar

substitutes such as Sweet-n-Low and Nutrasweet are also unlimited.

Other -free foods include:

1 Tbsp. catsup
Mustard

Unsweetened dill pickles

and vinegar

Seasonings can be very helpful in making food taste better. Examples

of seasonings that may be used are:

- Nutmeg, oregano, paprika, lemon pepper seasoning, mace, fennel seed,

red pepper, garlic, soy sauce, cinnamon, anise seed, almond

extracts, savory salt, tarragon, barbecue spice, lemon juice and

poultry seasoning.
 50

Combination foods do not fit into only one exchanqe list. It can be

quite hard to tell what is in a certain casserole dish or baked food

item.

The combination foods presented here represent a tvpical meal of manv

who live in the Southwest. Remember that these foods must be counted
as containing multiple exchances.

One Enchilada = 1 med. meat

1 bread/starch
2 fat

One Tamale = 1/2 med. meat

1/4 bread/starch
2 fat

Meat Taco = 2 med. meat

1 bread/starch

1 fat

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

In this program we have defined diabetes, meal planning and the

Exchange Lists. The Fxchange Lists in conjunction with appropriate

meal plans are one of the necessary tools for controlling the diabetic

condition. The six exchange lists provide a diabetic person with a

 51

wide variety 0"^ food choices. This selection of food provides for

good nutrition while allowing reasonable weight to be obtained.

For more information about diabetes ask vour doctor or contact:

The American Diabetes Association

1660 Duke Street

Alexandria, Virginia 22314

or
The American Dietetic Association
430 North Michigan Avenue
Chicago, Illinois 60611

Good luck and good eating!

 APPENDIX B
ADDITIONAL MATERIALS

52
 53

NUTRITION GAME SHEET

Name Date
Social Sec. No.
Meal A "
Exchanges Kcals

Bread/Starch

Meat and Substitutes

Vegetable
Fruit

Milk

Fat
Estimation of Total Kcals:
Type of Meat (if present in meal)
lean
medium-fat
high-fat

Meal B
Exchanges Kcals

Bread/Starch

Meat and Substitutes

Vegetable

Fruit

Milk

Fat
Estimation of Total Kcals:
Type of Meat (if present in meal)
lean

medium-fat

high-fat
 54

SURVEY INFORMATION
^^^^' Address:
Home Phone:
Place of Employment: Phone:
Social Security Number:
Please circle only oiie response to each of the following:
1. JOB TITLE
A. Food service supervisor
B. Head cook or food service aid
C. Member of Dietary Managers
D. Consulting dietitian approved by the state
E. Dietitian ADA and/or P.D.
F. Other (Identify
2. SEX
A. Female
B. Male
3. RACE
A. Black
B. Hispanic
C. White
D. Other
4. AGE GROUP
A. Under 30 years
B. 30-39 years
C. 40-49 years
D. 50 or above
5. PLACE OF EMPLOYMENT
A. Nursing home
B. Hospital
C. Private practice (Identify )
D. Other (Identify '
6. LENGTH OF EMPLOYMENT IN PRESENT FACILITY
A. Less than 1 year
R. 1 to 5 years
C. 5 to 10 years
D. 10 to 15 years
E. More than 15 vears
 55

7. NUMBER OF FULL-TIME EMPLOYEES IN DIETARY DEPARTMENT

A. Less than 5
B. 5 to 10
C. 10 to 15
D. 15 to 20
E. More than 20
8. APPROXIMATE AVERAGE DAILY PATIENT OR RESIDENT CFN<^US
A. Less than 10
B. 10 to 20
C. 20 to 30
D. 30 to 40
E. 40 to 50
F. Identify number .
9. HOW MANY HOURS DO YOU WORK PER WEEK?
A. 20 or less
B. 21 to 40
C. 41 or more

10. WHAT IS YOUR AVERAGE HOURLY INCOME?

A. Less than $4.00
B. $4.00 to $6.00
C. $6.00 to $8.00
D. $8.00 to $10.00
E. $10.00 to $15.00
F. More than $15.00
11. WHAT IS YOUR LEVEL OF EDUCATION COMPLETED?
A. Less than high school
B. GED by adult route
C. High School
D. Attended college but did not graduate
E. College graduate
F. Graduate degree
12. IF A COLLEGE GRADUATE, PLEASE SKIP THIS QUESTION.
WHAT TYPE OF TRAINING DID YOU HAVE IN ORDER TO OBTAIN YOUR
PRESENT POSITION?
A. Experience only
B. 90 class hour course
C. Approved 2 year Dietetic Technician Course (South Plains
College or other)
D. Other (Identify
13. THE DIET MANUAL USED IN YOUR FACILITY IS THE
A. Texas Diet Manual
B. Oklahoma Diet Manual
C. Other (Identify
D. I do not know
 56
14. THE MENUS FOLLOWED IN THE FACILITY WHERE YOU WORK ARE PLANNED BY
THE
A. Supervisor
B. Dietitian
C. Other (Identify )
D. I don't know

15. WHEN DIET INSTRUCTION IS NEEDED, IT IS GIVEN BY THE

A. Supervisor
B. Dietitian
C. Other (Identify )
D. I don't know
16. DO YOU FEEL THAT YOU HAVE A THOROUGH UNHERSTANDING OF PLANNING
AND SERVING DIABETIC DIETS?
A. Yes
B. No
17. WHAT IS THE AVERAGE NUMBER OF DIABETIC PATIENTS SERVED DAILY?
A. Less than 2
B. 2 to 5
C. 5 to 10
D. More than 10
18. DO YOU FEEL THAT YOU CORRECTLY USE THE FOOD EXCHANGE LISTS FOR
PLANNING WEIGHT CONTROL, SODIUM AND FAT CONTROL, AND DIABETIC
MENUS?
A. Yes
B. No
19. THE EXCHANGE LIST USED FOR MEAL PLANNING IN YOUR FACILITY WAS
PUBLISHED IN
A. 1976
B. 1986
C. I have no idea
20 DO YOU USE THE WORKBOOKS PROVIDED AT THE WHITE SWAN SEMINARS FOR
INSERVICE TRAINING AFTER YOU RETURN HOME?
A. Yes
B. No
C. This is my first time to attend
21. IF YOU ARE A MEMBER OF DIETARY MANAGERS, HAVE YOU TAKEN THE
EXAMINATION?
A. Yes
B. No
C. I am not a member
?2. DID YOU PASS THE DIETARY MANAGERS EXAM?
A. Yes
B. No
C. I have not taken it
 57

23. IS A MEMBER OF YOUR FAMILY ON A DIABETIC DIET?

A. Yes
B. No
24. IF ANSWER IS "YES" TO QUESTION 23, WHAT RELATIONSHIP IS THIS
PERSON TO YOU?

THANK YOU.
NOTE: Please turn this page over and quickly circle your immediate
response to each item.
 58

DIABETES EXCHANGE LIST QUESTIONNAIRE

1. An example of one fat exchange is

a. 3 tbsp. of salad dressing
b. 1 1/2 slices of crisp bacon
c. 1 tbsp. of safflower oil
d. 1 tsp. of margarine
e. 3 tsp. of butter

2. An example of one meat exchange is

a. 3 oz. of chicken breast
b. 1 slice of bacon
c. 1 oz. of flank steak
d. 3 oz. of chicken
e. 3/4 c. of tuna

3. Which food is not a member of the meat exchance group?

a. egg
b. bacon
c. chicken
d. tuna
e. cottage cheese
4. Which of the following would not be included in the fat exchange
lists?
a. mayonnaise
b. salad dressing
c. eggs
d. lb small olives
e. margarine
5. An example of one milk exchange is
a. 2 tbsp. of sour cream
b. 1/2 c. of ice cream
c. 1 c. of skim milk
d. 2 tbsp. of heavy cream
e. 1/4 c. of ice cream
6. An example of one bread exchange is
a. 1 c. of green beans
b. 1/2 ear of corn
c. 12 saltines
d. 1 c. macaroni
e. 1/2 c. of spaghetti
 59

7. Which of the following pairs of food items cannot be exchanged

for each other?
a. 1 c. 2% fat milk; 1 c. yogurt, lowfat
b. 1/2 of a 9 in. banana; 1 small apple
c. 1 egg; 1 slice 86% fat free luncheon meat
d. 1 c. orange juice; 1/2 med. grapefruit

8. Which of the following is not correct for examples of meat

portions?
a. 2 oz. of meat (2 meat exchanges) = 1 sm. chicken thigh
b. 3 oz. of meat (3 meat exchanges) = 1 med. pork chop
c. 2 oz. of meat (2 meat exchanges) = 1/4 c. tuna
d. 3 oz. of meat (3 meat exchanges) = 1 sm. hamburger
9. Which food is not a member of the vegetable exchance group?
a. carrots
b. asparagus
c. broccoli
d. string beans
e. potato
10. All but one of the following foods can be used in any amount
except
a. bouillon
b. skim milk
c. coffee
d. unsweetened dill pickles
e. diet soft drinks
11. An example of one fruit exchange is
a. 1 c. of peaches
b. 6 plums
c. 1/2 c. of fruit cocktail
d. 4 pear halves
e. 1 c. of orange juice
12. Each item on the fruit list contains approx. Calories
a. 40
b. 50
c. 60
d. 70
 60
DIABETES EXCHANGE LIST QUESTIONNAIRE

Name Date
Social Security No.
Please circle the correct response to each of the following:
1. Each item on the fruit list contains approx. Calories
a. 40
b. 50
c. 60
d. 70
2. An example of one milk exchanqe is
a. 2 tbsp. of sour cream
b. 1/2 c. of ice cream
c. 1 c. of skim milk
d. 2 tbsp. of heavy cream
e. 1/4 c. of ice cream
3. Which food is not a member of the vegetable exchance group?
a. carrots
b. asparagus
c. broccoli
d. string beans
e. potato
A. Which of the following pairs of food items cannot be exchanged
for each other?
a. 1 c. 2% fat milk: 1 c. yogurt, lowfat
b. 1/2 of a 9 in. banana; 1 small apple
c. 1 egg; 1 slice 86% fat free luncheon meat
d. 1 c. orange juice; 1/2 med. grapefruit
5. An example of one fat exchange is
a. 3 tbsp. of salad dressing
b. 1 1/2 slices of crisp bacon
c. 1 tbsp. of safflower oil
d. 1 tsp. of margarine
e. 3 tsp. of butter
6. Which of the following is not correct for examples of meat
portions?
a. 2 oz. of meat (7 meat exchanges) = 1 sm. chicken thigh
b. 3 oz. of meat (3 meat exchanges) = 1 med. pork chop
c. 2 oz. of meat (2 meat exchanges) = 1/4 c. tuna
d. 3 oz. of meat (3 meat exchanges) = 1 sm. hamburger
 61

7. Which food is not a member of the meat exchange group?

a. egg
b. bacon
c. chicken
d. tuna
e. cottage cheese
8. An example of one meat exchange is
a. 3 oz. of chicken breast
b. 1 slice of bacon
c. 1 oz. of flank steak
d. 3 oz. of chicken
e. 3/4 c. of tuna
9. All but one of the following foods can be used in any amount
except
a. bouillon
b. skim milk
c. coffee
d. unsweetened dill pickles
e. diet soft drinks
10. Which of the following would not be included in the fat exchange
lists?
a. mayonnaise
b. salad dressing
c. eggs
d. 10 small olives
e. margarine
11. An example of one bread exchange is
a. 1 c. of green beans
b. 1/2 ear of corn
c. 12 saltines
d. 1 c. macaroni
e. 1/2 c. of spaghetti
12. An example of one fruit exchange is
a. 1 c. of peaches
b. 6 plums
c. 1/2 c. of fruit cocktail
d. 4 pear halves
e. 1 c. of orange juice
 62

WHITE SWAN FOOD AND NUTRITION SEMINAR

PROGRAM EVALUATION FORM
(Dav 2)
May 20, 1987

soacf I n L - J ^ ^ presentation by placing a check in the appropriate

space. Specific comments will be helpful.

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1. Diabetic Instruction for 1987 40 42 12

2. Bacteria in the News 34 44 18
3. Salt Substitutes, Sugar Substitutes 26 36 32
and anti-oxidants

4. Gastric Surgery for Obesity: Dietary 40 37 17

Management
5. Today's Health Care Industry 30 28 28
6. Planning, Purchasing and Management 26 25 40
7. Helping Hands for Special Needs J4 25 23
8. Feeding People 24 31 32
Specific comments regarding quality of program, materials, discussion
leaders, and/or speakers

Future Program Suggestions: I wish I knew more about

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