GEM NO. 415

Menu Plans in a DiabetesSelf-management Weight Loss Program

Christina Cunningham, MPH, RD,Nutritionist, Beth Abrahams Hospital

Shannah Johnson, MPH, RD,Research Fellow, Indian Health Service

Brandy Cowell, MS, RD, ResearchNutritionist, Albert Einstein College ofMedicine, Bronx, NY

Nafisseh Soroudi, PhD, PostdoctoralFellow in Psychiatry, MassachusettsGeneral Hospital

C.J. Segal-Isaacson, EdD, RD,Assistant Professor of Epidemiology andPopulation Health, Albert EinsteinCollege of Medicine, Bronx, NY

Nichola J Davis, MD, MS, AssistantProfessor of Medicine, Albert EinsteinCollege of Medicine, Bronx, NY

Carmen R. Isasi, MD, PhD, AssistantProfessor of Epidemiology andPopulation Health, Albert EinsteinCollege of Medicine, Bronx, NY

Judith Wylie-Rosett, EdD, RD,*Professor of Epidemiology andPopulation Health, 1307 BelferBuilding, Albert Einstein College ofMedicine, 1300 Morris Park Avenue,Bronx, NY 10461; Phone: (718) 430-3345; Fax: (718) 430-8634; E-mail:jwrosett@aecom.yu.edu

( J Nutr Educ Behav. 2006;38:264-266)

*Author for correspondencedoi: 10.1016/j.jneb.2006.01.013

INTRODUCTION

Simplifying food choices seems to fa-cilitate weight loss success.1,2 Al-though flexibility in food choicesseems desirable, several studies haveshown that limiting food choices maybe an effective strategy for teachinginitial decision making skills.1

Wing and Jeffery et al reported

that weight loss from standard behav-

ioral therapy was improved by any of 3methods used for structuring meals.2

Overweight women were randomizedto behavioral therapy alone (as con-trol condition) with the addition ofmenu structuring by: (1) meal planswith a grocery list, (2) actual mealsthat were partially subsidized, or (3)actual meals that were totally subsi-dized (free to the participant). Theparticipants who received meal plansand grocery lists lost as much weightas the women who received actualmeals that were prepared from themenus, which were either totally orpartially subsidized by the study.3 Re-sults showed no significant differencein weight loss between menu groups,suggesting that the most effectivecomponents of structuring food intakewere the meal plans and grocery lists.The women who received menus thatthey prepared reported a greater re-duction in perceived barriers, greaterpositive changes in foods stored in thehome, and more regular meal patternsthan the women who received thestandard behavioral therapy with ei-ther no menus but with food that wasprepared for them, or with no menusand no food. Meal plans and grocerylists appear to work both by structur-ing eating behavior and by inducingchanges in the home environmentthat are conducive to weight loss. Ourprevious research indicated that two-thirds of participants found the struc-tured plan in our Complete Weight LossWorkbook helpful in losing weight.4,5

In the present study, we initiated thedietary intervention with two weeksof menus.

DESCRIPTION OFMEAL PLANNING

The parent randomized clinical studyfor this project, which has human sub-jects approval from the InstitutionalReview Boards of the Albert Einstein

College of Medicine and Montefiore

Medical Center, was designed to testthe effects of varying carbohydrate in-take on weight loss and metaboliccontrol in type 2 diabetes.

The objectives for developing atwo-week menu cycle and grocery listfor the initial two weeks of our diabe-tes weight loss study were to: (1) sim-plify decision making by providingmenus and grocery lists based on in-dividual situations and families; (2)provide support in making the transi-tion to a new way of eating; (3) de-velop self-efficacy and decision mak-ing skills; and (4) promote developinggrocery lists to increase awareness offoods they purchased and decrease im-pulse purchases of energy-dense snackfoods and beverages. The grocery listtemplate was divided by food groupsand included: meat and protein foods;cheeses and dairy; fruits; vegetables;grains, breads and starches; fats; andmiscellaneous. Each category listedacceptable options, which were ex-trapolated from the predevelopedmenus. Each item has a space pro-vided to indicate the quantity neededfor purchase. In addition, the lists pro-vided suggestions on items to avoidwhile grocery shopping.

IMPLEMENTATIONPROCEDURES

A registered dietitian (RD) met witheach program participant at the ran-domized visit to clarify the menu planand grocery list and to make modifi-cations based on needs or preferences.The calorie goals were calculatedbased on the approach used in theDiabetes Prevention Program (DPP),6

which included 4 standard calorie lev-els: 1200 calories for those with initialweight of 120-170 pounds, 1500 calo-ries for 175-215 pounds, 1800 caloriesfor 220-245 pounds, and 2000 caloriesfor an initial weight of more than 250pounds. The table lists the steps used

in developing individually tailored

Journal of Nutrition Education and Behavior ● Volume 38, Number 4, July/August 2006 265

menu plans. Each participant wasscheduled for two follow-up visits(one per week while using the twoweeks of structured menus). The pur-pose of these visits was to reviewprogress and to make the transition togreater independence in menu plan-ning. Medical staff evaluated glycemiccontrol and made any needed medica-tion adjustments.

EVALUATION AND EVIDENCEOF USEFULNESS

We evaluated the acceptability ofstructured menus in the pilot phase ofthe parent study. Our evaluation wasbased on semistructured interviewsand review of food diaries from thetwo-week structured menu periodwith the first 10 participants enrolledin the study (age range 42-61; BMI �25). Each participant was given a dig-ital scale, measuring cups, two weeksof menus, a grocery list, and a bloodglucose meter. The instructions toparticipants included keeping a diaryof food intake and measurement ofpre- and postprandial glucose levels.At the two-week visit, the food diarywas reviewed, and each participantwas interviewed to determine how themenus were used. Interview questionsincluded: (1) How closely did you fol-low your menu plan? (2) Whatchanges did you make? (3) How didyou control your portions? and (4)How often did you use frozen dinnersand shakes?

All (10/10) returned the menuforms and data from self-monitoringof blood glucose before and aftermeals; all also lost weight (range 2.2

Table. Steps for Individually Tailoring the Stand

1. Review the menu options and offer2. Plan a grocery shopping list using t3. Ask the participant to check off item4. Discuss the grocery list, and review

section based on the participant’s p5. Address portion sizes to purchase, a6. Encourage the participant to gradu

readily discussed in groups in conju

to 8 lbs); 80% (8/10) switched the day

for using a specific menu; 50% substi-tuted alternatives for specific meats(eg, chicken for lamb), starches (eg,rice for pasta), or vegetables, or sim-plified the recipes, while maintainingportion sizes and food category; 40%(4/10) used meal replacements (frozenentrees or shakes) more frequentlythan in the menu plan; 40% (4/10)changed seasoning, spices, or sauces tosuit their individual and ethnic tastes;and 20% (2/10) followed the menusexactly and chose to continue themafter the first two weeks. Participantfeedback indicated keeping food andglucose logs on the same form in-creased awareness of the food-glucoserelationship and the feeling of em-powerment to control blood glucoselevels. Participants reported thatmenus helped them with recipes, set-ting portion sizes, and with self-monitoring.

Practice Application

Meal planning can be an effectivestrategy for weight control as well asdiabetes management. Resources thatare readily available include publica-tions from the American Diabetes As-sociation (such as the Month of Mealsbooklets with all-American, Latin,soul food, and vegetarian as menu op-tions7) and our Complete Weight LossWorkbook, which has shopping tips,instructions on label reading, andsample menus as part of the behav-ioral strategies.4 The National Heart,Lung, and Blood Institute (NHLBI)offers a “menu planner” Web site,which provides semi-tailored menuselections.8 However, the NHLBI

enu Plan

natives and recipes on an as-neededopping template to identify items tha

ready in the household (eg, oil and egntial impulse purchases or other probences.propriate.crease independence in planning foon with review of food diaries and blo

Web site menu planning feature in-

cludes limited food choices and nooption for prepared foods.

Feedback from our participantssuggests that menu planning, whichincludes individual tailoring, can behelpful when starting a weight lossprogram. However, their feedbackalso indicates that menu planning alsoneeds to include a transition to lessstructure based on an assessment ofreadiness to make food choices.Therefore, we recommend using thesteps outlined in the table when start-ing weight loss or diabetes dietary in-terventions with a menu plan. Thetemplates for developing structuredmenus and self-monitoring (blood glu-cose and either carbohydrate intake orfat intake) can be downloaded from:http://www.aecom.yu.edu/nutrition/Self_monitoring_Forms.htm.

ACKNOWLEDGMENTS

This research received grant supportfrom the Diabetes Research andTraining Center, the General Clini-cal Research Center, and the Dr. Rob-ert C. Atkins Foundation.

REFERENCES

1. Delahanty LM. Evidence-based trends forachieving weight loss and increased physicalactivity: Applications for diabetes preven-tion and treatment. Diabetes Spectr. 2002;15(3):183-189.

2. Wing RR, Jeffery RW. Food Provision as aStrategy to Promote Weight Loss. Obes Res.2001;9(S4):271S-275S.

3. Wing RR, Jeffery RW, Burton LR, ThorsonC, Sperber-Nissinoff K, Baxter JE. Food pro-vision vs. structured meal plans in the be-havioral treatment of obesity. Int J Obes Re-

be needed.

by food group or by supermarket

grocery shopping. (This issue can beucose monitoring.)

ard M

alter basis.he sh t may

s al gs).pote lemsrefers ap

ally in d andnctio od gl

lat Metab Disord. 1996;20:56-62.

266 Wylie-Rosett et al/GEM NO. 415

4. Wylie-Rosett J, Swencionis C, Caban A,Friedler AJ, Schaffer N. The Complete WeightLoss Workbook. Alexandria, VA: AmericanDiabetes Association; 1997.

5. Wylie-Rosett J, Swencionis C, Ginsberg M,et al. Computerized weight loss interventionoptimized staff time: the clinical and cost

ducted in a managed care setting. J Am DietAssoc. 2001;101:1155-1162.

6. The Diabetes Prevention Program (DPP)Research Group. Diabetes Prevention Pro-gram: Description of lifestyle intervention.Diabetes Care. 2002;25(12):2165-2171.

7. American Diabetes Association. Month of

products/product_category.jsp?FOLDER%3C%3Efolder_id�2534374302023956&bmUID�1091975973023. Accessed March31, 2005.

8. National Heart Lung and Blood Institute.Interactive menu planner. Available at:http://hin.nhlbi.nih.gov/menuplanner/menu.

results of a controlled clinical trial con- Meals. Available at: http://store.diabetes.org/ cgi. Accessed March 31, 2005.

Invitation for Letters to the EditorThe Journal of Nutrition Education and Behavior welcomes timely and succinct lettersexpressing responsible criticism or reaction to material published in previous issues and letterscalling attention to topics of general interest to nutrition education professionals. Letters shouldbe addressed “To the Editor.” The Editor may send letters to other persons for reaction orrebuttal.

Submission of a letter to the editor constitutes permission for the Journal of Nutrition Educationand Behavior to publish it in our pages with appropriate editing and abridgment. Authors ofletters to the editor must acknowledge financial and other conflicts of interest within the letterand/or in an author affiliation footnote to accompany the letter.

Letters should be no more than 200 words. They should be typewritten and double-spaced with1" margins.

Letters regarding articles published in JNEB will receive priority preference for publishing.

Send letters to:Sandra K. Shepherd, PhD,RD, EditorJournal of Nutrition Education and BehaviorDepartment of Food Science and Human NutritionColorado State University502 W. Lake Street, Campus Delivery 1571Fort Collins, CO 80523-1571Tel: (970) 491-3060; Fax: (970) 491-7252e-mail: managingeditor@jneb.org