Original Article INTRODUCTION. Korean Diabetes J 2010;34: doi: /kdj pissn eissn

Transcription

1 Originl Article doi: 1.493/kdj pissn eissn The Smll Rice Bowl-Bsed Mel Pln ws Effective t Reducing Dietry Energy Intke, Body Weight, nd Blood Glucose Levels in Koren Women with Type 2 Dibetes Mellitus Hee Jung Ahn 1,*, Kyung Ah Hn 2,*, Hwi Ryun Kwon 1, Kyung Wn Min 1,2 1 Dibetes Center, Eulji Hospitl, Seoul, 2 Deprtment of Internl Medicine, Eulji University School of Medicine, Dejeon, Kore Bckground: The typicl Koren diet includes rice, which is usully served in rice bowl. We investigted the effects of mel pln using rice bowls of vrying sizes on dietry energy intke (EI), body weight (BW), nd blood glucose levels. Methods: Forty-two obese women with type 2 dibetes mellitus were rndomly ssigned to use either 2 ml smll rice bowl (SB), 38 ml regulr rice bowl (RB), or to control group (C). Both intervention groups were sked to reduce their EI by 5 kcl/dy for 12 weeks nd simple instructions for using the ssigned bowl were provided. Dietry EI nd proportion of mcronutrients (PMN) were estimted from 3-dy dietry records. Results: Reduction of EI ws more prominent in the SB group compred to the RB nd C group, lthough EI decresed significntly from bseline in ll groups. Crbohydrte nd ft intkes of the SB group were decresed greter thn those of the RB nd C group. However, chnges in PMN were not significnt cross the 3 groups. Reduction of BW nd HbA1c levels in the SB group ws more prominent compred to the C group. Although, BW nd HbA1c were decresed significntly from bseline in both bowl groups. There ws no sttisticl difference between the two groups. Conclusion: The smll rice bowl-bsed mel pln ws effective t reducing EI, BW, nd blood glucose levels, nd the observed reductions in EI, crbohydrte, nd ft intke were greter thn those of the regulr rice bowl-bsed mel pln. Keywords: Dibetes mellitus, type 2; Dibetic diet; Eduction; Obesity; Weight loss INTRODUCTION The mjority of type 2 dibetes mellitus ptients re obese, nd the risk of developing dibetes is ffected by body weight gin [1,2]. For such resons, the Americn Dibetes Assocition recommends decrese in the body weight of obese dibetes ptients or people who re t risk for dibetes [3]. The incresing prevlence of obesity is prlleled by incresing portion sizes. It hs been shown in severl experimentl trils tht portion size is n importnt fctor in totl energy intke [4]. Rolls et l. [5] reported tht when serving sizes re doubled, totl energy intke incresed even more. Pedersen et l. [6] gve obese type 2 dibetes mellitus ptients controlled diet using prtitioned pltes, divided for crbohydrtes, protein, cheese nd suce sections. The plte group eduction lost more body weight thn group receiving generl dibetes reg- Corresponding uthor: Kyung Wn Min Dibetes Center, Eulji Hospitl, 28-1 Hgye 1-dong, Nowon-gu, Seoul , Kore E-mil: minyungw@yhoo.co.kr Received: Jul. 11, 21; Accepted: Sep. 6, 21 *Hee Jung Ahn nd Kyung Ah Hn jointly contribute to this pper s first uthors. This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License ( which permits unrestricted non-commercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. Copyright 21 Koren Dibetes Assocition

2 Smll rice bowl useful in weight nd blood glucose control ultion, nd it ws reported tht the effective dosge of orl nti-dibetic gents could lso be decresed. For this reson, one of the methods for decresing the body weight of obese individuls is reducing serving size. Some orgniztions recommend using smller pltes in order to decrese the size of the portions to reduce totl energy intke [7]. Rolls et l. [8] pplied vrying plte sizes, nd when similr menus were vilble, the use of smller pltes decresed the totl energy intke; however, it ws reported tht this method ws ineffective. According to the 25 Ntionl Helth nd Nutrition Exmintion Survey [9], 7% of totl energy intke in Koren women with dibetes is consumed s crbohydrtes. Such results show tht Koren women with dibetes consume highcrbohydrte diets. It ws reported tht the primry dietry source of crbohydrtes ws rice [9]. We reported tht mong dibetes ptients who et three mels per dy, 96.4% of them consume over two mels of rice per dy [1], which suggests tht the proportion of rice per mel in Koren type 2 dibetes mellitus ptients is very high. In this study, the medin size of the rice bowl used by dibetes ptients ws 35 ml nd the size of the rice bowl correlted with the intke of energy intke from rice [1]. In previous study [11], 2 ml rice bowl ws effective t reducing totl energy intke nd crbohydrte intke fter two week period in overweight nd obese ptients. However, becuse this result ws just compred before nd fter intervention, it ws difficult to determine the effect of bowl size on totl energy intke nd crbohydrte intke, especilly considering tht the short study durtion (2 weeks) limited the observble body weight loss. In the present study, obese Koren women with type 2 dibetes mellitus consumed rice s stple food. We hve ttempted to determine if rice bowl size hs ny effect on totl energy intke, crbohydrte intke, body weight, nd blood glucose levels. We lso observed whether the rice bowls 5% smller thn regulr rice bowl hd ny metbolic effect. METHODS Subjects Subjects were femle type 2 dibetic ptients who visited the Eulji Hospitl dibetes outptient clinic between September 27 nd November 28. They were informed bout the purpose nd procedures involved in this study nd ll greed to prticipte. At the conclusion of the 12-week intervention period, totl of 42 ptients were nlyzed. The dignosis of type 2 dibetes mellitus in this study followed the dignostic stndrds estblished by the Americn Dibetes Assocition in Prticipnts in this study were between the ges of 2 nd 7, hd body mss index (BMI) 23 kg/m 2, nd glycosylted hemoglobin (HbA1c) levels between 6.% nd 1%. The following conditions were cuse for exclusion from this study: ptients treted with insulin or thizolidinedione medictions, ptients who consumed more thn one lcoholic beverge per dy, ptients who te out more thn twice per week, ptients with specil diets (e.g., vegetrins), ptients who were unble to exercise, ptients with indigestion, norexi, gesttionl dibetes, mlignnt tumors, crdiovsculr disese, ptients who hd consumed body weight loss drugs in the lst three months, ptients who were difficult to follow, nd ptients who refused investigtion. Method After the subjects enrolled, they were divided into smll rice bowl group, regulr rice bowl group, or control group, with the rndom number tble. Four weeks of screening period ws followed by 12 weeks intervention period. During the study period, the type nd dosge of orl nti-dibetic gents, blood pressure drugs, nd nti-lipid drugs were consistently mintined. However, in cses where blood glucose ws mesured to be less thn 7 mg/dl, or in cses showing symptoms of hypoglycemi, we decresed sulfonylure dosges in the orl hypoglycemic gents by 25% to 5%. Food energy intke nd totl energy consumption survey To determine food energy intke nd nutrient intke, the rice bowl groups kept dietry records 3 dys per week (2 weekdys nd 1 weekend dy) nd reported to us minimum of once every two weeks. Dily totl energy expenditure ws monitored using pedometer (HE-5; Helthengine, Yokohm, Jpn), which ws recorded during ech visit. The subjects were educted on the diet record method simply before writing the record sheet ctully nd they were sked to write mount nd kinds of ll foods tken for mel, nutrition supplementry foods nd snck for dy on the dietry record sheet by themselves. To increse ccurcy of the record, registered dietitin reviewed contents of the sheets by using rel-sized food models mesuring cups, mesuring spoons, when the sheets were returned. For dietry record resource, CAN-Pro (computer-ided nutritionl nlysis progrm, version 2.; Koren Nutrition Society, Seoul, Kore) ws used to 341

3 Ahn HJ, et l. convert nutrient intke for further nlysis. Diet nd exercise eduction The subjects mintined ordinry food intke nd exercise during the screening period. The smll rice bowl group consumed kcl of rice per dy from 2 ml bowl (Professionl Cermics [Sunsoodoyeh], Seoul, Kore). The regulr rice bowl group consumed kcl of rice per dy from 38 ml bowl (Worldwre, Seoul, Kore) [1]. For 12 weeks, individuls in both groups imed to lose.45 kg/wk by reducing their regulr dietry intke by 5 kcl/dy. The proportions of crbohydrte, protein nd ft to the totl energy intke were recommended to be 55 6%: 15-2%: 2-25%, respectively [12]. To ccomplish this, the subjects were supplied with leflet corresponding to prescribed energy nd were educted on tips for putting rice into the bowl nd tking side dishes, within 5-1 minutes individul eduction. Study prticipnts consumed n verge of 1,9 kcl/dy nd imed to consume t lest 1,4 kcl/dy. In cse of 1,4 kcl, the Kore Dibetes Assocition recommends 7 exchnge units of strch per dy, which mens 7 kcl of rice per dy. So, 2 mels in dy contin 2 kcl nd one mel in dy contins 3 kcl. In the smll rice bowl group, bowls were full of rice but not overflowing in cse of 2 kcl nd filled beyond the brim slightly overflowing in cse of 3 kcl. In the regulr rice bowl group, bowls were filled by hlf in cse of 2 kcl nd by three qurters in cse of 3 kcl. They were sked to use the bowl for every mel nd crbohydrte sources such s bred, rice cke, potto, sweet potto were limited through the leflet. Noodle could substitute for rice but ny specific mount for tht ws not suggested. Fruit intke ws shown s the mount per dy through the leflet. For fish, met nd vegetbles, the subjects were educted with pictures of diet fitting ech food exchnges unit nd were sked to prctice it but tht ws not emphsized intensively t ech visit. The picture of diet of fish, met nd vegetbles were included in the leflet by focusing on foods frequently found in the preliminry survey. For the control group, dietry eduction ws offered bsed on the dibetic dietry guideline of Koren Dibetes Assocition nd food intke ws investigted t the strt of the study nd fter 12 weeks. All subjects were given pedometers (HE-5) to mesure totl energy expenditure. The sme pedometer ws used for the durtion the study period (12 weeks). Physicl mesurement nd biochemicl test At the beginning of the study nd during ech visit, height, body weight, nd wist circumference were mesured. Subjects were mesured for height nd body weight dressed in thin clothe. BMI ws clculted by dividing the body weight (kg) with the squre of the height (m 2 ). The nrrowest line between the lower rib nd ilic crest ws mesured s wist circumference with tpeline when subject brethed out esily, nd blood pressure ws guged in sitting posture with mercury sphygmomnometer (Ymsu Co., Sitm, Jpn) fter1 minutes of rest. Blood chemistry mesurements were tken for ll groups t the beginning of the study, nd 12 weeks lter. Venous blood smples were collected following 1-hour or longer fst. Smples were seprted vi centrifuge t 3, rpm for 15 minutes. Serum ws isolted, stored t -7 C, nd used for nlysis. Fsting blood glucose levels were mesured using the glucose oxidtion method, nd HbA1c ws mesured using the HPLC method, bsed on ction exchnge resin. Totl cholesterol, triglycerides, high density lipoprotein cholesterol (HDL-C), nd low density lipoprotein cholesterol (LDL-C) were exmined with kits using enzymtic rections nd n utomtic biochemicl nlyzer (Hitchi 717; Hitchi, Tokyo, Jpn). Complince with rice bowl use To ssess complince of use of rice bowl, the subjects were sked to record whether they used the provided bowls during brekfst, lunch, or dinner. During biweekly visits, subjects were instructed to bring their complince reports nd rice bowl usge complince ws clculted s percentge. During ech visit, the reported vlues were verged nd overll complince ws clculted s: Complince of use of rice bowl (%) = frequency of using bowls/number of totl mels 1. Dt nlysis nd sttisticl nlysis Using the sttistics progrm SPSS version 15. (SPSS Inc., Chicgo, IL, USA), we clculted mens nd stndrd devitions for the mesured items. Vribles tht did not follow norml distribution were nlyzed following log trnsformtion. To compre the dt mong three groups (smll rice bowl, regulr rice bowl nd control), one-wy ANOVA test with Tukey post-hoc nlysis ws used. A pired t-test ws used to compre the groups before nd fter the intervention period. Ctegoricl vribles were compred using cross-nlysis. P vl- 342

4 Smll rice bowl useful in weight nd blood glucose control ues less thn.5 were considered to be sttisticlly significnt. RESULTS Generl chrcteristics of the subjects A totl of 42 subjects were enrolled in this study, nd ll subjects continued the study for the full 16-week durtion. The men ge of the subjects ws 55.1 ± 7.1 yers. The men durtion of dibetes ws 4.3 ± 3.9 yers nd men BMI ws 27.5 ± 3.6 kg/m 2. The men fsting blood glucose level ws ± 31.2 mg/dl nd the men HbA1c level ws 7.6 ±.9%. The groups did not show ny significnt difference in ge, durtion of dibetes, BMI, fsting blood glucose levels, nd HbA1c levels. For dibetes tretments, the proportion of life style modifiction only, combintion of metformin nd sulfonylure, Tble 1. Bseline chrcteristics Chrcteristic sulfonylure only nd, metformin only therpy were 57.8%, 26.7%, 4.4%, nd 11.1%, respectively. Among the ptients tken sulfonylure, the 31.6% of them reduced their sulfonylure dosge due to hypoglycemi during intervention period. By the conclusion of the study, the men sulfonylure dosge hd been reduced to 5% of the initil dosge. There ws no difference in the reduced mount of the drug dosge mong the groups. The dietry energy intkes nd number of steps were 1,928 ± 216 kcl nd 9,895 ± 4,42, respectively, with no significnt differences mong the groups. The proportions of crbohydrte, protein nd ft to the totl energy intke were 64. ± 5.8%, 16.1 ± 2.4% nd 2.2 ± 4.4%, respectively. There ws no significnt difference mong the three groups (Tble 1). The proportion of crbohydrtes in the diet ws higher thn tht recommended by the Koren Dibetes Assocition (55- Intervention ssignment P vlue No. of subjects Age, yr 54.4 ± ± ± BMI, kg/m ± ± ± Wist circumference, cm 92.2 ± ± ± Dibetes durtion, yr 5.3 ± ± ± Lbortory dt FPG, mg/dl ± ± ± HbA1c, % 7.7 ± ± ± SBP, mm Hg ± ± ± DBP, mm Hg 78.8 ± ± ± TC, mg/dl ± ± ± TG, mg/dl ± ± ± HDL, mg/dl 42.3 ± ± ± LDL, mg/dl 98.3 ± ± ± EI nd expenditure Dietry EI, kcl 1,932 ± 233 1,924 ± 234 1,924 ± Dily totl number of steps 9,157 ± 1,79 1,33 ± 1,2 1,656 ± 2, Mcronutrient intke Crbohydrte, % of EI 65.3 ± ± ± Protein, % of EI 15.3 ± ± ± Ft, % of EI 21. ± ± ± Vlues re presented s men ± stndrd devition. SB, smll size rice bowl (2 ml bowl); RB, regulr size rice bowl (38 ml bowl); C, control; BMI, body mss index; FPG, fsting plsm glucose; HbA1c, glycosylted hemoglobin; SBP, systolic blood pressure; DBP, distolic blood pressure; TC, totl cholesterol; TG, triglycerides; HDL, high density lipoprotein; LDL, low density lipoprotein; EI, energy intke. P vlues re for comprison mong the groups by one-wy ANOVA test. 343

5 Ahn HJ, et l. 6%). During the 12-week intervention period, the frequencies of rice bowl use during brekfst, lunch, nd dinner were 75.4 ± 24.3%, 47.6 ± 28.9%, nd 6.5 ± 25.8%, respectively. Between the smll nd regulr rice bowl groups, there ws no significnt difference in frequency of usge. Chnges in totl energy intke nd crbohydrte intke As chnges of dietry energy intke nd step counts per dy during 12 weeks were not consistent, their verges for the 12 weeks were used. Dietry energy intke nd nutrient intke were ssessed with 3-dy dietry record. Dietry energy intke ws significntly reduced by -583 ± 23 kcl/dy (-3.1 ± 9.8%) nd -294 ± 245 kcl/dy (-14.8 ± 12.8%) nd -13 ± 76 kcl/ dy (-6.9 ± 3.9%) in the smll rice bowl group, regulr rice bowl group nd control group, respectively in 12 weeks (P <.1). After 12 weeks, there ws difference in totl energy intke decrese mong the groups (P <.1), with the smll rice bowl group hving greter decrese thn the regulr rice bowl group nd control group (P <.5 nd P <.5, respectively). The totl energy intke of the smll rice bowl group decresed by 15.3% more thn the regulr rice bowl group (Fig. 1). Totl number of steps ws not different in 12 weeks compred to their initil levels nd the chnge of the three groups were lso not significntly different (Tble 2). During the 12-week intervention period, there ws significnt decrese in crbohydrte intke in the three groups (P <.5). There ws difference mong the three groups in their crbohydrte intke decrese (P <.1) nd the smll rice bowl group hd more significnt decrese thn the control nd regulr rice bowl group (P <.5 nd P <.5, respectively). After 12 weeks, rice bowl group showed significntly reduction protein intke (P <.5) nd the reduction mount of pro- Chnge of EI (kcl/dy) , b A Chnge of crbohydrte intke (g) , b B 5 5 Chnge of ft intke (g) 25-25, b Chnge of protein intke (g) C -5 D Fig. 1. Chnge of EI (A), crbohydrte intke (B), ft intke (C) nd protein intke (D) fter 12-week s intervention in obese women with type 2 dibetes mellitus. The reduction in EI, crbohydrte, nd ft intke in the SB group ws more prominent thn tht in the C group (P <.5). The reduction of EI nd crbohydrte intke in the SB group ws greter thn tht in the RB group (P <.5). C, control; EI, energy intke; SB, smll size rice bowl (2 ml bowl); RB, regulr size rice bowl (38 ml bowl). P vlues <.5 vs. C group, b P vlues <.5 vs. RB group. 344

6 Smll rice bowl useful in weight nd blood glucose control Tble 2. Chnges in dietry energy intke, mcronutrient composition Bseline Post-intervention Chnge P vlue Dietry EI, kcl SB 1,932.5 ± ,349.9 ± b ± 22.7 <.1 RB 1,924.2 ± ,629.8 ± b ± 245. C 1,924.6 ± ,794.9 ± b ± 76. Dily totl number of SB 9,495.2 ± 4, ,868.1 ± 4, ± 3, steps RB 1,33.1 ± 4, ,16. ± 5, ± 2445 C 1,656.8 ± 2, ,774.8 ± 2, ± Crbohydrte, g SB 315. ± ± 45.3 b ± 4.5 <.1 RB 3.2 ± ± 34.2 b ± 56.7 C 36.9 ± ± 43.6 b -25. ± 27. Protein, g SB 74. ± ± 9.6 b ± RB 81.4 ± ± 18.8 b ± 26.3 C 79.3 ± ± ± 13.5 Ft, g SB 45.1 ± ± 6.5 b ± RB 43.5 ± ± ± 14.8 C 4.4 ± ± ± 9.2 Fiber, g SB 8.9 ± ± ± RB 9.8 ± ± ± 3. C 8.8 ± ± ± 2.2 Cholesterol, mg SB ± ± ± RB ± ± ± C ± ± ± Sodium, mg SB 4,618.3 ± ,549.6 ± 1, ± 1, RB 4,934.8 ± ,278.9 ± 1, ± 1,593.4 C 5,21.6 ± 1,183. 5,1.2 ± ± 1,357. Energy complince, % SB ± ± 13.7 b -4.9 ± 3.5 <.1 RB ± ± 2. b ± 17.4 C ± ± 5.2 b -9.4 ± 5.3 Crbohydrte, % of EI SB 65.3 ± ± ± RB 62.7 ± ± ± 7.7 C 63.7 ± ± ± 5.2 Protein, % of EI SB 15.3 ± ± ± RB 16.9 ± ± ± 4.8 C 16.5 ± ± ± 2.9 Ft, % of EI SB 21. ± ± ± RB 2.2 ± ± ± 6.9 C 18.9 ± ± ± 3.9 Vlues re presented s men ± stndrd devition. EI, energy intke; SB, smll size rice bowl (2 ml bowl); RB, regulr size rice bowl (38 ml bowl); C, control. P vlues re for comprison for chnges from bseline to post-intervention mong the groups by one-wy ANOVA test, sttisticlly significnt in Tukey post-hoc nlysis, b P vlues <.5 re for comprison between bseline nd intervention within group by pired t-test. 345

7 Ahn HJ, et l. tein intke ws not significntly different mong the three groups. There lso ws significnt decrese in ft intke in the smll rice bowl group (P <.1), which ws greter thn tht of the regulr rice bowl nd control group (P <.5, P <.5, respectively) (Fig. 1). Although the proportions of crbohydrte, protein nd ft to totl energy intke initilly recorded 64.1:16.:2.6%, they chnged into 61.:16.6:22.5% in 12 weeks which were more similr with the proportions recommended by Kore Dibetes Assocition. There ws no significnt difference mong the groups. Fiber, cholesterol nd sodium intke were lso not different in 12 weeks compred to their initil levels nd the chnges of the three groups were lso not significntly different (Tble 2). Chnge in body weight During the 12-week study period, the smll rice bowl group, the regulr rice bowl group nd control group showed significntly reduced body weight by -3.7 ± 2.4 kg (-5.1 ± 2.6%), -2.5 ± 2.4 kg (-3.8 ± 3.8%) nd -1.5 ± 2.4 kg (-2.3 ± 1.8%) (P <.1). All three groups hd differences in the chnges for body weight loss (P =.31); the smll rice bowl group showed significnt decrese in body weight compred to the control group (P <.5) (Fig. 2). Following the 12 week study period, the smll rice bowl group, regulr rice bowl group nd control group showed significntly reduced wist circumferences by -4.8 ± 3.8 cm (-5.1 ± 3.7%), -3.4 ± 3.8 cm (-3.8 ± 4.2%), nd -1.6 ± 1.3 cm (-1.8 ± 1.5%), respectively nd there ws no significnt difference in the reduced level mong the groups (Tble 3). Chnge in blood glucose nd lipid levels After the 12-week study period, HbA1c levels in the smll rice bowl nd regulr rice bowl group decresed significntly: -.8 ±.6% nd -.8 ±.7%, respectively (P <.1). There ws significnt difference in the decrese in HbA1c levels mong the groups (P =.25); the smll rice bowl nd regulr rice bowl group hd greter decrese thn the control group (P <.5). However, there ws no significnt difference in the reduced HbA1c levels between the bowl groups (Fig. 2). Totl cholesterol, triglycerides, HDL-C nd LDL-C levels were not different in 12 weeks compred to their initil levels nd the chnges of the three groups were lso not significntly different. Systolic blood pressure ws decresed significntly in the smll rice bowl group (P <.5) but there ws no significnt difference in the reduced levels mong the three groups (Tble 3). DISCUSSION The Americn Dibetes Assocition recommends tht obese type 2 dibetes mellitus ptients should reduce their dietry energy intke by 5-1, kcl [13] nd initilly result in loss of.5 1 kg/wk. Severl orgniztions recommend the use of smller dishes s strtegy for reducing the portion size, with the gol of decresing energy intke [14]. In one study, Rolls et l. [5] provided 5 g nd 1, g of mcroni nd cheese nd reported tht doubling one serving size (to 1, g) incresed energy intke by 3%. In nother study, Krl et l. [15] provided mels composed of pst, vegetbles, nd cheese t 5 g, Percent chnge of BW (%) Chnge of HbA1c (%) A -5 B Fig. 2. Chnge in body weight (A) nd HbA1c (B) fter 12-week bowl intervention or control in obese women with type 2 dibetes mellitus. BW decresed in the SB group but not in the RB group, compred to the C group (P <.5). HbA1c levels decresed in the bowl groups without difference between the bowl groups (P <.5). HbA1c, glycosylted hemoglobin; BW, body weight; C, control; SB, smll size rice bowl (2 ml bowl); RB, regulr size rice bowl (38 ml bowl). P vlues <.5 vs. C group. 346

8 Smll rice bowl useful in weight nd blood glucose control Tble 3. Chnge in body weight, blood glucose, nd plsm lipids Bseline Post-intervention Chnge P vlue BW, kg SB 7.7 ± ± 1.6 b -3.7 ± RB 64.7 ± ± 6.4 b -2.5 ± 2.4 C 64.2 ± ± 5.1 b -1.5 ± 1.1 BMI, kg/m 2 SB 28.7 ± ± 4.1 b -1.5 ± RB 26.8 ± ± 2.8 b -1. ± 1. C 26.6 ± ± 2.2 b -.6 ±.5 Wist circumference, cm SB 92.2 ± ± 8.8 b -4.8 ± RB 86.1 ± ± 6.9 b -3.4 ± 3.8 C 86.6 ± ± 5.2 b 1.6 ± 1.3 SBP, mm Hg SB ± ± 13.6 b -8.2 ± RB ± ± ± 15.7 C 122. ± ± ± 12.2 DBP, mm Hg SB 78.8 ± ± ± RB 8. ± ± ± 1.5 C 79.3 ± ± ± 9.4 HbA1c, % SB 7.7 ±.8 7. ±.8 b -.8 ±.6.25 RB 7.8 ±.9 7. ± 1. b -.8 ±.7 C 7.2 ± ±.9 -. ±.9 TC, mg/dl SB ± ± ± RB ± ± ± 44. C 177. ± ± ± 23.1 TG, mg/dl SB ± ± ± RB ± ± ± C ± ± ± 42.3 HDL, mg/dl SB 42.3 ± ± ± RB 49.7 ± ± ± 12.2 C 4. ± ± ± 8. LDL, mg/dl SB 98.2 ± ± ± RB 12.4 ± ± ± 43.7 C 11.9 ± ± ± 19.3 Vlues were presented s men ± stndrd devition. BW, body weight; SB, smll size rice bowl (2 ml bowl); RB, regulr size rice bowl (38 ml bowl); C, control; BMI, body mss index; SBP, systolic blood pressure; DBP, distolic blood pressure; HbA1c, glycosylted hemoglobin; TC, totl cholesterol; TG, triglycerides; HDL, high density lipoprotein; LDL, low density lipoprotein. P vlues re for comprison for chnges from bseline to post-intervention mong the groups by one-wy ANOVA test, sttisticlly significnt in Tukey post-hoc nlysis, b P vlues <.5 re for comprison between bseline nd post-intervention within group by pired t-test. 7 g, nd 9 g. They reported tht the 9 g serving resulted in 2% greter energy intke thn the 5 g serving. Rolls et l. [8] provided equl quntities of food on 17 cm, 22 cm, nd 26 cm pltes, ech used on different dys. Using the smll plte did not show to reduction in food intke. In this study, we ttempted to reduce dietry energy intke by 5 kcl in obese type 2 dibetes mellitus ptients through portion control using vrying rice bowl sizes. The smll rice bowl group reduced totl energy intke by -583 kcl, the regulr rice bowl group by -294 kcl. The dietry energy intke of 347

9 Ahn HJ, et l. the smll rice bowl group ws reduced compred to the control group. Reducing the size of the serving bowl by 5% (smll rice bowl vs. regulr rice bowl) ppers to reduce dietry energy intke by 15% (289 kcl/dy). Thus, the reson why the results of this study differ from those reported by Rolls et l. my be becuse the process of filling the smll rice bowl with smller portions ws mesured exctly, resulting in totl energy intke decrese. Steyn et l. [16] showed subjects 29 g of rice 3 minutes fter portion size demonstrtion, nd hd the ptients choose the portion tht ws closest to the 29 g portion tht they hd seen in 3-D food model. Hlf the subjects were ble to mtch the portions of equl size, while the others mistook 5 g servings to be 29 g servings. This result shows tht ptients recognize food portions s being lrger thn they truly re, nd it is possible tht consumption is then greter thn expected. To reduce body weight nd blood glucose levels in obese type 2 dibetes mellitus ptients, totl energy intke nd pproprite proportions of mcronutrients intke should be emphsized. The Koren Dibetes Assocition [17] dvises dibetes ptients to consume diets tht consist of 55-6% crbohydrtes, 15-2% protein, nd 2-25% ft. According to survey of dietitins from generl hospitls done by the Food nd Nutrition Commission of the Koren Dibetes Assocition [18], 89.1% educte ptients using food exchnge tble. Eduction of obese type 2 dibetes mellitus ptients using the smll rice bowl proved to be just s effective s the food exchnge tble in meeting the recommended levels of crbohydrtes, protein, nd ft [19]. The pplied eduction method for using the smll rice bowl reduced the intke of crbohydrtes, protein, nd ft. In this study, crbohydrte intkes for the smll rice bowl group were reduced by more thn those of the control group. Reducing the size of the serving bowl lso reduces the mount of crbohydrte intke. Additionlly, the ft intke in the smll rice bowl group ws significntly reduced following the 12-week study period. Similr results were observed in previous experiment [19]. The reson tht ft intke ws reduced in the smll rice bowl group ws solely bsed on reduction of rice portion size. This is becuse rice is stple in typicl Koren diet, nd the consumption of soyben oil nd sesme oil, which re dded to side dishes, hs n effect on energy intke [19]. The Americn Dibetes Assocition recommends tht obese type 2 dibetes mellitus ptients reduce their body weight by 5-1%. By reducing dietry energy intke by 5-1, kcls, ptients cn expect to reduce their body weight by 8% in 6 months [13]. In this study, educting subjects on the ppliction of the bowls for 12-week period resulted in 5.1% reduction in body weight in the smll rice bowl group, compred to 2.3% reduction in the control group, which ws significnt reduction in body weight. However, the body weight did not show lrger reduction in the stndrd bowl group thn control group. In type 2 dibetes mellitus ptients, medicl nutrition therpy by registered dietitins ws ssocited with.2-2.9% decrese in HbA1c fter 3-6 months [3]. Wilson et l. [2] reported tht medicl nutrition therpy by registered dietitins ws ssocited with % decrese in HbA1c in ptients with type 2 dibetes mellitus (verge HbA1c 8%). Kim et l. [21] utilized food exchnges tble oriented towrds Koren dibetes ptients for 12 weeks using the combined diet nd exercise strtegies recommended by the dibetes ssocition s guide, HbA1c levels decresed by.7% (from 8.9% to 8.2%). In this study, reducing crbohydrte intke using rice bowl in obese type 2 dibetes ptients decreses the HbA1c in smll rice bowl group nd regulr rice bowl group. But even though dietry totl energy intke nd crbohydrte intke ws reduced more in smll rice bowl group. There ws no significnt difference in HbA1c levels between smll rice bowl group nd regulr rice bowl group, which ws due to the effects of different orl nti-dibetic gents, durtion of dibetes, initil glycted hemoglobin levels, nd exercise level [22]. In this study, we observed tht Koren type 2 dibetes mellitus ptients who consumed rice-centered mels using smll rice bowls hd lower totl energy intke nd crbohydrte intkes compred to control group, which in turn reduced body weight nd blood glucose levels. There ws more significnt reduction in totl energy intke nd crbohydrte intke in smll rice bowl group thn regulr rice bowl group without dditionl dietry eduction. But, there ws no ddition benefit in body weight nd glucose control becuse the regulr rice bowl group nd control group hd more ptients who were regulting dibetes through diet nd exercise thn the smll rice bowl group. The regulr rice bowl nd control groups lso hd shorter durtion of dibetes nd consisted of ptients with higher HbA1c levels. Becuse this study ws conducted only in single hospitl nd its smple size ws smll, the effects nd chnges of body weight nd HbA1c levels could not be exmined. In ddition, future studies re needed to compre effects of eduction using vrying rice bowl size with obese ptients with 348

10 Smll rice bowl useful in weight nd blood glucose control different knowledge levels, gender nd ge. In prticulr, this study hd limittions tht it exmined only women who took reltively more crbohydrte nd followed further mngement reltively well nd tht it did not show clinicl outcomes of vrious groups. REFERENCES 1. Li Z, Hong K, Sltsmn P, DeShields S, Bellmn M, Thmes G, Liu Y, Wng HJ, Elshoff R, Heber D. Long-term efficcy of soy-bsed mel replcements vs n individulized diet pln in obese type II DM ptients: reltive effects on weight loss, metbolic prmeters, nd C-rective protein. Eur J Clin Nutr 25; 59: Colditz GA, Willett WC, Rotnitzky A, Mnson JE. Weight gin s risk fctor for clinicl dibetes mellitus in women. Ann Intern Med 1995;122: Americn Dibetes Assocition. Stndrds of medicl cre in dibetes--21. Dibetes Cre 21;33 Suppl 1:S Ledikwe JH, Ello-Mrtin JA, Rolls BJ. Portion sizes nd the obesity epidemic. J Nutr 25;135: Rolls BJ, Morris EL, Roe LS. Portion size of food ffects energy intke in norml-weight nd overweight men nd women. Am J Clin Nutr 22;76: Pedersen SD, Kng J, Kline GA. Portion control plte for weight loss in obese ptients with type 2 dibetes mellitus: controlled clinicl tril. Arch Intern Med 27;167: Hebert JR, M Y, Clemow L, Ockene IS, Speri G, Stnek EJ 3rd, Merrim PA, Ockene JK. Gender differences in socil desirbility nd socil pprovl bis in dietry self-report. Am J Epidemiol 1997;146: Rolls BJ, Roe LS, Hlverson KH, Meengs JS. Using smller plte did not reduce energy intke t mels. Appetite 27;49: Ministry of Helth nd Welfre. The Koren ntionl helth nutrition exmintion survey 25. Seoul: Ministry of Helth nd Welfre; Ahn HJ, Koo BK, Jung JY, Kwon HR, Chung MY, Ku YH, Kim JT, Hn KA, Min KW. Assocition between volume of bowls nd the dietry intkes in subjects with type 2 dibetes. Koren Dibetes J 29;33: Ahn HJ, Eom YK, Hn KA, Kwon HR, Kim HJ, Prk KS, Min KW. The effects of smll sized rice bowl on crbohydrte intke nd dietry ptterns in women with type 2 dibetes. Koren Dibetes J 21;34: Koren Dibetes Assocition. A guideline for dibetes eduction. 2nd ed. Seoul: Gold Agency; Klein S, Sherd NF, Pi-Sunyer X, Dly A, Wylie-Rosett J, Kulkrni K, Clrk NG; Americn Dibetes Assocition; North Americn Assocition for the Study of Obesity; Americn Society for Clinicl Nutrition. Weight mngement through lifestyle modifiction for the prevention nd mngement of type 2 dibetes: rtionle nd strtegies: sttement of the Americn Dibetes Assocition, the North Americn Assocition for the Study of Obesity, nd the Americn Society for Clinicl Nutrition. Dibetes Cre 24;27: Ello-Mrtin JA, Ledikwe JH, Rolls BJ. The influence of food portion size nd energy density on energy intke: implictions for weight mngement. Am J Clin Nutr 25;82(1 Suppl): 236S-41S. 15. Krl TV, Roe LS, Rolls BJ. Combined effects of energy density nd portion size on energy intke in women. Am J Clin Nutr 24;79: Steyn NP, Senekl M, Norris SA, Whti L, Mckeown JM, Nel JH. How well do dolescents determine portion sizes of foods nd beverges? Asi Pc J Clin Nutr 26;15: Koren Dibetes Assocition. Stged dibetes mngement. 3rd ed. Seoul: Koren Dibetes Assocition; 27. p Cho JW. The present sttus of dibetes eduction nd opinion reserch of food exchnge list. Koren Dibetes J 28;32(Suppl 2):S Ahn HJ, Hn KA, Kwon HR, Koo BK, Kim HJ, Prk KS, Min KW. Smll rice bowl-bsed mel pln versus food exchngebsed mel pln for weight, glucose nd lipid control in obese type 2 dibetic ptients. Koren Dibetes J 21;34: Wilson C, Brown T, Acton K, Gillilnd S. Effects of clinicl nutrition eduction nd eductor discipline on glycemic control outcomes in the Indin helth service. Dibetes Cre 23;26: Kim SH, Kng ES, Prk SY, Lee SJ, Kim MJ, Yoo JS, Ahn CW, Ch BS, Lim SK, Lee HC. The effects of lifestyle modifiction on the metbolic prmeters of type 2 dibetes. J Koren Dibetes Assoc 24;28: Khn MA, St Peter JV, Breen GA, Hrtley GG, Vessey JT. Dibetes disese stge predicts weight loss outcomes with long-term ppetite suppressnts. Obes Res 2;8: