Originl Article doi: 10.4093/kdj.2010.34.3.166 pissn 1976-9180 eissn 2093-2650 The Effects of Smll Sized Rice Bowl on Crbohydrte Intke nd Dietry Ptterns in Women with Type 2 Dibetes Hee-Jung Ahn 1, *, Yu-Kyung Eom 2, *, Kyung-Ah Hn 3, Hwi-Ryun Kwon 1, Hyun Jin Kim 3, Kng Seo Prk 3, Kyung-Wn Min 3 1 Dibetes Center, Eulji Hospitl, Seoul, 2 Kore Dibetes Clinicl Reserch Center, Seoul, 3 Deprtment of Internl Medicine, Eulji University School of Medicine, Dejeon, Kore Bckground: The min source of crbohydrte in the Koren diet is rice, which is usully served in rice bowl. This study investigted the impct of mel pln using smller rice bowls on dietry energy intke nd mcronutrient composition in overweight or obese ptients with type 2 dibetes mellitus. Methods: A totl of 67 women with type 2 dibetes were enrolled in our study. We divided these prticipnts into three groups: norml-weight group (NW; body mss index [BMI] < 23 kg/m 2 ; n = 17), n overweight group (OW; 23 BMI < 25 kg/m 2 ; n = 24) nd n obese group (OB; BMI 25 kg/m 2 ; n = 26). Three-dy dietry records were nlyzed for totl energy intke (TEI) nd mcronutrient composition both before enrollment nd two weeks fter ptients received instruction in dietry pln bsed on using smll (200 ml) rice bowl. Results: After the intervention, TEI decresed in the OW nd OB groups. Decresed crbohydrte (NW, -4 ± 5%; OW, -4 ± 5%; OB, -3 ± 6%) nd incresed ft intkes were found in ll three groups, which complies with Koren Dibetes Assocition recommendtions. The protein proportion of TEI significntly incresed only in the OW group. Body weight decresed both in the OW nd OB groups. Conclusion: A short-term, smll-rice-bowl-bsed mel pln ws effective for body weight control nd mcronutrient blnce in overweight or obese women in Kore with type 2 dibetes. Keywords: Crbohydrte restriction; Dibetes mellitus, type 2; Dibetic diet INTRODUCTION The crbohydrte proportion of totl energy intke of Koren nd Americns re 64.5%, 51.7%, respectively (Ntionl Helth nd Nutrition Exmintion Survey) [1]. Usully Korens consume high intke of crbohydrte thn Americns. According to the Kore Helth nd Nutrition Exmintion Survey (KHA NES), crbohydrte proportion of totl energy intke in Koren with type 2 dibetes ws 68% which is bove the crbohydrte recommendtions of Koren Dibetes Assocition (KDA); 55 to 60% [2,3]. Yng nd Kim [4] reported tht dibetes ptients consume more crbohydrtes thn individuls without dibetes, nd Jung et l. [5] lso pointed out tht reducing crbohydrte intke my decrese risk fctors of crdiovsculr disese in the dults. Another study reported tht crbohydrte intke ffects blood glucose; excessive intke leds to obesity by promoting ppetitite nd the secretion of insulin, which increse body ft [6,7]. Hollenbeck et l. [8] reveled tht when type 2 dibetes ptients increse crbohydrte proportion of totl energy in- Corresponding uthor: Kyung-Wn Min Dibetes Center, Eulji Hospitl, 280-1 Hgye 1-dong, Nowon-gu, Seoul 139-872, Kore E-mil: minyungw@yhoo.co.kr *Hee-Jung Ahn nd Yu-Kyung Eom jointly contribute to this pper s first uthors. Received: Jn. 26, 2010; Accepted: Apr. 20, 2010 This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License (http://cretivecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. Copyright 2010 Koren Dibetes Assocition
Smll sized rice bowl nd crbohydrte intke tke from 50% to 60%, both triglyceride nd postprndil blood glucose levels rise, nd the higher blood glucose ws difficult to control even fter dministrtion of more insulin in Korens. The trditionl Koren rice-bsed diet includes numerous side dishes, becuse rice itself is blnd. Koren side dishes tend to hve strong tstes, such tht they re difficult to et without rice [9]. Therefore, the totl energy intke for Korens who et rice-bsed diet is dependent on the bsolute mount of rice consumed [10]; decresing rice intke by recommending the use of smller rice bowls cn influence totl energy intke. Ahn et l. [11] found tht type 2 dibetes ptients te ricebsed mels n verge of 19.9 ± 2.3 times per week; the mount of rice intke ws relted to the sizes of the rice bowl used by ptients. A 380-mL rice-bowl-bsed mel pln, which is most frequently used for type 2 dibetes ptients in Kore, hs lredy been reported to be s effective in controlling crbohydrte, protein nd ft intke s food exchnge system-bsed mel plns [12]. However, it is still unknown how dietry intke ptterns ffect obesity when ptients with type 2 dibetes use smller rice bowls. This ws preliminry study to investigte the clinicl effects of smll rice-bowl-bsed mel pln in Koren type 2 dibetes ptients. We exmined the effects of short-term chnges in crbohydrte nd totl energy intke through mels nd sncks ccording to obesity by decresing only rice bowl size. METHODS Prticipnts We recruited women with type 2 dibetes who visited the Dibetes Center of Eulji Hospitl locted in the Seoul from July 2009 to August 2009. The study prticipnts included totl of 67 women ged 20 to 69 yers with glycosylted hemoglobin (HbA1c) levels between 7% nd 11%. Ptients who hd ny specil dietry hbit (i.e., vegetrin diet), gesttionl dibetes, mlignnt tumors, been treted with renl replcement therpy, secondry dibetes, or were difficult to follow-up, refused exmintion, te mels t resturnts more the two times per week, nd hd dyspepsi or norexi were excluded from our smple. The prticipnts were divided by body mss index (BMI) score into norml weight (NW) group (BMI < 23 kg/m 2, n = 17), n overweight (OW) group (23 kg/m 2 BMI < 25 kg/m 2, n = 24) nd n obese (OB) group (BMI 25 kg/m 2, n = 26), nd their dt were nlyzed nd compred. Eduction Rice bowls (Seonsu Chinwre, Seoul, Kore) of 200 ml tht hold bout 200 kcl of rice were given to ll prticipnts, nd ech received five minutes of individulized eduction on tips for putting rice in the bowl nd for utilizing the bowl. The prticipnts were informed tht the rice bowl should be used for every mel nd tht no more rice should be eten thn would fit in the bowl. An informtionl leflet ws provided to inform prticipnts tht other sources of crbohydrte, such s bred, rice cke, potto nd sweet potto should lso be limited. Eduction regrding dily fruit intke ws lso provided through leflet. Survey of bowl size The prticipnts were sked to bring the rice bowl they usully used to their mels. Becuse the sizes nd shpes of bowls differed mong prticipnts, the sizes were determined by mesuring the volume of wter contined in the bowl with 100 ml nd 500 ml mesuring cylinders. Dietry nutrient intke nd ptterns To compre nd nlyze chnges of energy intke during the study tht resulted from mels nd sncks, ny foods tht could be clssified s fruit or diry in the food exchnge system (Koren Dibetes Assocition, Koren Dietetic Assocition, Koren Nutrition Society, 1994) nd lso those tken between mels were defined s sncks. The intke of mels nd sncks ws guged using three-dy dietry record (two weekdys nd one weekend dy). A simple preliminry eduction on how to record mels nd sncks ws provided to help prticipnts understnd how to record food intke. Types nd mount of ll foods eten ech dy were recorded; prticipnts divided their intke into mels or supplementry foods nd sncks. To increse the ccurcy of these three-dy food records, nutritionists reviewed exmples using life-sized food models, mesuring cups, mesuring spoons, nd dt on eye mesurement of foods (Koren Dietetic Assocition, 1999) with prticipnts when the record sheet ws returned. The contents of the records were nlyzed with CAN-Pro version 2.0 (Computer-Aided Nutritionl Anlysis Progrm; Koren Nutrition Society, Seoul, Kore) nd then trnslted into nutrient intke dt. As dietry energy intke differed ccording to obesity, the rtio of dietry energy intke to recommended energy intke ws clculted nd ssessed for ech ptient. The recommended energy intke ws obtined by multiplying the idel body 167
Ahn H-J, et l. weight by 30 kcl/kg [13]. To observe dietry ptterns nd plces for mels eten on weekdys nd weekends, the totl number of mels, the number of mels consisting of rice nd side dishes, nd plces where the prticipnts te the mels were investigted [14,15], nd ptients showing unusul dietry energy ptterns (e.g., birthdy prty) were excluded from this study. Physicl mesurements nd biochemicl tests Heights nd body weights of ll prticipnts were mesured t the beginning of the study nd gin following the 2-week. Height nd body weight mesurements were tke in light clothing (no outerwer), nd BMI ws clculted by dividing the body weight (kg) with the squre of the height (m 2 ). HbA1c ws mesured with high-performnce liquid chromtogrphy (HPLC) using ction exchnge resin. Sttisticl nlyses All dt were nlyzed with the SPSS version 15.0 (SPSS Inc., Chicgo, IL, USA), nd the mens nd stndrd devitions of ll items were clculted. To investigte chnges in physicl chrcteristics for the two weeks of the study nd to compre nutritient intke before nd fter the use of the smller rice bowl, pired smple t-test ws used. One-wy ANOVA nd Duncn s post hoc tests were used to compre the three ptient groups. A P vlue of less thn 0.05 ws considered to be sttisticlly significnt. Tble 1. Bseline clinicl chrcteristics of study subjects Chrcteristics NW OW OB Totl P vlue No. of subjects 17 24 26 67 Age, yr 64.1 ± 6.7 62.5 ± 6.1 59.8 ± 6.1 61.9 ± 6.4 0.081 Height, cm 155.3 ± 4.8 155.1 ± 3.3 154.6 ± 3.7 155.0 ± 3.8 0.839 Weight, kg 52.7 ± 4.2 57.9 ± 2.9 67.8 ± 6.9 60.4 ± 8.0 < 0.001 BMI, kg/m 2 21.8 ± 0.9 24.0 ± 0.6 28.3 ± 2.3 25.1 ± 3.1 < 0.001 Dibetes durtion, yr 16.1 ± 5.3 15.0 ± 8.3 15.4 ± 6.3 15.4 ± 6.8 0.879 Eduction, n (%) High school grdute or bove 4 (23.5) 8 (33.3) 12 (46.2) 24 (35.8) 0.682 Middle school grdute 5 (29.4) 6 (25.0) 6 (23.1) 17 (25.5) Elementry school grdute 8 (47.1) 6 (25.0) 5 (19.2) 19 (28.4) Below elementry school grdute 0 (0.0) 4 (16.7) 3 (11.5) 7 (10.4) Dibetes eduction, n (%) Yes 14 (82.4) 24 (100.0) 25 (96.2) 63 (94.0) 0.179 No 3 (17.6) 0 (0.0) 1 (3.8) 4 (6.0) No. of people treted with Diet nd exercise only 1.5 7.5 0 9 Orl hypoglycemic gents 11.9 13.4 7.5 32.8 Insulin 11.9 14.9 31.3 58.1 HbA1c, % 8.0 ± 0.8 8.2 ± 1.0 8.6 ± 0.7 8.3 ± 0.9 0.063 Rice bowl size, ml 336.5 ± 30.7 343.7 ± 60.2 353.6 ± 46.9 345.6 ± 48.7 0.530 Dietry energy intke, kcl/dy 1,587 ± 165 1,694 ± 143 1,844 ± 198 1,725 ± 199 < 0.001 Crbohydrte, % of EI 61.9 ± 4.8 63.1 ± 6.0 63.5 ± 11.7 63.0 ± 8.4 0.829 Protein, % of EI 17.3 ± 1.7 16.8 ± 2.1 17.0 ± 2.9 17.1 ± 2.3 0.823 Ft, % of EI 21.3 ± 4.4 20.8 ± 5.2 21.8 ± 5.5 21.4 ± 5.1 0.801 The vlues were men ± stndrd devition or frequency (%). Sttisticl significnce ws tested by independent t-test or chi-squre test. NW, norml weight; OB, obese; OW, overweight; BMI, body mss index; EI, energy intke; HbA1c, glycosylted hemoglobin. Men or frequency (%) comprison groups. 168
Smll sized rice bowl nd crbohydrte intke RESULTS Prticipnt chrcteristics Our study initilly included 78 ptients (NW, n = 26; OW, n = 26; OB, n = 26), but fter excluding those who hd unusul dietry ptterns (n = 3), those who refused to prticipte (n = 5), nd those who hd two or more mels week t resturnts (n = 3), 67 ptients were finlly included s prticipnts. There were no significnt differences in the drop-out rtes mong the three groups. The men ge, durtion of dibetes nd HbA1c of the prticipnts were 61.9 ± 6.4 yers, 15.4 ± 6.8 yers nd 8.3 ± 0.9%, respectively, nd they were not significntly different mong the groups. Among our prticipnts, 10.4% hd not received forml eduction; eductionl sttus ws not significntly different mong the three groups. For dibetes tretments, the rtes of using insulin, orl hypoglycemic gents nd diet therpy were 58.1%, 32.8%, nd 9%, respectively, nd there were no significnt differences mong the groups for ny of these vribles. Ninety-four percent of our smple hd received some type of dibetes eduction, but significnt differences resulting from this eduction were not observed mong the three groups (Tble 1). Dietry totl energy intke nd nutrient intke by BMI before rice bowl bsed mel pln The dietry totl energy intke of the prticipnts before eduction ws 1,725 ± 199 kcl/dy, nd the OW nd OB groups took in significntly more dietry energy thn the NW group (P < 0.001, P < 0.001, respectively). The rtio of dietry energy intke to recommended energy intke were 104 ± 10%, 111 ± 8%, nd 122 ± 13% in the NW, the OW, nd the OB groups, respectively; those of the OW nd the OB groups were higher thn tht of the NW group (Tble 2). The crbohydrte, protein nd ft proportion of totl energy intke were 62.2%, 17.1%, nd 21.4%, respectively, nd the crbohydrte proportion of totl energy intke ws higher thn the 55 to 60% recommended by the KDA. There were no significnt differences mong the three groups for mcronutrient intke (Tble 2) [2]. Dietry energy intke nd nutrient intke by BMI fter rice bowl bsed mel pln After eduction on the benefits of using 200 ml rice bowl, totl energy intke for prticipnts remined the sme in the NW group, but ws significntly reduced by 200 ± 181 kcl/dy nd 199 ± 224 kcl/dy in the OW nd the OB groups, respectively (P < 0.001, P < 0.001, respectively). The rtio of dietry Tble 2. Dietry energy intke nd mount nd proportion of mcronutrients in study subjects Bseline Energy, kcl 1,587 ± 165 Crbohydrte, g 245.4 ± 28.6 Protein, g 69.2 ± 11.6 NW OW OB Totl 1,555 ± 154 Bseline 1,694 ± 143 226.1 ± 267.9 ± 25.8 38.8 70.9 ± 13.1 71.6 ± 11.0 Ft, g 37.6 ± 9.0 41.7 ± 39.1 ± 9.1 9.9 Energy complince, % 104.5 ± 10.5 102.3 ± 9.8 111.8 ± 8.6 Bseline 1,494 ± 206 1,844 ± 198 220.7 ± 282.7 ± 36.6 40.0 68.4 ± 11.9 39.6 ± 11.9 78.9 ± 16.2 45.0 ± 12.7 98.7 ± 122.5 ± 13.5 13.0 Bseline 1,644 ± 1,725 ± 236 199 230.4 ± 65.2 267.9 ± 39.3 74.0 ± 17.0 43.5 ± 12.9 73.8 ± 13.9 41.0 ± 11.2 109.0 ± 114.1 ± 14.6 13.1 1,568 ± 215 P vlue b 0.006 b 225.8 ± 47.5 0.057 71.3 ± 14.4 41.7 ± 11.7 0.261 0.202 103.7 ± 13.8 0.365 Crbohydrte, % of TEI 61.9 ± 4.8 58.3 ± 4.7 63.1 ± 6.0 59.2 ± 6.1 61.5 ± 7.7 58.4 ± 8.2 62.2 ± 6.4 58.6 ± 6.7 0.805 Protein, % of TEI 17.4 ± 1.7 18.2 ± 2.6 16.9 ± 2.1 18.4 ± 2.4 17.1 ± 2.9 18.0 ± 2.9 17.1 ± 2.3 18.2 ± 2.7 0.668 Ft, % of TEI 21.4 ± 4.4 24.1 ± 4.1 20.9 ± 5.2 23.7 ± 5.2 21.9 ± 5.5 23.8 ± 5.9 21.4 ± 5.1 23.8 ± 5.2 0.776 The vlues were presented s men ± stndrd devition. Dietry energy complince ws totl dily energy intke (kcl) / prescribed energy intke (kcl) 100. NW, norml weight; OB, obese; OW, overweight; TEI, totl energy intke. P vlues < 0.05 for comprison between bseline nd intervention, b P vlues < 0.05 for comprison groups. 169
Ahn H-J, et l. Energy intke (Kcl/dy) 1,800 1,700 1,600 1,500 1,400 1,300 1,200 Bseline 150 NW OW OB NW OW OB A Mel Snck Energy intke (Kcl/dy) 450 400 350 300 250 200 Bseline Fig. 1. Ptterns of mel nd snck intke ccording to the body mss index. Vlues re energy intkes s mels nd sncks. (A) Differences by energy intke s mel. (B) Differences by energy intke s snck. The energy intke s mel ws decresed both in OW nd OB (P = 0.001, P < 0.001), but not with in NW. The energy intke s snck ws decresed in OW (P = 0.005). NW, norml weight; OW, overweight; OB, obese. P vlues <0.05 for comprison between bseline nd intervention. B Weight (kg) 80 75 70 65 60 55 50 45 NW OW OB Bseline Fig. 2. Chnge of weight ccording to the body mss index. The weight ws decresed both in OW nd OB (P = 0.003, P = 0.007), but not with in NW. NW, norml weight; OW, overweight; OB, obese. P vlues <0.05 for comprison between bseline nd intervention. energy intke to recommended energy intke lso did not chnge in the NW group, but it reched the recommended levels t 98 ± 13% nd 109 ± 14% in the OW nd the OB groups, respectively (P < 0.001, P < 0.001, respectively) (Tble 2). After eduction, the crbohydrte proportion of totl energy intke decresed by 3.7 ± 4.5%, 3.9 ± 4.7%, nd 3.1 ± 6.0% in the NW, the OW, nd the OB groups, respectively, nd their proportions becme closer to those recommended by the KDA (P = 0.004, P < 0.001, nd P = 0.015, respectively) [2]. Although the protein proportion of totl energy intke incresed by 1.4 ± 1.7% only in the OW group, it did not exceed the recommended dily level (P < 0.001). Chnges of the protein proportion of totl energy intke were not significntly different mong the three groups. The ft proportion of totl energy intke grew significntly by 2.7 ± 4.3%, 2.8 ± 5.1%, nd 1.9 ± 4.6%, respectively (P = 0.019, P = 0.014, nd P = 0.043, respectively), but it ws still within the recommended KDA rnge [2]. There were no significnt differences in ft proportion of totl energy intke mong the three groups (Tble 2). Chnges of energy intke through mels nd sncks When mesuring totl energy intke, we clssified milk nd fruit s sncks nd considered ll other foods to be mels. Totl energy intke from mels declined significntly by 142 ± 185 kcl/dy nd 189 ± 207 kcl/dy in the OW nd the OB groups, respectively (P = 0.001, P < 0.001, respectively), but totl energy intke did not chnge in the NW group. Totl energy intke from sncks decresed significntly by 59.1 ± 106.5 kcl/dy only in the OW group (P = 0.005) but did not significntly chnge in the NW or the OB groups (Fig. 1). Chnges of body weight After the eduction, body weight ws reduced significntly by 0.4 ± 0.6 kg (-0.7%) nd 0.5 ± 0.8 kg (-0.7%) in the OW nd the OB groups, respectively (P = 0.003, P = 0.007, respectively), nd no significnt chnge ws observed in the NW group. When considered s percentge of idel body weight, body weight ws reduced from 115 ± 3.1% to 114 ± 3.0% nd from 135 ± 11.4% to 134 ± 11.3% in the OW nd the OB groups fter the eduction, respectively (P = 0.003, P = 0.007, respectively) (Fig. 2). DISCUSSION In 2005, the KNHANES reported tht the crbohydrte proportion of totl energy intke in Koren women with dibetes ws 70.3% [3]. Therefore, Koren women with dibetes consume reltively high crbohydrte diet [16]. In ddition, the KNH ANES reveled tht min source of crbohydrtes re obtined 170
Smll sized rice bowl nd crbohydrte intke from white rice, nd mixed grins nd white rice rnked first in frequently consumed food; these findings confirm tht Korens typiclly consume rice-centered diet [3]. Among our prticipnts, the crbohydrte proportion of totl energy intke ws 61.9%, 63.1%, nd 63.5% in the NW, the OW, nd the OB groups, respectively. These figures were lower thn the proportion of 70.3% found by the KNHANES in 2005 [3] nd lso tht of study of Song nd Lee [17] tht reported proportions of 66.1%, 66.8%, nd 67.4%, in norml, overweight, nd obese type 2 dibetes ptients, respectively. These vritions were considered to result from differences in dietry ptterns ccording to survey period nd ge [18], region [19], economic sttus [20,21] nd level of dibetes eduction. In our study, 94% of the prticipnts received eduction on dibetes, nd our prticipnts were observed to better control crbohydrte intke s result. Nevertheless, we found tht the crbohydrte proportion of totl energy intke (62.2%) ws higher thn the recommended KDA rnge (55 to 60%), which suggests tht more dietry eduction is needed to reduce crbohydrte consumption [2]. In this study, eduction using smller rice bowl effectively decresed crbohydrte intke in Koren women with dibetes regrdless of BMI. Food-exchnge-system-bsed eduction, which is commonly used for dibetes ptients, teches prticipnts to regulte energy intke nd mrcronutrient composition [22]. Lee nd Chng [22] reported tht the crbohydrte proportion of type 2 dibetes ptients decresed significntly from 62.3% to 59.6% following food-exchnge-system-bsed eduction, nd Ahn et l. [12] lso reveled tht crbohydrte proportion could decrese significntly from 61% to 57.3% with this type of eduction method. However, conventionl eduction methods using food exchnge system require gret del of time nd intensive eduction or dditionl mngement eduction becuse ptients cnnot understnd them esily; the shortge of vilble nutritionists lso prevents dequte eduction [23]. To ddress the problem of food-exchnge-systembsed eduction, Ahn et l. [12] insted educted type 2 dibetes ptients using n ordinry-sized rice bowl (380 ml) nd found tht portion control lone could decrese the crbohydrte proportion from 60.7% to 58.1%, or to the levels recommended by the KDA. Eduction bsed on using smller rice bowl hs been found to significntly increse the protein proportion from 17.1% to 18.2% while not exceeding the rnge of 15% to 20% recommended by the KDA; there ws no significnt difference mong the groups [2]. This is similr to the findings of study by Lee nd Chng [22] showing tht in type 2 dibetes ptients, the protein proportion to totl energy intke incresed from 16.7% before eduction bsed on the food exchnge system to 18.1% fter it; nd in this study, eduction bsed on smller rice bowl lso regulted the protein proportion to totl energy intke within the recommended rnge [2]. Although the ft proportion of totl energy intke lso incresed significntly from 21.4% before the eduction to 23.8% fter it, it still fell within the recommended rnge (P < 0.001), nd no significnt difference mong the groups ws observed. According to study of Lee nd Chng [22] eduction bsed on the food exchnge system significntly incresed the ft proportion of totl energy intke by following the decrese of totl energy intke in obese middle-ged womn, Ahn et l. [12] found tht fter 12-week eduction progrm using food exchnge system for obese femles with type 2 dibetes, the ft proportion to totl energy intke incresed, lthough the chnge ws not sttisticlly significnt. In this study, the ft proportion of totl energy intke becme significntly higher in ll three groups, nd this chnge ws thought to be cused by the decrese of the crbohydrte proportion of totl energy intke. However, since the ft proportion of totl energy intke incresed significntly but ws still within the recommended rnge, further studies on its long-term nd clinicl effects re necessry. Smller rice bowl bsed diets reduced engery intke by 200 ± 181 kcl/dy nd 199 ± 224 kcl/dy in the OW nd OB groups of our study, respectively. In the OW group, energy intke from mels nd sncks ws reduced; in the OB, energy intke from mels lso declined. This finding ws similr to tht of Lee [24], who reported tht eduction bsed on food exchnge system for middle-ged women decresed totl dietry energy intke but did not reduce snck intke. Therefore, other ctive methods were needed to control snck intke, lthough our eduction method of using smll sized rice bowl ws effective in lowering dietry energy intke from mels in the OW nd the OB groups. We used rice bowl tht could hold enough rice to provide 200 kcl of energy. Athough rice bowl of tht could hold 200 kcl to 300 kcl per mel ws recommended, we chose the 200- kcl size becuse ptients could potentilly hep or push more rice in their bowl nd exceed its 200-kcl cpcity. Becuse our study only lsted for two weeks, we could not conclude tht the eduction nd the smller rice bowl led to effective energy intke control or clinicl outcomes in our prticipnts. In ddi- 171
Ahn H-J, et l. tion, the method, frequency nd period of eduction in this study were different thn those other studies tht bsed their eduction on n ordinry-sized rice bowl, so it ws lso difficult to determine tht using smller rice bowl ws more effective thn using n ordinry-sized rice bowl. Nevertheless, the eduction pln tht we prescribed decresed the crbohydrte proportion of totl energy intke regrdless of obesity nd prticulrly in the OW nd the OB groups. These findings suggest our method s potentil effectiveness for overweight nd obese ptients, nd long-term studies will be needed to determine the effect of our eduction on intke control. Unlike previous study tht controlled the mount of foods, our eduction progrm used method bsed on bowl size, nd its effect s plte method hd been proven in foreign countries. Pedersen et l. [25] reported tht using smller plte for mels helped effectively reduce the body weight of women with dibetes, nd Diliberti et l. [26] lso showed tht smll-sized plte decresed totl energy intke t resturnts. Athough our short-term study could not observe mjor chnges in body weight fter the eduction progrm using the smller bowl, the body weight of the OW nd the OB groups ws reduced significntly. Further long-term studies on decresed body weight following the use of smller rice bowl re necessry. In conclusion, our eduction progrm reduced totl energy intke in overweight nd obese ptients. Our mel eduction progrm reduced rice intke effectively so prticipnts could more closely rech the recommended crbohydrte intke. However, becuse this study ws conducted only in single hospitl nd its smple size ws smll, the effects nd chnges of dietry ptterns (such s gender nd ge) could not be exmined. In ddition, this study included three-dy dietry record to observe mcronutrient intke chnges, but it ws difficult to evlute the dily intke of dibetes ptients using this record. Dietry records re more effective thn recll methods, which hve been widely used to survey food intke. Ptients using recll methods tend to report lower intke thn ws ctully consumed due to fctors such s decresed memory in elderly ptients; however, since the food frequency method is not suitble for investigtions on short-term chnges, our study used the three-dy dietry record [27]. Our study used two-week study period to exmine chnges of crbohydrte intke fter using smller rice bowl, but this short period mde it difficult to determine the effect of the rice-bowl-bsed mel pln. Therefore, dditionl studies investigting long-term chnges using similr eduction method re necessry. REFERENCES 1. Americn Dibetes Assocition. Dignosis nd clssifiction of dibetes mellitus. Dibetes Cre 2007;30 Suppl 1:S42-7. 2. Koren Dibetes Assocition. Guidelines for eduction of dibetes mellitus. 2nd ed. Seoul: Gold Agency; 2006. 3. Ministry of Helth nd Welfre, Kore Centers for Disese Control nd Prevention. The Third Kore Ntionl Helth nd Nutrition Exmintion Survey (KNHANES III), 2005. Seoul: Ministry of Helth nd Welfre; 2006. 4. Yng EJ, Kim WY. The influence of dietry fctors on the incidence of non-insulin-dependent dibetes mellitus. Koren J Nutr 1999;32:407-18. 5. Jung HK, Yng EJ, Prk WO. Crbohydrte intke ssocition with risk fctors of coronry hert disese in the dults: NHANES III. Koren J Nutr 2000;33:873-81. 6. Prk YM, Son CM, Jng HC. Correltion of crbohydrte intke with obesity in type 2 dibetes mellitus ptients. J Koren Diet Assoc 2006;12:254-63. 7. Feskens EJ, Bowles CH, Kromhout D. Crbohydrte intke nd body mss index in reltion to the risk of glucose intolernce in n elderly popultion. Am J Clin Nutr 1991;54:136-40. 8. Hollenbeck CB, Chen N, Chen YD, Reven GM. Reltionship between the plsm insulin response to orl glucose nd insulin-stimulted glucose utiliztion in norml subjects. Dibetes 1984;33:460-3. 9. Chng UJ, Jung EY, Hong IS. The effect of the reduced portion size by using diet rice bowl on food consumption nd stiety rte. Koren J Community Nutr 2007;12:639-45. 10. Son SM. Rice bsed mel for prevention of obesity nd chronic disese. Koren J Community Nutr 2001;6:862-7. 11. 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 2009;33:335-43. 12. Ahn HJ, Koo BK, Jung JY, Kwon HR, Kim HJ, Prk KS, Hn KA, Min KW. Bowl-bsed mel pln versus food exchngebsed mel pln for dietry intke control in Koren type 2 dibetic ptients. Koren Dibetes J 2009;33:155-63. 13. Koren Dibetes Assocition. Stged dibetes mngement. 3rd ed. Seoul: Koren Dibetes Assocition; 2007. p3-9. 14. Sevick MA, Npolitno MA, Ppndontos GD, Gordon AJ, Reiser LM, Mrcus BH. Cost-effectiveness of lterntive p- 172
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