OBJECTIVE -To compare a simple meal plan emphasizing healthy food choices with a traditional exchange-based meal plan in reducing HbA 1c levels in urban African Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS -A total of 648 patients with type 2 diabeteswere randomized to receive instruction in either a healthy food choices meal plan (HFC) or an exchange-based meal plan (EXCH) to compare the impact on glycemic control, weight loss, serum lipids, and blood pressure at 6 months of follow-up. Dietary practices were assessed with food frequency questionnaires.RESULTS -At presentation, the HFC and EXCH groups were comparable in age (52 years), sex (65% women), weight (94 kg), BMI (33.5), duration of diabetes (4.8 years), fasting plasma glucose (10.5 mmol/l), and HbA 1c (9.4%). Improvements in glycemic control over 6 months were significant (P Ͻ 0.0001) but similar in both groups: HbA 1c decreased from 9.7 to 7.8% with the HFC and from 9.6 to 7.7% with the EXCH. Improvements in HDL cholesterol and triglycerides were comparable in both groups, whereas other lipids and blood pressure were not altered. The HFC and EXCH groups exhibited similar improvement in dietary practices with respect to intake of fats and sugar sweetened foods. Among obese patients, average weight change, the percentage of patients losing weight, and the distribution of weight lost were comparable with the two approaches.CONCLUSIONS -Medical nutrition therapy is effective in urban African Americans with type 2 diabetes. Either a meal plan emphasizing guidelines for healthy food choices or a low literacy exchange method is equally effective as a meal planning approach. Because the HFC meal plan may be easier to teach and easier for patients to understand, it may be preferable for low-literacy patient populations. Diabetes Care 26:1719 -1724, 2003M inority groups have a high prevalence of type 2 diabetes (1-4). In the National Health and Nutrition Examination Survey III and BRFSS (Behavioral Risk Factor Surveillance System), the age-standardized prevalence of diabetes was 1.6-fold higher in African Americans than in Caucasians (5,6). The disproportionate frequency of diabetes in African Americans is especially impressive in women (4,7), even after correcting for the prevalence of obesity (4,8 -10). The problem of diabetes for African Americans is particularly striking above the age of 45 years, when the prevalence of diabetes in African Americans is almost twice that in Caucasians (11); diabetes is present in 29% of African Americans 65-74 years of age (5). It is especially alarming that the frequency of altered metabolism is rising even in younger African Americans; recent studies found the prevalence of impaired glucose tolerance to be 20% in a group with an average age of 34 years (12) and 8.6% in girls between 5 and 10 years old (13).Medical nutrition therapy is essential in preventing the development of diabetes (14 -16), and medical nutrition therapy is well recognized as a cornerstone of management in patients who have diabetes. Med...

A substantial number of persons anticipated a barrier to diabetes education. Interventions at multiple levels that address the demographic and socioeconomic obstacles to diabetes education are needed to ensure successful self-management training.

Limited access to health care is associated with adverse outcomes, but few studies have examined its effect on glycemic control in minority populations. Our observational cross-sectional study examined whether differences in health care access affected hemoglobin A1c (HbA1c) levels in 605 patients with diabetes (56% women; 89% African American; average age, 50 years; 95% with type 2 diabetes) initially treated at a municipal diabetes clinic. Patients who had difficulty obtaining care had higher A1c levels (9.4% vs. 8.7%; p=0.001), as did patients who used acute care facilities (9.5%; p<0.001) or who had no usual source of care (10.3%; p<0.001) compared with those who sought care at doctors' offices or clinics (8.6%). In adjusted analyses, HbA1c was higher in persons who gave a history of trouble obtaining medical care (0.57%; p=0.04), among persons who primarily used an acute care facility to receive their health care (0.49%; p=0.047), and in patients who reported not having a usual source of care (1.08%; p=0.009). Policy decisions for improving diabetes outcomes should target barriers to health care access and focus on developing programs to help high-risk populations maintain a regular place of health care.

Numerous studies'&dquo; document the fact that diabetes care practices do not meet recommended standards of care. Advanced clinical training has long been advocated for delivering effective diabetes care.' A recent comprehensive review' of over 100 studies documents that short-term ( 1-day) continuing medical education (CME) courses have little effect on professional practice. Recognizing the need for different models for educating health professionals in practice,&dquo; the staff of the Diabetes Unit of the Grady Health System reevaluated its mini-residency program.' Our 5-day mini-residency program, which is distinct from didactic CME courses, incorporates observational and participatory learning methods to facilitate skills development and problem solving in diabetes care and education. The purpose of this article is threefold : first, to describe the effect of the program on participants' knowledge and attitudes about diabetes and its treatment; second, to summarize participants' behavior change goals and the difficulties encountered when measuring how much change OCCUITed; and third, to present lessons learned and recommendations for developing and assessing behavior change goals in professional training programs, based on the difficulties encountered and a review of the literature on goal setting III History and Objectives of the Mini-Residency Program Our program, Modern Methods of Diagnosing and Treating Diabetes Mellitus and Its Complications: A MiniResidency, was established in 1973 in collaboration with the Georgia Department of Human Resources and Emory University School of Medicine. Our mission is to improve the delivery of care to persons with diabetes. Thernini-residency program, which is held in the Diabetes Unit of the Grady Health System in Atlanta, Georgia, provides continuing education credits to physicians, nurses, dietitians, and pharmacists. Class size is limited to 1 I participants to maximize interaction among the participants and between the participants and the program faculty. The objectives of the program are as f~ollows:Understand the management goals. and strategies for each type of diabetes. Understand the classification and pathogenesis of the types of diabetes.Know the acute and chronic complications, and their management and prevention. Identify nutritional goals s and strategies. Identify teaching/learning methods that will enhance patient education. Explain the rationale for utilizing the multidisciplinary team approach. Be cognizant of future treatment and prevention procedures.Program faculty consists of endocrinologists, nurses, dietitians, podiatrists, and pharmacists who specialize in diabetes care. The curriculum incorporates current approaches to diabetes management and education. An outline of the major topics and activities of the mini-residency is available from the authors. Sessions are informal, and questions and discussion are encouraged to create a nurturing and challenging learning environment. Instructors use active learning techniques such as asking questions ...

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