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Don't 'super-size me': portion-control plates.

The Problem

A 54-year-old man with a history of hypertension, coronary artery disease, and obesity (his body mass index is 36 kg/[m.sup.2]) presents to you for follow-up of elevated blood sugars. His fasting glucose level was 164 mg/dL 6 months previously Currently, his fasting blood sugar is 182 mg/dL and his hemoglobin [A.sub.1c] is 7.3%. You diagnose him with diabetes mellitus type 2 and discuss treatment options, focusing on weight-loss strategies. He reminds you of all of the unsuccessful approaches he has tried over the years, including meeting with a dietitian, committing to diet plans, trials of sibutramine and orlistat, increasing his activity level, and decreasing his alcohol consumption, snacking, and eating in restaurants (especially the all-you-can-eat buffets). He tells you that despite all of this, he has been unable to lose any weight. In desperation, you conduct a PubMed search for new randomized, controlled trials for weight loss. To your delight, you find a recent trial on portion-control plates, which is something that he has never tried.

The Question

In patients with diabetes mellitus and obesity, does the use of portion-control plates result in clinically meaningful weight loss, compared with dietary recommendations alone?

The Search

You go to PubMed (www.pubmed.gov) and enter "obesity AND diabetes AND weight loss" and limit the search to randomized, controlled trials. You identify a relevant study. (See box at right.)

Our Critique

This intervention is exciting because of its simplicity and low cost. Because of the design, we cannot distinguish between the effect of the plate and the effect of the accountability encouraged through the use of a logbook since both were a component of the intervention. Previous research has shown the use of logbooks to record daily dietary intake to be a successful strategy for weight control; however, patients who maintain a dietary logbook may be more motivated and, therefore, more likely to lose weight. Subjects in the intervention group who were taking insulin lost more weight than the controls on insulin, while no differences were observed between the groups not taking insulin. However, these are subgroup analyses and should be interpreted with caution.

Clinical Decision

You recommend use of a portion-control plate that the patient could purchase over the Internet ("just Google it"). You encourage the patient to record use in a logbook and to update you regarding his progress in 1 month.

S.D. Pedersen, et al.

Portion control plate for weight loss in obese patients with type 2 diabetes mellitus: A controlled clinical trial. Arch. Intern. Med. 2007; 167:1277-83.

* Design and Setting: Randomized, unblinded study done at a single center in Calgary, Alta.

* Subjects: Potential subjects were eligible for enrollment if they had diabetes mellitus type 2, a BMI of 30 or more, were clients of the enrolling diabetes center, and had undergone at least 6 months of teaching and management by diabetes nurse educators and dietitians. Subjects were excluded if they had cancer, were using a weight-loss medication, had a history of bulimia or anorexia, were under the care of a psychiatrist, had surgery in the 3 months before enrollment or planned during the study period, had weight loss exceeding 4.5 kg in the 2 months preceding enrollment, and ate dinner at a restaurant more than twice weekly or ate more than 30% of meals at restaurants.

* Intervention: The intervention group received a calibrated dinner plate and cereal bowl and a booklet containing instructions on their use, as well as a 10- to 15-minute individual counseling session. The caloric goal is achieved by dividing the plate into sections designed to contain the predetermined amounts of carbohydrates, proteins, cheeses, and sauces, with the rest of the plate for vegetables. Plate sizes are gender specific, with the plate for men approximating an 800-calorie meal and the plate for women approximating a 650-calorie meal. The cereal bowl was not gender specific and was designed to allow a 200-calorie meal with cereal and 1/2 cup of milk. Subjects were instructed to use the calibrated plate for their largest meal and to use the bowl when they ate cereal for breakfast. Subjects were also instructed to document adherence in a daily logbook. The control group did not receive any treatment or counseling outside their usual clinical assessment and dietary teaching.

* Outcomes: The primary end point was defined as the percentage change from baseline weight. Outcomes were assessed at 6 months.

* Results: Of a total of 130 subjects, 65 were randomized to the intervention and 65 to a control group. Subjects were comparable at baseline; they had a mean age of 56 years, 59% were women, and 42% were on insulin. Median compliance was 71% in the intervention group based on the logbook entries. The intervention group lost significantly more weight than did control subjects (mean 1.8% vs. 0.1%, P = .006), with absolute values of 2.1 kg vs. 0.1 kg (P = .01). A significantly greater proportion of intervention subjects lost at least 5% of their baseline weight (16.9% vs. 4.6%, P = .048). A significantly higher proportion of intervention group subjects experienced a decrease in hypoglycemic medication use (26.2% vs. 10.8%, P = .04).

BY JON O. EBBERT, M.D., AND ERIC G. TANGALOS, M.D.

DR. EBBERT and DR. TANGALOS are with the Mayo Clinic in Rochester, Minn. They have no conflict of interest to report. To respond to this column or suggest topics for consideration, write to Dr. Ebbert and Dr. Tangalos at our editorial offices or e-mail them at imnews@elsevier.com.
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Article Details
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Title Annotation:MINDFUL PRACTICE
Author:Ebbert, Jon O.; Tangalos, Eric G.
Publication:Internal Medicine News
Geographic Code:1USA
Date:Mar 15, 2008
Words:929
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