A Controlled Evaluation of Staging Dietary Patterns to Reduce the Risk of Diabetes in African-American Women

Wendy Auslander, PHD, Debra Haire-Joshu, PHD, Cheryl Houston, PHD, RD, Chaie-Won Rhee, MSW, James Herbert Williams, PHD


Diabetes Care. 2002;25(5) 

In This Article


This study addressed the following question: To what extent does a peer-led program that tailors content to participants’ readiness to make dietary changes reduce fat intake and increase low-fat dietary patterns, and maintain these changes over a follow-up phase? Other intermediate outcomes of interest included increasing skill-based knowledge (e.g., label reading) and knowledge and attitudes about dietary fat. The EWLW was evaluated using an experimental design with 3-month intervals between pre- and posttest assessments and posttest and follow-up assessments.

A critical finding in this study was that greater reductions were seen in fat intake of the EWLW group when compared with the control group and that the reductions were maintained at the 3-month follow-up assessment. At the posttest assessment, women in the EWLW condition had reduced their fat intake by 3.8% vs. 0.4% for the control group. At follow-up, fat intake remained significantly lower in the EWLW than in the control group (32.3 vs. 34.5%), which brought the former group closer to the public health goal of ≤30% of calories from fat, as recommended by the Healthy People 2000 guidelines [21]. Within-group comparisons of the control group showed a slight decrease in fat intake from pretest to follow-up assessment. One possible reason for the decrease in fat intake in the control group is the effect of testing. Because subjects completed three 45-min food frequency questionnaires over 6 months, it is possible that by the follow-up assessment, the control group subjects had increased their awareness of fat and overall food intake simply by completing the questionnaires, and that this influenced their eating habits. This is particularly plausible given that the women in the control condition were motivated to change their eating habits, as evidenced by the fact that they responded to our recruitment efforts and may have sought out other strategies to modify their eating patterns outside of our program.

A second finding was the significant increases in low-fat dietary patterns among the EWLW group compared with the control group at posttest and follow-up assessments. It is likely that changes in dietary patterns led to the reduction of total fat intake. This was true across all dietary patterns except for "replacement" (replacing high-fat foods with fruits, vegetables, grains, and bread). Several explanations for why participants did not make significant changes in this dietary pattern are possible: 1) content on "replacement" was delivered in the 11th session (out of 12 sessions), and 38.7% did not receive the content on "replacement" because of attrition; 2) the program did not emphasize increasing intake of fiber (i.e., fruits and vegetables), but rather focused on reducing total fat; and 3) this pattern may involve a greater change in cuisine in that the replacement food looks and tastes different than the high-fat food. The data on increasing participants’ readiness to change dietary patterns is consistent with the above-mentioned findings on dietary patterns. A greater percentage of participants in the treatment group moved from pre-action to action stages across all dietary patterns, and maintained their significant gains at the follow-up assessment.

Intermediate outcomes, such as knowledge of fat in foods and reading and interpreting food labels, were increased and maintained for the participants in the treatment group when compared with the control group. Attitudinal change was not influenced by the intervention. This may be in part have been because of the low-to-fair reliability of the total attitudinal scale (alpha = 0.62). Another explanation for this result may be that attitudes about food and dietary preferences are difficult to change because they are embedded in family tradition and ethnic and cultural practices.

There was no significant weight loss among participants at the follow-up assessment. The reasons for the lack of weight loss are unclear. This finding may be attributable to measurement problems associated with dietary assessment. Specifically, it is possible that the women in both conditions, either through social desirability or difficulty in recalling intake over the previous month, underreported their intake. However, there was consistency in underreporting across pre- and posttest and follow-up assessments and across conditions, which lends some support to the suggestion that the differences between groups may have been real.

It is important to note that the objective of the EWLW was not to lower caloric intake but to lower fat intake and change dietary patterns, a recognized strategy for reducing the risk of diabetes [5,6]. This focus, which proved effective, was culturally appropriate, as African-American women are not generally as concerned about weight loss as their Caucasian counterparts [22–24]. Also, changing dietary patterns may be a first step toward other diabetes risk-reduction strategies, as successful attainment of more immediate goals holds relevance as a motivating factor for more long-term prevention goals (e.g., maintaining weight loss).

Finally, these findings do not negate the importance of weight reduction in diabetes prevention, but rather suggest what strategies might work for certain outcomes in this population. Reduction in fat intake alone does not necessarily result in a reduction of weight. Future programs that emphasize increases in fiber (fruits and vegetables) and physical activity, in addition to decreases in fat intake, may be more effective in decreasing weight and BMI than the EWLW.

In conclusion, the gathered data indicated that a stage-based intervention conducted by trained peer leaders in the community is effective in changing dietary patterns and reducing fat intake among low-income African-American women. The EWLW program uses strategies that could be expanded to include a greater emphasis on physical activity and increased fiber intake. A peer-led approach with the collaboration of a community organization that is located in the target neighborhoods holds promise for reducing the risk of diabetes among lower-income African-American women.

Abbreviations: EWLW, Eat Well, Live Well Nutrition Program • FFQ, food frequency questionnaire


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