Designing culturally sensitive dietary interventions for African Americans: review and recommendations

Effect of tamarind (Tamarindus indica L.) on the cardiometabolic health of patients living with HIV and elevated triglyceride levels: a dose-response double-blind, randomized exploratory trial

Background: The increase in cardiometabolic diseases in sub-Saharan Africa calls for sustainable remedies. In particular, people living with HIV (PLWH) have an increased risk of metabolic syndrome. Tamarind (Tamarindus indica L.), a fruit native to Africa, is rich in polyphenols and may optimize cardiometabolic health. In an exploratory trial, we assessed the potential of tamarind fruit juice to improve lipid metabolism in PLWH. Methods: We conducted a 4-week, parallel double-blinded trial of 50 patients equally allocated to two doses of tamarind juice. The primary outcome was triglycerides (TG), and eligible participants were aged 30 to 60 years with TG ≥ 150 mg dL-1. Patients consumed 600 mL of tamarind juice daily, containing either 10% or 30% tamarind fruit pulp corresponding to 1556 mg or 1631 mg of the analyzed polyphenols, respectively. Fasted blood samples were analyzed for lipid profile. Blood pressure (BP) and vascular function were measured. Patients were required to maintain their habitual diet and lifestyle. Dietary intake, background polyphenol intake, and physical activity were measured. All analyses were performed according to intention-to-treat. Study registration was done at clinicalTrial.gov, NCT06058845. Results: The 30% fruit pulp juice significantly reduced TG by -39.8 mg dL-1 (95% CI: -67.7, -11.9), P = 0.006, corresponding to a 17.3% reduction of the baseline TG levels, while no statistically significant effect was noted for the 10% fruit pulp juice. None of the doses had a significant effect on total cholesterol, LDL, and HDL. The 10% fruit pulp juice significantly reduced systolic blood pressure (SBP), mean arterial pressure, and SBP (aorta) by -7.4 mmHg (95% CI: -14.5, -0.26), P = 0.043, -5.1 mmHg, 95% CI [-9.3, -0.99], P = 0.016, and -11.7 mmHg, 95% CI [-20.9, -2.6], P = 0.013, respectively. Physical activity, dietary intake, and background polyphenol intake between the study groups did not significantly change across the study period. Conclusion: Although our trial was not adequately powered to draw definitive conclusions, we showed that T. indica L. fruit juice potentially ameliorates TG metabolism and blood pressure homeostasis. This study provides a basis for future full-scale trials.

A qualitative evaluation of the effectiveness of behaviour change techniques used in the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) intervention

BACKGROUND

Type 2 diabetes (T2D) is up to three times more common in people of Black African and Black Caribbean heritage living in the UK, compared to their White British counterparts. Structured education is the cornerstone of care but is less successful for people from minority ethnic groups. Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) was developed to support diabetes self-management in people of Black African and Caribbean heritage living with T2D in the UK. The intervention was designed using COM-B/behaviour change wheel methodology to specify the theory of change. In a process evaluation study, we explored how the selected behaviour change techniques (BCTs) supported behaviour change in the intervention.

METHODS

Focus groups and interviews were conducted with participants who were randomised to receive the HEAL-D intervention in a feasibility trial. A topic guide directed discussions to explore experiences of HEAL-D, key learnings and impact, and behaviour change; the interviews gave the opportunity to probe further the focus group themes and areas requiring clarification. Sessions were audio-recorded and transcribed. Framework analysis was used to explore how the selected BCTs supported behaviour change in those attending HEAL-D.

RESULTS

Thirty-six participants took part in one or both activities (44% Black African, 50% Black Caribbean, 6% Mixed race; 61% female, 83% first-generation; mean age 59.5 years, SD 10.02). Participants reported increased physical activity, reduced carbohydrate portion size and engagement in weight monitoring behaviour. BCTs to increase social opportunity (social comparison, social support) and overcome motivational barriers (credible sources and modelling) were effective in addressing cultural barriers relating to diet, stigma and health beliefs. BCTs to develop capability (demonstration, instruction, information on health consequences) were effective because of the cultural salience of the developed components. Less impactful BCTs were problem solving, graded tasks, goal setting, and feedback on outcomes.

CONCLUSIONS

BCTs in the HEAL-D intervention were effective in supporting behaviour change, particularly those promoting social opportunity, as normative cultural habits and beliefs can conflict with diabetes self-management guidance. In addition, lifestyle interventions should include opportunity for experiential learning alongside culturally salient information provision.

TRIAL REGISTRATION

number: NCT03531177, May 18th 2018.

Feasibility of the MIND+SOUL Culturally Tailored Brain Healthy Diet: A Pilot Study

Alzheimer's disease (AD) disproportionately impacts Black Americans, who are three times more likely to develop AD. While heart-healthy diets have shown potential in reducing AD risk, research on adapted dietary interventions for Black American communities remains limited. This pilot study assessed the feasibility and acceptability of an adapted brain healthy diet intervention (MIND + SOUL) and explored changes in cardiometabolic risk and cognition. Twenty-nine participants completed the 12-week intervention, which included culturally tailored health education, cooking classes, health coaching, and groceries. Feasibility was assessed by attendance and retention rates, while acceptability was measured by two questionnaires. Participants had a mean age of 70.3, with 10.3% male. The intervention demonstrated high feasibility (89.3% retention) and acceptability (mean = 71.9, SD = 8.59), with meaningful improvements in body mass index (estimate = -0.54, P = 0.009), dietary intake (estimate = 28.39, P = 0.042), and executive function (estimate = 3.32, P < 0.001). However, no significant changes in blood-based biomarkers were observed. The MIND + SOUL intervention demonstrated high feasibility and acceptability, improvements in body composition, cognitive function, and dietary behaviors, despite no significant changes in blood-based biomarkers. Findings suggest potential benefits for reducing AD risk factors and promoting healthy aging. Clinical Trials Registry: ClinicalTrials.Gov; NCT05414682.

African Americans' perceptions of nutrition interventions: a scoping review

Nutrition education and policy, systems and environmental (PSE) change interventions may be able to address food insecurity and obesity, conditions which are disproportionately experienced by African Americans. Work that seeks to address these disparities and advance social justice should uplift and learn from participant voices, particularly from marginalised groups. This scoping review aimed to summarise the available literature describing African Americans' perceptions of and experiences participating in nutrition interventions. We conducted an electronic literature search with the assistance of a research librarian which encompassed six databases (MEDLINE, PyscINFO, Agricola, ERIC, SocINDEX and ProQuest Dissertations & Theses) and identified thirty-five sources meeting our inclusion criteria. The majority of studies assessing African Americans' satisfaction with interventions examined educational interventions alone, and about half of the included studies assessed satisfaction through quantitative methods alone. The only studies which found participants to be dissatisfied with interventions used qualitative methods and examined interventions providing education alone. Future work should evaluate African Americans' experience with nutrition-focused PSE changes, interventions which may be better able to address racial disparities in obesity and food insecurity. Nutrition educators working with African Americans should also consider evaluating future interventions using qualitative inquiry, to obtain an in-depth understanding of participant experiences with interventions.

Development of a Culturally Adapted Dietary Intervention to Reduce Alzheimer's Disease Risk among Older Black Adults

The objective of this study is to identify and understand knowledge and attitudes that influence dietary practices among older Black adults using a community-engaged approach. This is a non-interventional mixed methods study designed to inform the development of an adapted brain-healthy soul food diet intervention. A purposive sampling approach was used to conduct seven semi-structured focus group discussions and an online quantitative survey. In total, 39 participants who self-identified as Black, aged 55 years and older, English speaking, and who were cognitively normal with an AD8 < 2; (25.6% men; 74.4% women) participated in the online survey and one of the seven 60 min virtual focus group discussions (5-7 per focus group). Quantitative frequency data from the online surveys were analyzed using descriptive statistics. Qualitative focus group data were analyzed using a 6-step thematic analysis process. Five themes emerged: dementia awareness; practices shaping food choices and consumption; barriers to eating healthy; instrumental support; and elements of a culturally adapted brain-healthy dietary intervention. Older Black adults perceived an adapted MIND dietary model as the most acceptable with the incorporation of salient cultural characteristics and strategies within both the design and delivery phases.

Nutrition interventions addressing structural racism: a scoping review

African Americans experience high rates of obesity and food insecurity in part due to structural racism, or overlapping discriminatory systems and practices in housing, education, employment, health care and other settings. Nutrition education and nutrition-focused policy, systems and environmental changes may be able to address structural racism in the food environment. This scoping review aimed to summarise the available literature regarding nutrition interventions for African Americans that address structural racism in the food environment and compare them with the 'Getting to Equity in Obesity Prevention' framework of suggested interventions. An electronic literature search was conducted with the assistance of a research librarian encompassing six databases: MEDLINE, PyscINFO, Agricola, ERIC, SocINDEX and ProQuest Dissertations & Theses. A total of thirty sources were identified detailing interventions addressing structural barriers to healthy eating. The majority of nutrition interventions addressing structural racism consisted of policy, systems and/or environmental changes in combination with nutrition education, strategies focused on proximal causes of racial health disparities. Only two articles each targeted the 'reduce deterrents' and 'improve social and economic resources' aspects of the framework, interventions which may be better suited to addressing structural racism in the food environment. Because African Americans experience high rates of obesity and food insecurity and encounter structural barriers to healthy eating in the food environment, researchers and public health professionals should address this gap in the literature.

African American Perceptions of Service Provided by Supplemental Nutrition Assistance Program-Education: A Qualitative Exploration

OBJECTIVE

To assess African Americans' satisfaction with Supplemental Nutrition Assistance Program-Education (SNAP-Ed) in Louisiana.

METHODS

African American facilitators conducted 5 focus group discussions with 25 African American SNAP-Ed participants according to issues identified by African American SNAP-Ed implementers in Louisiana. Focus group discussion transcripts were coded independently using inductive and in vivo coding by 2 members of the research team.

RESULTS

Participants viewed lessons as race-neutral and thought they should include more information about African American history and culture. Participants also noted a lack of engagement with the African American community and stressed the need for the program to employ African American staff. However, participants thought the information was important for African Americans in the context of medical issues faced by their community.

CONCLUSIONS AND IMPLICATIONS

Findings indicate that SNAP-Ed in Louisiana be modified to address African American food history and culture, additional African American staff and better engagement with the African American community.

Developing a Diet and Physical Activity Intervention for Hispanic/Latina Breast Cancer Survivors

Objectives

There is limited guidance on how to effectively educate cancer survivors to adopt and maintain specific diet and physical activity recommendations, especially among underserved and under-resourced populations. Here, the objective is to present the development of a behavioral and theoretically-based multi-modal diet and physical activity intervention program for Hispanic/Latina breast cancer survivors, Mi Vida Saludable (My Healthy Life).

Methods

The development process was based on the 6 steps of the Nutrition Education DESIGN Procedure: (1). Decide behaviors; (2). Explore determinants; (3). Select theory-based model; (4). Indicate objectives; (5). Generate plans; and (6). Nail down evaluation. The theoretical framework for the intervention is Social Cognitive Theory.

Results

The resulting behavioral intervention consists of 2 components. The first component is in-person group education consisting of 4 lessons over 1 month. Each 4-hour group lesson includes a hands-on cooking component, a physical activity component, and facilitator-led nutrition education and discussion, with 2 field trips to a local grocery store and farmers’ market. The second component is an e-Health program that includes weekly text messages, biweekly emailed newsletters, and ongoing website access.

Conclusion

The systematic DESIGN Procedure provided practical guidance for developing a behaviorally-focused, theory-based, and culturally sensitive program that addresses both dietary and physical activity behaviors for delivery both in-person education and through eHealth. The Procedure may be useful for developing other behaviorally focused and theory-based interventions.

Culturally Sensitive Behavior Intervention Materials: a Tutorial for Practicing Behavior Analysts

Behavior analytic interventions for people with disabilities often rely on implementation by novice caregivers and staff. However, behavior intervention documents are ineffective at evoking the level of performance needed for behavior change, and intensive training is often needed (Dogan et al., 2017; Ward-Horner & Sturmey, 2012). The cost and time requirements of intensive training may not be viable options for some clients, leading to nonadherence or attrition (Raulston et al., 2019). In addition, others may feel that prescribed interventions are not appropriate or will not work (Moore & Symons, 2011). These barriers may reflect a cultural mismatch (Rathod et al., 2018). One potential way to increase efficacy of intervention materials is to improve the cultural sensitivity and comprehensibility of these documents. Although the body of research on cultural adaptation of behavioral interventions is becoming more robust, adaptation of behavior intervention documents as a means to create effective behavior change when cultural and linguistic diversity are factors, is an area of behavior analytic practice that is not well researched and there remains a need for cultural humility. Because diversity can include expansive differences between individuals, such as race/ethnicity, socioeconomic status, religion, gender and sexuality; understanding and adapting to each of these areas may be best done through separate reviews. It is the intent of this article to focus on ethnic diversity in the United States as a starting point and frame of reference for cultural adaptation. This tutorial includes tips learned from health communication research to give step-by-step guidance on creating comprehensible, culturally adapted intervention plans through the example of training for parents of autistic children.

Impacts of A Taste of African Heritage: A Culinary Heritage Cooking Course

OBJECTIVE

To examine changes in cooking and dietary behaviors and health outcomes following participation in A Taste of African Heritage, a culinary heritage cooking course.

DESIGN

One group, pre-post program design, surveys, and physical assessments.

SETTING

Community centers, churches, health care settings, homes, and housing complexes.

PARTICIPANTS

Participants (n = 586, 84% women) were recruited by partner organizations from 2013-2018 across 21 states and the District of Columbia.

INTERVENTION(S)

A 6-week cooking curriculum that teaches history, nutrition, and cooking techniques to reconnect participants with the vibrant, healthy traditions of the African Diaspora.

MAIN OUTCOME MEASURE(S)

Weekly frequency of cooking, food group intake, and exercise assessed by surveys, measured weight, waist circumference, and blood pressure.

ANALYSIS

Linear and logistic mixed-effects models with random intercepts for participant and teacher, sex and site type as covariates comparing pre-post physical measurements and binary behavioral outcomes, P < 0.0033 for statistical significance after Bonferroni correction.

RESULTS

Intake frequencies of fruit, vegetable, and greens and exercise frequency were improved from preprogram to postprogram (all P < 0.0021). Weight, waist circumference, and systolic blood pressure were also improved from preprogram to postprogram (all P <0.0001).

CONCLUSIONS AND IMPLICATIONS

Participation in A Taste of African Heritage was associated with positive behavior changes and health outcomes. Integrating cultural heritage and behaviors are positive components to connect participants to healthy old ways or traditions.

Superwoman's kryptonite: The superwoman schema and perceived barriers to weight management among U.S. Black women

The role that the superwoman schema (SWS) plays in U.S. Black women's perceptions of barriers (biological, psychological, and sociological) to healthy weight management is unknown. This exploratory study examined whether 122 women classified as normal weight, overweight or obese differed in their perceptions of types of barriers and if the SWS predicted perceived barriers to weight management. Women classified as obese reported more barriers than those classified as normal weight. The SWS uniquely positively predicted perceived psychological and sociological barriers. Our findings suggest that the SWS may play a vital role in the self-management of weight in U.S. Black women.

Association of body image dissatisfaction, behavioral responses for healthy eating, and cardiovascular health in African-American women with overweight or obesity: A preliminary study

BACKGROUND

African-American (AA) women have the lowest prevalence of ideal categorizations of diet and body mass index (BMI), as defined by the American Heart Association (AHA) Life's Simple 7 (LS7) cardiovascular health (CVH) components compared to other racial/ethnic groups, regardless of sex/gender. There is limited research exploring the interplay of unique psychosocial influences on CVH such as body image dissatisfaction (BID) and behavioral responses for healthy eating among AA women with overweight or obesity.

OBJECTIVE

This study aimed to assess the association of BID with behavioral responses for healthy eating and LS7 components.

METHODS

A cross-sectional analysis of baseline data was conducted among 32 AA women with overweight or obesity from a larger, community-based participatory research study. Self-reported measures were used to assess BID and behavioral responses to healthy eating (diet self-regulation to reduce fat or caloric intake and motivation for healthy eating [intrinsic motivation and integrated regulation]) using previously validated instruments. The LS7 components (e.g., BMI, diet, etc.) and composite score were evaluated using the AHA LS7 metrics rubric.

RESULTS

Women with no or lower BID had greater diet self-regulation to reduce fat or caloric intake (mean, 3.5 vs 3.0; P=.05), intrinsic motivation for healthy eating (mean, 5.3 vs 4.2; P=.01), and integrated regulation for healthy eating (mean, 5.3 vs 3.7; P=.002) than those with higher BID. These significant differences remained after adjustment for BMI. Women with higher BID had a higher proportion of BMI within the obesity range compared with those with no or lower BID (94.4% vs 57.1%, P=.03). BID was not significantly associated with other LS7 components or composite score.

CONCLUSION

BID and other psychosocial influences for healthy eating are potential targets for culturally tailored lifestyle interventions among AA women.

Pilot Study of a Farm-to-Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Intervention Promoting Vegetable Consumption

BACKGROUND

Vegetable intake is below recommended levels among adults served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

OBJECTIVE

The aim of this study was to determine whether a novel, theory-driven, farm-to-WIC intervention to promote vegetable intake showed promise of being successful and is therefore appropriate for efficacy testing.

DESIGN

From June 2019 to January 2020, the intervention was piloted in three WIC agency sites (one randomized to the intervention study group and two to the control group) selected based on similarity in size and the demographics of participants served.

PARTICIPANTS/SETTING

Recruited between June 3, 2019 and August 1, 2019, participants were 297 primarily Hispanic adults served by a large WIC agency located in a densely populated urban area in New Jersey (160 were enrolled at the intervention site and 137 at control sites).

INTERVENTION

The intervention combined behaviorally focused instruction and handouts with the introduction of a WIC-based farmers' market, field trips to an area farmers' market, telephone coaching and support before and after trips, and recipe demonstrations and tastings.

MAIN OUTCOME MEASURES

The primary outcomes were vegetable intake (measured objectively using dermal carotenoids as a biomarker of intake and via self-report) and the redemption of vouchers provided through the WIC Farmers' Market Nutrition Program (FMNP) for fruit and vegetable purchases at farmers' markets (objectively assessed using data provided by WIC).

STATISTICAL ANALYSES PERFORMED

Between-group differences in vegetable intake were examined at mid- and post-intervention (3 and 6 months post-baseline, respectively) with linear mixed-effects models adjusted for baseline vegetable intake and covariates. Logistic regression analysis was used to relate FMNP voucher redemption to study group and covariates.

RESULTS

At mid-intervention, objectively measured vegetable intake was higher among participants in the control group as compared with the intervention group; self-reported intake did not differ by group. Post-intervention, objectively measured and self-reported vegetable intake were higher among participants in the intervention group as compared with the control group. Receipt of the intervention was associated with a greater likelihood of FMNP voucher redemption. Voucher redemption rates were 87% in the intervention group and 28% in the control group (odds ratio = 17.39, 95% confidence interval [8.64, 35.02]).

CONCLUSIONS

Meaningful associations found between the intervention, vegetable intake, and FMNP voucher redemption suggest that the program is appropriate for efficacy testing.

Providing culturally sensitive diabetes self-management education and support for black African and Caribbean communities: a qualitative exploration of the challenges experienced by healthcare practitioners in inner London

INTRODUCTION

Poor access to, and engagement with, diabetes healthcare is a significant issue for black British communities who are disproportionately burdened by type 2 diabetes (T2D). Tackling these inequalities is a healthcare priority. The purpose of this research was to explore the experiences of healthcare practitioners providing diabetes self-management education and support (DSMES) to African and Caribbean adults living with T2D to inform the development of a culturally tailored DSMES program.

RESEARCH DESIGN AND METHODS

Semi-structured interviews were carried out with a range of healthcare practitioners including diabetes specialist nurses, dietitians and general practitioners based in primary care in inner London. Thematic content analysis was used to identify barriers and facilitators relating to the provision of effective DSMES.

RESULTS

Ten interviews were conducted. There was a strong consensus among healthcare practitioners for the importance of DSMES in T2D healthcare. However, practitioners discussed this area of practice as overwhelmingly challenging and recognized a wide range of barriers that they face. Four themes were identified: (1) The tension between structural and responsive care needs, particularly with growing numbers of patients alongside incentivized targets driving a care agenda that does not meet the needs of diverse communities; (2) challenges posed by cultural beliefs and practices, particularly a distrust of conventional medicine, rejection of body mass index standards and a belief in 'God's will'; (3) building relationships through cultural understanding: insiders and outsiders, particularly the benefits of racial concordance and cultural knowledge/resources and (4) getting the messages across, particularly the need to address gaps in structured education.

CONCLUSION

Provision of culturally sensitive DSMES is a challenging area of practice for practitioners, who recognize the need for more training and resources to support them in developing cultural competence. Nonetheless, practitioners recognize the importance of DSMES and are striving to provide culturally sensitive care to their patients.

Psychosociocultural Contributors to Maladaptive Eating Behaviors in African American Youth: Recommendations and Future Directions

Childhood overweight and obesity disproportionately affects African Americans, and these children benefit less from standard pediatric weight management treatment programs compared to other racial/ethnic groups. Maladaptive eating behavior has been identified as a behavioral contributor to obesity and is also associated with the development of nonrestrictive eating disorders over time. Unique psychosociocultural factors have been identified that may promote higher risk for maladaptive eating behaviors in African American children beyond the effects of economic disparity. To best treat this group, it is important for practitioners to have a thorough understanding of these factors. We review several of these considerations and describe ways they may interact to contribute to the subsequent development of maladaptive eating behaviors and increased weight. Recommendations are made regarding how attention to these factors could be incorporated into current pediatric weight management treatments to better serve this population via a patient-centered care approach. Future directions will also be discussed.

Church-based interventions to address obesity among African Americans and Latinos in the United States: a systematic review

CONTEXT

Multilevel church-based interventions may help address racial/ethnic disparities in obesity in the United States since churches are often trusted institutions in vulnerable communities. These types of interventions affect at least two levels of socio-ecological influence which could mean an intervention that targets individual congregants as well as the congregation as a whole. However, the extent to which such interventions are developed using a collaborative partnership approach and are effective with diverse racial/ethnic populations is unclear, and these crucial features of well-designed community-based interventions.

OBJECTIVE

The present systematic literature review of church-based interventions was conducted to assess their efficacy for addressing obesity across different racial/ethnic groups (eg, African Americans, Latinos).

DATA SOURCES AND EXTRACTION

In total, 43 relevant articles were identified using systematic review methods developed by the Center for Disease Control and Prevention (CDC)'s Task Force on Community Preventive Services. The extent to which each intervention was developed using community-based participatory research principles, was tailored to the particular community in question, and involved the church in the study development and implementation were also assessed.

DATA ANALYSIS

Although 81% of the studies reported significant results for between- or within-group differences according to the study design, effect sizes were reported or could only be calculated in 56% of cases, and most were small. There was also a lack of diversity among samples (eg, few studies involved Latinos, men, young adults, or children), which limits knowledge about the ability of church-based interventions to reduce the burden of obesity more broadly among vulnerable communities of color. Further, few interventions were multilevel in nature, or incorporated strategies at the church or community level.

CONCLUSIONS

Church-based interventions to address obesity will have greater impact if they consider the diversity among populations burdened by this condition and develop programs that are tailored to these different populations (eg, men of color, Latinos). Programs could also benefit from employing multilevel approaches to move the field away from behavioral modifications at the individual level and into a more systems-based framework. However, effect sizes will likely remain small, especially since individuals only spend a limited amount of time in this particular setting.

Designing the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) self-management and support programme for UK African and Caribbean communities: a culturally tailored, complex intervention under-pinned by behaviour change theory

Background

UK African and Caribbean (AfC) communities are disproportionately burdened by type 2 diabetes (T2D). Promoting healthy eating and physical activity through structured education is the cornerstone of T2D care, however cultural barriers may limit engagement in these communities. In addition, changes in lifestyle behaviour are shaped by normative influences within social groups and contextual factors need to be understood to facilitate healthful behaviour change. The Behaviour Change Wheel (BCW) and associated COM-B framework offer intervention designers a systematic approach to developing interventions. The aim of this study was to apply the BCW in the design of a culturally sensitive self-management support programme for T2D in UK AfC communities.

Methods

An intervention development study was conducted. Focus groups were held with 41 AfC patients with T2D to understand healthful weight-management, diet and physical activity behaviours. The COM-B framework and BCW were used to evaluate the qualitative data, identify appropriate behaviour change techniques and specify the intervention components.

Results

Participants were motivated to avoid diabetes-related consequences although did not always understand the negative impact of their current health behaviours on long-term diabetes outcomes. Barriers to healthful behaviour included gaps in knowledge related to diet, physical activity and weight management guidance. In addition, motivation and social opportunity barriers included an acceptance of larger body sizes, rejection of body mass index for weight guidance and cultural identity being strongly linked to consumption of traditional starches. There was a lack of social opportunity to perform moderate to vigorous physical activity, although walking and dance were culturally acceptable. The resulting Healthy Eating & Active Lifestyles for Diabetes (HEAL-D) intervention uses social support, social comparison, credible sources and demonstration as key behaviour change techniques.

Conclusion

Use of COM-B and the BCW highlighted the need for an intervention to address motivational and social opportunity barriers to engaging in healthful behaviours, as well as addressing key gaps in knowledge. This framework facilitated the linkage of theoretical behaviour constructs with evidence-based behaviour change techniques, which will enable us to evaluate operationalisation of our chosen BCTs and their impact on behaviour change in a future feasibility study.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7411-z) contains supplementary material, which is available to authorized users.

Healthy Eating and Active Lifestyles for Diabetes (HEAL-D): study protocol for the design and feasibility trial, with process evaluation, of a culturally tailored diabetes self-management programme for African-Caribbean communities

INTRODUCTION

Black British communities are disproportionately burdened by type 2 diabetes (T2D) and its complications. Tackling these inequalities is a priority for healthcare providers and patients. Culturally tailored diabetes education provides long-term benefits superior to standard care, but to date, such programmes have only been developed in the USA. The current programme of research aims to develop the Healthy Eating and Active Lifestyles for Diabetes (HEAL-D) culturally tailored T2D self-management programme for black British communities and to evaluate its delivery, acceptability and the feasibility of conducting a future effectiveness trial of HEAL-D.

METHODS AND ANALYSIS

Informed by Medical Research Council Complex Interventions guidance, this research will rigorously develop and evaluate the implementation of the HEAL-D intervention to understand the feasibility of conducting a full-scale effectiveness trial. In phase 1, the intervention will be developed. The intervention curriculum will be based on existing evidence-based T2D guidelines for diet and lifestyle management; codesign methods will be used to foster community engagement, identify the intervention's underpinning theory, identify the optimal structure, format and delivery methods, ascertain adaptations that are needed to ensure cultural sensitivity and understand issues of implementation. In phase 2, the intervention will be delivered and compared with usual care in a feasibility trial. Process evaluation methods will evaluate the delivery and acceptability of HEAL-D. The effect size of potential primary outcomes, such as HbA1c and body weight, will be estimated. The feasibility of conducting a future effectiveness trial will also be evaluated, particularly feasibility of randomisation, recruitment, retention and contamination.

ETHICS AND DISSEMINATION

This study is funded by a National Institute of Health Research Fellowship (CDF-2015-08-006) and approved by National Health Service Research Ethics Committee (17-LO-1954). Dissemination will be through national and international conferences, peer-reviewed publications and local and national clinical diabetes networks.

TRIAL REGISTRATION NUMBER

NCT03531177; Pre-results.

Experiences and Perspectives of Dietary Management Among Patients on Hemodialysis: An Interview Study

OBJECTIVES

Diet and fluid management can reduce mortality, serious comorbidities, and debilitating symptoms in patients on hemodialysis, but restrictions may also be a major burden, and nonadherence remains high. We aimed to describe the perspectives and experiences of patients on hemodialysis regarding their dietary management to understand both facilitators and barriers to adherence and to identify strategies to improve care.

DESIGN AND METHODS

Semi-structured interviews were conducted with 35 people on maintenance hemodialysis from six dialysis units in New South Wales, Australia. Transcripts were thematically analyzed using principles of grounded theory.

RESULTS

We identified 5 major themes. Two themes reflect barriers to dietary change: exacerbating disruption (adding to treatment burden, contradicting healthy eating, confused by fragmented advice, conflicting cultural norms, changing appetite and palate, isolation from family and friends) and losing control (crises derailing discipline, frustrated by failure, combating bodily need for hydration). Three themes represent enablers for dietary change: attaining health benefits (avoiding medical catastrophes, enhancing benefits of dialysis, alleviating and managing symptoms, improving health), achieving treatment goals (building familiarity and acceptance, flexibility and moderation, taking personal responsibility), and succeeding withsupport (leaning on family for strength, trusting expert guidance, empowered with flexible and practical advice, relying on reminders and cues, motivation through shared experience).

CONCLUSIONS

Patients on hemodialysis believe dietary control helps to reduce symptom burden and enhance general health and well-being, but competing medical and social issues coupled with contradictory and/or irrelevant dietary advice prevents them from implementing diet and fluid restrictions. Interventions involving collaborative multidisciplinary care including clinicians with dietetic expertise, and consistent information that addresses cultural and personal circumstances, may support adherence to dietary recommendations and improve outcomes.

Comorbid Diabetes and Depression in African Americans: Implications for the Health Care Provider

Health care providers (HCPs) face many obstacles as they undertake efforts to meet the challenges of caring for African American patients with comorbid diabetes and depression. This review article discusses the incidence of comorbid diabetes and depression in African Americans, cultural factors affecting diabetes self-management, and clinical practice implications for the HCP. The role of patient-centered care, engagement, and best-practice strategies are discussed to provide the HCP with guidelines regarding the minimal standards that support improved health care outcomes for African Americans with comorbid diabetes and depression.

Non-communicable disease risk factors and treatment preference of obese patients in Cape Town

BACKGROUND

Insights into the characteristics of treatment seekers for lifestyle changes and treatment preferences are necessary for intervention planning.

AIM

To compile a profile of treatment-seeking obese patients with non-communicable diseases (NCDs) or NCD risk factors and to compare patients who choose group-based (facility-based therapeutic group [FBTG]) versus usual care (individual consultations) treatment.

SETTING

A primary healthcare facility in Cape Town, South Africa.

METHODS

One hundred and ninety-three patients were recruited in this cross-sectional study. Ninety six chose FBTG while 97 chose usual care. A questionnaire, the hospital database and patients' folders were used to collect data. Weight, height and waist circumference were measured. STATA 11.0 was used for descriptive statistics and to compare the two groups.

RESULTS

The subjects' mean age was 50.4 years, 78% were women and of low education levels and income, and 41.5% had type 2 diabetes, 83.4% hypertension and 69.5% high cholesterol. Mean (s.d.) HbA1c was 9.1 (2.0)%, systolic BP 145.6 (21.0) mmHg, diastolic BP 84.5 (12.0) mmHg, cholesterol 5.4 (1.2) mmol/L), body mass indicator (BMI) 39.3 (7.3) kg/m2 and waist circumference 117 (12.6) cm). These figures were undesirable although pharmacological treatment for diabetes and hypertension was in place. Only 14% were physically active, while TV viewing was > 2h/day. Mean daily intake of fruit and vegetables (2.2 portions/day) was low while added sugar (5 teaspoons) and sugar-sweetened beverages (1.3 glasses) were high. Usual care patients had a higher smoking prevalence, HbA1c, number of NCD risk factors and refined carbohydrate intake, and a lower fruit and vegetable intake.

CONCLUSION

Treatment seekers were typically middle-aged, low income women with various modifiable and intermediate risk factors for NCDs. Patients choosing usual care could have more NCD risks.

From Bench to Bedside: Understanding Stress-Obesity Research Within the Context of Translation to Improve Pediatric Behavioral Weight Management

A growing body of literature suggests that stress, including chronic stress and acute physiologic stress reactivity, is one contributor to the development and maintenance of obesity in youth. Little has been done to apply the literature on stress and obesity risk to inform the development of pediatric behavioral weight control (BWC) interventions. The aims of this review are to (1) discuss research linking stress and pediatric obesity, (2) provide examples of the implications of the stress-obesity research for pediatric BWC development, and (3) propose that a mindfulness-based approach may be useful in targeting stress reduction within pediatric BWC.

Comparing dietary macronutrient composition and food sources between native and diasporic Ghanaian adults

BACKGROUND

Dietary acculturation may contribute to the increased burden of non-communicable diseases (NCDs) in diasporic populations of African ancestry.

OBJECTIVE

To assess nutritional composition and the contribution that traditional foods make to the diets of native and UK-dwelling Ghanaian adults.

DESIGN

An observational study of Ghanaian adults living in Accra (n=26) and London (n=57) was undertaken. Three-day food records were translated to nutrient data using culturally sensitive methods and comparisons were made for energy, macronutrients, and dietary fibre between cohorts. The contribution of traditional foods to dietary intake was measured and the foods contributing to each nutrient were identified.

RESULTS

Compared to native Ghanaians, UK-Ghanaians derived a significantly higher proportion of energy from protein (16.9±3.9 vs. 14.1±2.8%, p=0.001), fat (29.9±7.9 vs. 24.4±8.5%, p=0.005), and saturated fat (8.5±3.4 vs. 5.8±3.7%, p<0.001) and a significantly lower energy from carbohydrate (52.2±7.7 vs. 61.5±9.3%, p<0.001). Dietary fibre intake was significantly higher in the UK-Ghanaian diet compared to the native Ghanaian diet (8.3±3.1 vs. 6.7±2.2 g/1,000 kcal, p=0.007). There was significantly less energy, macronutrients, and fibre derived from traditional foods post-migration. Non-traditional foods including breakfast cereals, wholemeal bread, and processed meats made a greater contribution to nutrient intake post-migration.

CONCLUSIONS

Our findings show the migrant Ghanaian diet is characterised by significantly higher intakes of fat, saturated fat, and protein and significantly lower intakes of carbohydrate; a macronutrient profile which may promote increased risk of NCDs amongst UK-Ghanaians. These differences in the nutrient profile are likely to be modulated by the consumption of 'Western' foods observed in migrant communities.

Trying to make things right: adherence work in high-poverty, African American neighborhoods

Adherence to treatment recommendations for chronic diseases is notoriously low across all patient populations. But African American patients, who are more likely to live in low-income neighborhoods and to have multiple chronic conditions, are even less likely to follow medical recommendations. Yet we know little about their contextually embedded, adherence-related experiences. We interviewed individuals (n = 37) with at least two of the following conditions: hypertension, diabetes, and chronic kidney disease. Using an "invisible work" theoretical framework, we outline the adherence work that arose in patients' common life circumstances. We found five types: constantly searching for better care, stretching medications, eating what I know, keeping myself alive, and trying to make it right. Adherence work was effortful, challenging, and addressed external contingencies present in high-poverty African American neighborhoods. This work was invisible within the health care system because participants lacked ongoing, trusting relationships with providers and rarely discussed challenges with them.

Systematic review of behavioural interventions with culturally adapted strategies to improve diet and weight outcomes in African American women

Behavioural interventions incorporating features that are culturally salient to African American women have emerged as one approach to address the high rates of obesity in this group. Yet, the systematic evaluation of this research is lacking. This review identified culturally adapted strategies reported in behavioural interventions using a prescribed framework and examined the effectiveness of these interventions for diet and weight outcomes among African American women. Publications from 1 January 1990 through 31 December 2012 were retrieved from four databases, yielding 28 interventions. Seventeen of 28 studies reported significant improvements in diet and/or weight change outcomes in treatment over comparison groups. The most commonly identified strategies reported were 'sociocultural' (reflecting a group's values and beliefs) and 'constituent involving' (drawing from a group's experiences). Studies with significant findings commonly reported constituent-involving strategies during the formative phases of the intervention. Involving constituents early on may uncover key attributes of a target group and contribute to a greater understanding of the heterogeneity that exists even within racial/ethnic groups. Available evidence does not, however, explain how culturally adapted strategies specifically influence outcomes. Greater attention to defining and measuring cultural variables and linking them to outcomes or related mediators are important next steps.

Determinants of fruit and vegetable intake in low-income children and adolescents

Although low-income youth are likely to have low or less frequent fruit and vegetable intake, current understanding of the influences on intake in youth is limited. A systematic review of quantitative research on determinants of fruit and vegetable intake among low-income youth (i.e., persons aged <20 years) was conducted. The aims were to identify which determinants have been studied and which are consistently associated with intake. Fifty-eight papers published between 2003 and August 2013 were included. Across studies, 85 unique determinants were identified. Those best supported by evidence were race/ethnicity (with intake consistently higher among Hispanic as compared with African American and white youth), fruit and vegetable preferences, and maternal fruit and vegetable intake. For many potential determinants, the consistency of evidence could not be examined because of a lack of studies. Findings highlight racial/ethnic differences in fruit and vegetable intake and influences on intake that should be considered when designing dietary interventions for low-income youth. Further research on intake determinants in this at-risk population is needed to establish an evidence base to guide interventions.