En Balance: the effects of Spanish diabetes education on physical activity changes and diabetes control

Cultural Relevancy of Culinary and Nutritional Medicine Interventions: A Scoping Review

Background. Taking into account the disproportionate impacts of disease burden from chronic conditions by racial and ethnic group, this scoping review sought to examine the extent to which nutritional interventions incorporated culturally relevant topics into their design and analyses. Methods. A literature search of 5 databases was conducted for any peer-reviewed studies on nutritional and culinary medicine interventions published between 2000 and 2019. Results. Studies were divided into 2 categories, medical education interventions (n = 12) and clinical/community interventions (n = 20). The majority of medical education interventions were not culturally tailored and focused on obesity/weight management within the Northeast and Southeast United States. In contrast, clinical/community interventions were primarily culturally tailored for Latinos/Hispanics and African American/Black populations residing in the Northeast and diagnosed with prediabetes/diabetes mellitus or hypertension/cardiovascular disease. Conclusions. This review identified an existent gap and need for inclusive studies that consider the culturally relevant topics into the design and implementation of nutritional intervention studies. Studies within medical education appeared to be the area where these changes can be most beneficial. There may be some value among clinic and communal-based studies in stratifying heterogeneous subgroups because of the missed cultural nuances missed when grouping larger racial cohorts.

Hispanic Caregivers' experience of pediatric type 1 diabetes: A qualitative study

OBJECTIVE

It is widely recognized that Type 1 Diabetes (T1D) outcomes are worse among Hispanic children; however, little is published about the perspectives of these patients and their caregivers. Our intent was to characterize the lived experience of Hispanic caregivers of children with T1D, focusing on the role of language and culture and their perspectives on current medical care and alternative care models. We studied Hispanic caregivers of patients (age 2-17 years) with T1D of greater than 6 months' duration.

RESEARCH DESIGN AND METHODS

We completed semi-structured interviews and focus-groups of a purposive sample of 20 members of our population of interest. We developed a codebook and completed multidisciplinary consensus coding, then conducted iterative thematic analysis using qualitative software and discussion to generate themes.

RESULTS

We gathered data from 20 Hispanic caregivers of T1D patients (11.37 ± 3.00 years old, 4.80 ± 2.84 years since diagnosis). 85% of caregivers were female, 80% preferred Spanish, and 15% were college-educated. Our analysis yielded 4 themes across the participants: (1) Culturally-based nutrition challenges, (2) Social isolation and lack of support for T1D care, (3) Hesitancy to fully embrace diabetes technology, and (4) Deferential views of care experience and providers. Overarching all of these themes was support for Hispanic group-based models of care tailored to address these concerns.

CONCLUSIONS

The unique concerns among Hispanic caregivers of children with T1D suggest the importance of culturally tailored interventions to improve care. With successful implementation, such interventions could diminish widening disparities in healthcare outcomes.

Cost and healthcare utilization analysis of culturally sensitive, shared medical appointment model for Latino children with type 1 diabetes

OBJECTIVE

This study evaluated costs and healthcare utilization associated with a culturally-sensitive, medical and education program for pediatric Latino patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Program participants included Latino children ages 1-20 years old diagnosed with type 1 diabetes (n = 57). Control subjects with type 1 diabetes were matched by age, sex, and zip code to intervention participants from the Colorado All Payer Claims Database. Data included emergency department (ED) visits, hospitalizations, demographic information, and health insurance claims data 180 days prior to program start/index date through 1 year after program start/index date. We tracked program staff time and estimated costs for healthcare utilization using data from the scientific literature. Generalized Estimating Equation (GEE) models with logit link were used to estimate group differences in probabilities of ED visits and hospitalizations over 6-month periods pre/post-study, accounting for correlation of within-subject data across time points. Sensitivity analyses modeled longer-term cost differences under different assumptions.

RESULTS

The intervention group had fewer hospitalizations, 2% versus 12% of controls (p = 0.047,OR = 0.13;95%CI: 0.02-0.97) for 6 months following start date. The intervention group had fewer ED visits, 19% versus 32% in controls (n.s.; p = 0.079,OR = 0.52;95%CI:0.25-1.08) and significantly fewer hospitalizations, 4% versus 15% of controls (p = 0.039,OR = 0.21;95%CI: 0.05-0.93) 6-12 months post-start date. One-year per-patient program costs of $633 and healthcare cost savings of $2710 yielded total per-patient savings of $2077, or a 5-year cost savings of $14,106.

CONCLUSION

This unique type 1 diabetes management program altered health service utilization of program participants, reducing major healthcare cost drivers, ED visits, and hospitalizations.

Effects of Exercise and Diet on Body Composition and Physical Function in Older Hispanics with Type 2 Diabetes

Type 2 Diabetes mellitus (DM2) affects 9.3% of the U.S. population. Health disparities are evident in DM2; twice as many Hispanics as non-Hispanic Whites have DM2. The objective of this study was to pilot test the feasibility of implementing and evaluating trends of nutrition and exercise interventions to improve diabetes management and physical function in 29 disadvantaged older Hispanics with DM2. We delivered combined diet and exercise (n = 8) and diet-only (n = 6) interventions and compared the results to a control/no intervention group (n = 15). We cluster-randomized the participants into the three arms based on the senior center they attended. The interventions were delivered twice a week for 3 months (24 sessions) and assessments were conducted pre and post intervention. The results indicate the feasibility of implementing the interventions and slight improvements in both intervention groups compared to the control group. The diet-only group tended to have larger improvements on body composition measures (especially in muscle mass), while the diet + exercise group tended to have larger improvements on physical function (especially in chair stands). There was a high rate of attrition, especially in the diet + exercise group, but those who completed the intervention tended to have improvements in body composition and physical function.

Short-term effectiveness of a theory-based intervention to promote diabetes management behaviours among adults with type 2 diabetes in Iran: A randomised control trial

BACKGROUND

Diet and physical activity are recommended for diabetes management. Evidence suggests theory-based interventions are more efficacious than non-theory approaches. This study aimed to test the short-term effectiveness of an integrated theoretical model-based intervention to encourage compliance for low-fat food consumption, carbohydrate counting and physical activity in adults with type 2 diabetes.

METHODS

A 4-week parallel randomised control trial was conducted in Iran. Data were collected using a self-report questionnaire at baseline and 8-weeks post-intervention. This survey assessed the theory of planned behaviour (TPB) constructs of attitude, subjective norm (others' approval) and perceived behavioural control (PBC). We also assessed risk perceptions (motivational) and planning (volitional) from the health action process approach (HAPA). Furthermore, weight, body mass index, triglyceride (TG) and LDL-cholesterol were measured, with a sub-sample of participants providing haemoglobin A1c (HbA1c) assessments.

RESULTS

For both low-fat food consumption and physical activity, only planning revealed a significant improvement over time for intervention rather than control participants (F = 8.78, P ≤ .001 for low-fat vs F = 11.26, P ≤ .001 for physical activity). For carbohydrate counting, significant effects were found for behaviour (F = 4.37, P = .03), intention (F = 8.14, P ≤ .001), PBC (F = 7.52, P ≤ .001) and planning (F = 4.54, P = .03), reflecting improvements over time in the intervention participants compared to controls. Furthermore, the effects of the intervention on behaviour were partially mediated via participants' degree of planning (B = 0.10, SE = 0.06, CI = 0.01 to 0.26). The serum TG level was significantly reduced from pre to post-intervention for intervention rather than for control participants (F = 18.69, P ≤ .001) as did Hb1Ac in a sub-sample of study participants.

CONCLUSIONS

This intervention showed promising short-term effects for carbohydrate counting but did not show improvements for low-fat diet nor physical activity. Given the improvement in psychological measures and self-reported behaviour for carbohydrate counting, coupled with the findings for TG, future research is needed to demonstrate longer-term improvements.

En Balance: The Contribution of Physical Activity to the Efficacy of Spanish Diabetes Education of Hispanic Americans with Type 2 Diabetes

PURPOSE

En Balance, a culturally sensitive diabetes education program, improves glycemic control in Hispanics with type 2 diabetes. The program emphasized diet, physical activity, and other factors important for glycemic control. However, the individual contributions of these education factors are unclear. The purpose of this study is to assess the contribution of physical activity to the success of En Balance in improving the health of Mexican Americans with type 2 diabetes.

METHODS

A retrospective study was conducted with plasma samples collected pre- and post-3-month study. Samples from 58 (18 males and 40 females) Hispanic subjects with type 2 diabetes were analyzed for the concentration of kynurenines, known to decrease in response to exercise. After three months, health outcomes for the active group (decreased kynurenines) and the rest of the cohort were evaluated by paired Wilcoxon signed-rank test.

RESULTS

Half of the subjects had increased kynurenine levels at the end of the educational program. We found that the subjects in the active group with decreased kynurenine concentrations displayed statistically greater improvements in fasting blood glucose, A1C, cholesterol, and triglycerides despite weight loss being higher in the group with increased kynurenine concentrations.

CONCLUSIONS

En Balance participants with decreased kynurenine levels had significantly improved glycemic control. These data suggest that physical activity significantly contributes to the success of the En Balance education program. This analysis indicates that diabetes public health educators should emphasize the benefit of physical activity on glycemic control even in the absence of major weight loss.

Novel, culturally sensitive, shared medical appointment model for Hispanic pediatric type 1 diabetes patients

BACKGROUND/OBJECTIVE

Latino patients with type 1 diabetes (T1D) face cultural and language barriers leading to poor outcomes. Shared medical appointments (SMAs) are recognized as effective models of care. Our aim is to develop a culturally sensitive, cost effective SMA program for Latino T1D.

SUBJECTS

Spanish speaking Latinos 1 to 20 years with T1D (n = 88) and their families.

METHODS

Routine care alternating with SMAs that included group education was provided. Teens, ages >11 received the SMA separate from parents. Younger children were seen together. Hemoglobin A1c (HbA1c), behavioral questionnaires, and use of diabetes technology were measured at baseline and every 3 to 6 months.

RESULTS

57.7% of children and 77.27% of teens completed the 2 years of the Program. There was a significant association between age and change in HbA1c from baseline to year 1 (P = .001) and baseline to year 2 (P = <.0001). For participants <12 years, there was a significant improvement in HbA1c from baseline to year 1 (P = .0146) and from year 1 to year 2 (P = .0069). Participants ≥12 years, had an increase in HbA1c from year 1 to year 2 (P = .0082). Technology use increased significantly from baseline to year 2 for participants <12 years of age (19%-60%, P = .0455) and for participants who were ≥12 years of age (10%-23%, P = .0027). Participants reported a 98% satisfaction rate.

CONCLUSIONS

The culturally sensitive SMA proved to be an appreciated, feasible, and effective alternative to care for Latinos with T1D.

Identification of Anti-Long Chain Saturated Fatty Acid IgG Antibodies in Serum of Patients with Type 2 Diabetes

High levels of serum long chain saturated fatty acids (LCSFAs) have been associated with inflammation in type 2 diabetes. Dietary SFAs can promote inflammation, the secretion of IgG antibodies, and secretion of the proinflammatory cytokine IL-1β. This study characterizes anti-LCSFA IgG antibodies from patients with type 2 diabetes. Serum samples from several cohorts with type 2 diabetes were analyzed for the presence of anti-LCSFA IgG, the cytokine IL-1β, and nonesterified fatty acids. Anti-LCSFA IgG was isolated from patient samples and used for in vitro characterization of avidity and specificity. A cohort participating in En Balance, a diabetes health education program that improved diabetes management, tested positive for anti-LCSFA IgG. Following the 3-month program, the cohort showed a significant reduction in anti-LCSFA IgG levels. Anti-LCSFA antibodies isolated from these patients demonstrated high avidity, were specific for long chain SFAs, and correlated with serum fatty acids in patients with managed type 2 diabetes. Interestingly, anti-LCSFA IgG neutralized PA-induced IL-1β secretion by dendritic cells. Our data shows that nonesterified SFAs are recognized by IgG antibodies present in human blood. The identification of anti-LCSFA IgG antibodies in human sera establishes a basis for further exploration of lipid induced immune responses in diabetic patients.

Twelve-month physical activity outcomes in Latinas in the Seamos Saludables trial

BACKGROUND

Physical activity interventions designed for Latinas have shown short-term behavior change, but longer-term change and maintenance is rarely measured.

PURPOSE

To assess physical activity change at 12 months, following 6-month tapered completion of an RCT of a physical activity intervention for Latinas.

METHODS

Two hundred sixty-six underactive (<60 minutes/week physical activity) Latinas were randomized to an individually tailored, culturally and linguistically adapted physical activity intervention, or a wellness contact control. Participants received the materials through the mail for 6 months, then received booster doses at 8, 10, and 12 months. Minutes per week of moderate to vigorous physical activity were measured by the 7-Day Physical Activity Recall interview at baseline and 6 and 12 months. Data were collected at Brown University between 2009 and 2013, and analyses were conducted in 2013.

RESULTS

At 12 months, increases in moderate to vigorous physical activity were significantly greater in the intervention than in the wellness group (mean difference=52 minutes/week, SE=9.38, p<0.01), with both groups showing slight increases in moderate to vigorous physical activity from 6 to 12 months. Intervention participants were also more likely to meet national moderate to vigorous physical activity guidelines (OR=3.14, p=0.01).

CONCLUSIONS

The intervention was more effective than the wellness control at 12 months, and physical activity increases from baseline to 6 months were maintained, suggesting the intervention may lead to sustainable behavior change.

TRIAL REGISTRATION

This study is registered at Clinicaltrials.gov NCT01583140.

Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus

BACKGROUND

Ethnic minority groups in upper-middle-income and high-income countries tend to be socioeconomically disadvantaged and to have a higher prevalence of type 2 diabetes than is seen in the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus.

SEARCH METHODS

A systematic literature search was performed of the following databases: The Cochrane Library, MEDLINE, EMBASE, PsycINFO, the Education Resources Information Center (ERIC) and Google Scholar, as well as reference lists of identified articles. The date of the last search was July 2013 for The Cochrane Library and September 2013 for all other databases. We contacted authors in the field and handsearched commonly encountered journals as well.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of culturally appropriate health education for people over 16 years of age with type 2 diabetes mellitus from named ethnic minority groups residing in upper-middle-income or high-income countries.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When disagreements arose regarding selection of papers for inclusion, two additional review authors were consulted for discussion. We contacted study authors to ask for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

A total of 33 trials (including 11 from the original 2008 review) involving 7453 participants were included in this review, with 28 trials providing suitable data for entry into meta-analysis. Although the interventions provided in these studies were very different from one study to another (participant numbers, duration of intervention, group versus individual intervention, setting), most of the studies were based on recognisable theoretical models, and we tried to be inclusive in considering the wide variety of available culturally appropriate health education.Glycaemic control (as measured by glycosylated haemoglobin A1c (HbA1c)) showed improvement following culturally appropriate health education at three months (mean difference (MD) -0.4% (95% confidence interval (CI) -0.5 to -0.2); 14 trials; 1442 participants; high-quality evidence) and at six months (MD -0.5% (95% CI -0.7 to -0.4); 14 trials; 1972 participants; high-quality evidence) post intervention compared with control groups who received 'usual care'. This control was sustained to a lesser extent at 12 months (MD -0.2% (95% CI -0.3 to -0.04); 9 trials; 1936 participants) and at 24 months (MD -0.3% (95% CI -0.6 to -0.1); 4 trials; 2268 participants; moderate-quality evidence) post intervention. Neutral effects on health-related quality of life measures were noted and there was a general lack of reporting of adverse events in most studies - the other two primary outcomes for this review. Knowledge scores showed improvement in the intervention group at three (standardised mean difference (SMD) 0.4 (95% CI 0.1 to 0.6), six (SMD 0.5 (95% CI 0.3 to 0.7)) and 12 months (SMD 0.4 (95% CI 0.1 to 0.6)) post intervention. A reduction in triglycerides of 24 mg/dL (95% CI -40 to -8) was observed at three months, but this was not sustained at six or 12 months. Neutral effects on total cholesterol, low-density lipoprotein (LDL) cholesterol or high-density lipoprotein (HDL) cholesterol were reported at any follow-up point. Other outcome measures (blood pressure, body mass index, self-efficacy and empowerment) also showed neutral effects compared with control groups. Data on the secondary outcomes of diabetic complications, mortality and health economics were lacking or were insufficient.Because of the nature of the intervention, participants and personnel delivering the intervention were rarely blinded, so the risk of performance bias was high. Also, subjective measures were assessed by participants who self-reported via questionnaires, leading to high bias in subjective outcome assessment.

AUTHORS' CONCLUSIONS

Culturally appropriate health education has short- to medium-term effects on glycaemic control and on knowledge of diabetes and healthy lifestyles. With this update (six years after the first publication of this review), a greater number of RCTs were reported to be of sufficient quality for inclusion in the review. None of these studies were long-term trials, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of the studies made subgroup comparisons difficult to interpret with confidence. Long-term, standardised, multi-centre RCTs are needed to compare different types and intensities of culturally appropriate health education within defined ethnic minority groups, as the medium-term effects could lead to clinically important health outcomes, if sustained.

The effects of a community-based, culturally tailored diabetes prevention intervention for high-risk adults of Mexican descent

PURPOSE

This article reports the results of a community-based, culturally tailored diabetes prevention program for overweight Mexican American adults on weight loss, waist circumference, diet and physical activity self-efficacy, and diet behaviors.

METHODS

The intervention used content from the Diabetes Prevention Program but culturally tailored the delivery methods into a community-based program for Spanish-speaking adults of Mexican descent. The design was a randomized controlled trial (N = 58) comparing the effects of a 5-month educational intervention with an attention control group. The primary study outcome was weight loss. Secondary outcomes included change in waist circumference, body mass index, diet self-efficacy, and physical activity self-efficacy.

RESULTS

There were significant intervention effects for weight, waist circumference, body mass index, and diet self-efficacy, with the intervention group doing better than the control group. These effects did not change over time.

CONCLUSIONS

Findings support the conclusion that a community-based, culturally tailored intervention is effective in reducing diabetes risk factors in a 5-month program.

Physical Activity in Latino Men and Women

Latinos report less leisure time physical activity (PA) than non–Latino Whites and suffer disproportionately from diseases related to sedentary lifestyle, yet remain underserved and understudied. Gaining a better understanding of PA behavior in Latinos is critical to intervene on this significant public health issue. This article discusses the growing literature on the facilitators and barriers of PA in Latino men and women and reviews recent interventions to promote activity. Apart from acculturation influences, facilitators of PA in Latinos are similar to those of non–Latino Whites, with most research focusing on self-efficacy and social support. Barriers for Latinas, however, are more culturally distinct, such as a focus on caregiving and cultural standards for body shape. Barriers unique to Latino men largely have not been studied. Researchers have adopted a variety of approaches to increase PA, including using promotores and incorporating culturally appropriate activities, and have had mixed success. However, the community and randomized controlled trials almost exclusively included only women. Studies reviewed here suggest that interventions should target culturally specific barriers beyond language to successfully increase PA in Latinos and highlight a need for formative research and design of interventions for Latino men.

A family-based diabetes intervention for Hispanic adults and their family members

AIMS

The purpose of this quasi-experimental, 1-group longitudinal study is to examine the effects of a family-based intervention program on diabetes self-management behaviors, A1C, other biomarkers, psychosocial factors, and health-related quality of life in Hispanics with diabetes.

METHODS

Adult patients with diabetes (n = 36) and family members (n = 37) were recruited from a community clinic in rural central North Carolina. Patients and family members attended an 8-week culturally tailored diabetes educational program taught in Spanish. Data were collected pre- and post-intervention for both patients and family members, with an additional data collection for patients 1 month post-intervention.

RESULTS

Most patients and family members were female, and almost all were immigrants. A1C decreased by 4.9% on average among patients from pre-intervention to 1 month post-intervention. Patients showed significant improvements in systolic blood pressure, diabetes self-efficacy, diabetes knowledge, and physical and mental components of health-related quality of life. Higher levels of intake of healthy foods and performance of blood glucose tests and foot inspections were reported. Family members significantly lowered body mass index and improved diabetes knowledge from pre-intervention to immediately post-intervention. No significant changes in levels of physical activity were found among patients with diabetes or family members.

CONCLUSIONS

Findings suggest that including family members in educational interventions may provide emotional and psychological support to patients with diabetes, help to develop healthy family behaviors, and promote diabetes self-management.