The Science of Diabetes Self-Management and Care2023, Vol. 49(1) 65 –76© The Author(s) 2023Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/26350106221146473journals.sagepub.com/home/tde
Abstract
Purpose: The purpose of the study was to examine the influences of sex and acculturation on dietary behaviors, macronutrient intake, and dietary quality in participants enrolled in a diabetes prevention initiative in Starr County, Texas.
Methods: Baseline data from the Starr County diabetes prevention study (N = 300) were analyzed—acculturation (country of origin, years in Starr County, language and food preferences), depressive symptoms (Patient Health Questionnaire-9), healthy eating self-efficacy (Weight Efficacy Lifestyle Questionnaire-Short Form), diet quality (USDA Healthy Eating Index), fat avoidance (Fat Avoidance Scale, Spanish version), and macronutrients. Descriptive statistics and univariate analysis of covariance were used to examine differences based on acculturation, controlling for sex.
Results: Participants were predominantly female (73%) and, on average, 51 years of age. Language and food preferences favored Spanish language and Hispanic foods, respectively. The majority (71%) was born in Mexico but had resided in Starr County for 33 years, on average. Depressive symptoms were moderate, and eating self-efficacy scores suggested low confidence in making healthy food choices, particularly for saturated fats. Spanish language preference was associated with worse dietary habits. The mean dietary quality score was lower than the national average (54 vs 59 nationally); females had slightly higher dietary quality than males and a higher mean fat avoidance score, although differences were not clinically significant. Intakes of carbohydrate, saturated fats, and cholesterol were higher than recommended daily allowances.
Conclusions: The overall preference for speaking Spanish and the influence of language on dietary intake should inform future dietary interventions. Accommodating cultural norms and food preferences remain major challenges to improving dietary quality among the diverse Hispanic ethnic groups.
Obesity, a growing global epidemic, plays a major role in the development of insulin resistance, dyslipidemia, and hypertension, common precursors of cardiovascular events and premature deaths.1-6 The National Diabetes Prevention Program (DPP) demonstrated that small weight reductions (≥7%) enhanced insulin sensitivity and glycemic control and delayed diabetes onset and related diabetes comorbidities, particularly in populations at high risk for developing type 2 diabetes mellitus (T2DM).7 Since the DPP, diabetes prevention has been a significant clinical and research priority, particularly among populations at high risk for T2DM. Recently, researchers estimated that annually 5.3% of older adults with A1C-verified prediabetes progressed to T2DM.8
Hispanics constitute one of the fastest growing populations at highest risk for T2DM; they tend to be diagnosed at an earlier age and experience high rates of diabetes-related comorbidities.9 The US Census Bureau estimated that in 2019, approximately 60 million Hispanics resided in the United States, making them the largest minority group; 65% were of Mexican origin.10 Obesity rates are particularly high in Mexican Americans who reside along the Texas-Mexico border, likely due in part to dietary factors and well-documented low rates of physical activity.11-13 In previous Starr County diabetes self-management and support (DSMES) intervention clinical trials, these researchers documented a high rate of obesity (mean body mass index [BMI] = 31) and a high dietary intake of saturated fat.14,15 Research team members witnessed grocery store shoppers purchasing carts full of multiple gallon-sized containers of lard for their weekly meal preparation. Thus, for more than 30 years, a major health goal of previous Starr County diabetes-related intervention studies has been to reduce saturated fat intake, especially during food preparation, while maintaining cultural food preferences of study participants.
Table 1 shows current general recommendations for dietary-related factors, such as kilocalories (kcal) and fiber, and recommended daily allowances for macronutrients (protein, carbohydrate, and fats), taking sex differences into account. These are general guidelines, and adjustments are frequently made, depending on individual characteristics, such as physical activity levels and age. Experts generally agree that the intake of saturated fat is more important than total fat in terms of avoiding negative health effects; that is, dietary saturated fat intake should be limited.16 The good news is that in Starr County, awareness of the obesity-diabetes link and the other multiple negative health effects of obesity, including the documented links to serious COVID-19 outcomes,17 seems to have increased over the years, based on the research team members’ past observations in this community.
A healthy diet, physical activity, and hypoglycemic medications are the 3 mainstays for preventing or treating T2DM. However, in this underserved minority rural border population, a healthy diet is the primary focus. Extreme environmental, cultural, and social issues preclude the residents of Starr County, a typical US-Mexico border community, from incorporating significant increases in physical activity. Environmental challenges associated with living along the US-Mexico border include extremely hot weather during a major portion of the year, lack of paved streets and/or walking paths, and safety concerns. For women, cultural mores pose significant obstacles to incorporating physical activity/exercise into daily routines.18,19 Furthermore, high rates of poverty serve as a barrier to effective and/or adequate treatment with recommended hypoglycemic agents, including oral medications and/or insulin injections, and the follow-up testing to determine treatment effectiveness.
In 2017, this research team obtained funding from the National Institutes of Health to test in Starr County a DSMES-type diabetes prevention program culturally tailored for Spanish-speaking Mexican Americans with verified prediabetes. The purpose of the analyses reported here was to examine dietary behaviors, macronutrient intake, and diet quality by sex, with a focus particularly on saturated fat intake, in participants enrolled in the current diabetes prevention initiative ongoing in Starr County (N = 300). Furthermore, the influences of 4 measures of acculturation—country of origin (US vs Mexico), number of years living in Starr County, and language (Spanish vs English) and food (Hispanic vs American) preferences—on these dietary factors were also examined. Information obtained from these analyses is critical to the development of dietary-focused interventions that incorporate cultural preferences yet are effective in reversing the obesity and diabetes epidemic in the growing, high-risk Mexican American population.
For these analyses, baseline data of the Starr County diabetes prevention study collected from March 2018 through September 2019 were examined. Note that this time frame was prior to the COVID-19 pandemic. Starr County, the site of this study and previous studies conducted by this research team, has been described in detail in previous publications of these researchers.14,15,20 Briefly, Starr County is 1 of 14 Texas counties located adjacent to the Rio Grande River that borders northern Mexico. A research field office located in Rio Grande City, the county seat, serves as the center of operations for all research projects. Starr County is one of the poorest counties in Texas and the United States. Some areas of the county from which study participants were recruited involve unincorporated settlements, called colonias, that experience even more severe poverty, pollution, and deprivation. The current estimated population of Starr County is 66 049; 96.3% is Mexican American.21 The community is designated by the State of Texas as a Health Professional Shortage/Medically Underserved Area. The significant impact of T2DM in this community has been well documented.22
Criteria employed for recruiting study participants from Starr County for the study were (1) between 25 and 55 years of age, (2) no history of prior diabetes diagnosis (excluding gestational), and (3) verified prediabetes (impaired fasting glucose [≥100 and <126 mg/dL], impaired glucose tolerance [≥140 and <200 mg/dL on 2-hour postload glucose], and/or A1C ≥5.7% and <6.5%). Exclusion criteria included (1) a diabetes diagnosis at baseline, (2) a history of using any hypoglycemic medications (except during pregnancy), (3) currently pregnant or within 3 months postpartum, or (4) medical conditions for which changes in diet and/or physical activity would be contraindicated (eg, heart failure or other conditions that require special diets and/or restricted physical activity). The study was approved by the Institutional Review Boards (IRB) of academic institutions directly involved: The University of Texas at Austin (IRB No. 2016120040) and the University of Texas Health Science Center at Houston (IRB No. HSC-SPH-03-056). All recruited enrollees signed Spanish or English consent forms to participate.
Table 2 shows the categories of variables that were included in these analyses. For the assessment of acculturation, 4 measures were used: country of origin (Mexico vs United States), number of years living in Starr County, language preference, and food preferences. For language and food preferences, a higher score on the respective survey signified more frequent use of English and intake of American foods. For psychological factors, the Patient Health Questionnaire-9 (PHQ-9) was used to screen for depressive symptoms; a score of ≥10 indicates potential major depression.23 To measure healthy eating self-efficacy, the Weight Efficacy Lifestyle Questionnaire-Short Form (WEL-SF; Spanish language version) was used; lower scores indicated higher levels of self-efficacy.24 Dietrelated factors included the Fat Avoidance Scale (FAS; Spanish version), a 7-item scale that is used to determine the degree to which individuals avoid foods containing saturated fats either in dietary intake and/or during food preparation.25 Questions were designed to reflect traditional Mexican American cultural food preferences, for example, “What type of fat oil do you use most often in cooking? (lard, meat fat, butter, shortening, margarine, vegetable oil).” FAS scores range from 0 to 1; lower scores indicate use of less desirable types of fat in the diet. The USDA’s Healthy Eating Index (HEI-2015) was used to measure general dietary quality in relationship to current national dietary recommendations.26 Two other dietary variables—energy intake (in kcal) and fiber intake (in grams)—were also calculated. Specific macronutrients in the diet—protein, carbohydrate, total fat, saturated fat, and cholesterol—were estimated from a Food Frequency Questionnaire, a semiquantitative measure that was validated previously in Starr County.27 With this instrument, researchers were able to collect information on amount and number of times certain foods, including cultural foods, were eaten during the previous month. Frequency data were converted to raw intakes and nutrient densities for analyses.
For diabetes-related physiological outcomes, 3 key indicators of overweight/obesity and diabetes risk were measured—BMI, Visceral Adiposity Index (VAI),28 and A1C. Body weights were measured with a balance beam scale with individuals in street clothing and without shoes; heights were obtained using a secured stadiometer. BMI was then calculated using the equation: body weight (in kg) / height (in meters2). The VAI is based on waist circumference, BMI, and triglyceride and HDL cholesterol concentrations. The monotest cholesterol procedure and the GPO triglyceride procedure of Boehringer Mannheim were used for assessing cholesterol and triglycerides. A1C was analyzed onsite using a point-of-care device (Siemens DCA Vantage Analyzer, Malvern, PA).
Baseline data were checked for accuracy and then imported from an Excel computer database (Microsoft Corp, version 16.51) into SPSS Statistics (IBM Corp, Armonk, NY, version 26.0) for analyses. The statistical significance was set at P = .01 to adjust for repeated significance testing.29 Participant characteristics (Table 2), involving both categorical and continuous measures, were analyzed using descriptive statistics (eg, frequencies, means). Sex differences in behavioral factors and physiological outcomes have been found consistently in previous and current Starr County studies.20 Accordingly, univariate analysis of covariance (ANCOVA) was used to analyze sex differences (Table 2) and also to examine the effects of the 4 acculturation variables—country of origin, number of years in Starr County, language preference, and food preferences—on psychological factors, diet-related factors, and macronutrient intake while simultaneously controlling for sex differences and additionally controlling for age for the variable, number of years in Starr County (Table 3). ANCOVA, a statistical test that combines analysis of variance and regression, is typically used to remove the influence of 1 or more antecedents, potentially confounding variables.30 As previously reported, power analyses for the intervention study (N = 300) indicated a power of 86.6% for the priority outcome of weight loss, which is above the desired power of 80% for such analyses.31 This sample size provided adequate power for the analyses reported here.
Table 2 shows the baseline characteristics of the 300 participants enrolled in the Starr County diabetes prevention clinical trial. In general, the sample was predominantly female who, on average, was 51 years of age and had 10 years of education. Language and food preferences trended toward Spanish language and Hispanic foods, respectively. The majority of the sample (71%) was born in Mexico but had resided in Starr County for 33 years, on average. Depressive symptoms were moderate, and eating self-efficacy scores suggested low confidence in making healthy food choices, especially in avoiding intake of saturated fats. Diet-related factors and macronutrient intake, the major foci of the analyses reported here, indicated a 2000 kilocalorie daily intake, on average, and low conformity to national dietary recommendations (HEI-2015). The mean HEI-2015 for the sample was 54, which is a lower food quality score than that of the general population (mean = 59);26 fiber intake measured in this sample was also low. For macronutrients, the daily protein intake was meeting or exceeding the recommendation of the American Dietetic Association (ADA), a recommendation that varies by age, sex, and body weight but, in general, ranges from 46 to 56 g per day.32 The daily carbohydrate intake of 229 g was higher than that recommended by the ADA (130 g), and the intake levels of saturated fat (25 g) and cholesterol (403 g) were higher than recommended thresholds as well; the general recommendation for saturated fat is 10% or less of daily calorie intake (eg, 20 g based on a daily intake of 2000 kilocalories). More than 70% of study participants reported a daily calorie intake of saturated fat higher than the recommended 10%. Mean BMI and VAI levels were high, as expected among individuals with prediabetes, and the mean A1C (5.7%) was consistent with a prediabetes diagnosis, an inclusion criterion for the study.
Table 2 also shows sex differences for each of the baseline variables included in these analyses. Although women outnumbered men in this study, the large sample size suggests the analyses should be sufficiently robust to violations of the assumption of relatively equal groups. Using an adjusted significance level of P = .01, no significant sex differences were detected for demographic characteristics (age, years of education), acculturation variables (country of origin, number of years in Starr County, language/food preferences), psychological factors (depression, healthy eating self-efficacy), or physiological outcomes (BMI, VAI, A1C). For diet-related factors, males had a higher daily intake of kcal compared with females; general guidelines for adults include 2500 kcal/d for males and 2000 kcal/d for females, although adjustments are made for physical activity level, age, and body weight.32 Thus, as expected, data analyses here found significant sex differences (P < .001) for each of the 5 measured macronutrients (protein, carbohydrate, total fat, saturated fat, cholesterol) and fiber intake. Both fat avoidance and healthy eating (HEI-2015) scores were significantly higher for females compared with males (P < .001 and P = .001, respectively). Note that fat avoidance and HEI-2015 scores, adjusted for sex differences, were significantly correlated (r = .22, P < .001). Contrary to previously reported research,33 there were no statistically significant associations between depressive symptoms or healthy eating self-efficacy and any of the macronutrient intake levels.
Table 3 shows the results of the analyses examining the 4 acculturation factors. For the acculturation variable country of origin, there were no statistically significant differences based on whether the individual was born in Mexico versus the United States, controlling for potential sex differences and using the adjusted significance level of P ≤ .01. However, those born in Mexico had tendencies for a higher mean fiber intake (P = .05) and a higher score on the HEI-2015 dietary quality measure (P = .04). In fact, those born in Mexico reported a higher intake in all areas except saturated fat. For the acculturation variable years in Starr County, there were no statistically significant differences based on the median split of years residing in that community, except for protein intake (P = .01). However, it is worth noting that individuals who had lived in the United States for 32 or more years reported a lower intake of total fat (P = .04), saturated fat (P = .06), and cholesterol (P = .02). For the acculturation variable language preference, there were statistically significant differences for most dietary measures, with those who preferred to speak Spanish reporting a higher intake of calories (P = .003), fiber (P < 0.001), protein (P = .002), carbohydrate (P = .004), and total fat (P = .01). Individuals speaking mostly Spanish reported higher intake levels of saturated fat (P = .039) and cholesterol (P = .044) compared to those who mostly spoke English. For the acculturation variable food preferences, there were no statistically significant differences based on whether individuals tended to prefer mostly Hispanic versus American foods.
The purpose of the analyses reported here was to describe diet-related factors, particularly macronutrient intake with a focus on saturated fat, of a rural Mexican American population with verified prediabetes who reside on the Texas-Mexico border and to examine differences based on sex, acculturation, and psychological factors. The importance of dietary quality in addressing the epidemic of obesity and T2DM was the primary factor that motivated these analyses. Exploration of baseline data from an ongoing diabetes prevention clinical trial may enable clinicians to focus dietary interventions on key targets specific to this growing population, such as sex differences in specific dietary factors such as carbohydrate, saturated fat, and cholesterol, while accommodating cultural food preferences.
On average, study participants were 51 years old, female, obese, and diagnosed with verified prediabetes.20 The acculturation variable language preference was significantly associated with dietary intake. Overall dietary quality, as measured by the HEI-2015, was lower than the national average; females had a slightly higher mean dietary quality than males and a higher mean fat avoidance score, although differences were not statistically significant. Intake of carbohydrate, saturated fat, and cholesterol were higher than recommended daily allowances.32 Starr County findings are consistent with recently reported analyses of the National Health and Nutrition Examination Survey (NHANES) data. In the large NHANES sample, racial/ethnic and sex differences in the HEI-2015 scores were documented; Hispanic dietary quality scores were relatively low, and males scored lower on dietary quality than females.34,35
The Starr County findings suggest two major issues that need to be addressed when planning future prediabetes intervention programs: (1) an overall preference for speaking Spanish coupled with the significant effect of language on dietary intake and (2) the ongoing challenge of improving dietary quality while accommodating cultural norms and food preferences in this border community and other similar communities across the United States.
The majority of people who immigrate to the US border areas from Mexico tend to speak and understand primarily Spanish and speak little English, despite residing in the United States for many years.36 Language concordance between health care providers and their messages and patients/clients has been found to significantly affect the adoption of health behavior recommendations.37 Lack of ability to speak and understand English serves as a major barrier to motivating individuals to make needed changes in health behaviors.38 Despite the large numbers of Mexican Americans who reside in the United States, the availability of appropriate, high-quality Spanishlanguage health education tools continues to be limited.39 Furthermore, given the diversity of the Hispanic ethnicity—Mexican Americans, Puerto Ricans, Cubans, and so on—providing guidance in the preferred language is a challenge. Significant language and cultural differences, such as food preferences, exist among Hispanic subgroups and continue years after immigrating into the United States. Funding for development of educational tools to address the language preferences of these diverse groups is scarce, although funding is more available today than it was in the past. Compounding these challenges is the low health literacy rates that have been documented among Hispanic groups, particularly among immigrants.40 A further characteristic, particularly among Mexican Americans who reside in communities along the Texas-Mexico border, is that they tend to speak a unique form of Spanish, often referred to as “Spanglish,” which is a blend of Spanish and English, or referred to as “conversational slang.” Additionally, the use of technology for educational purposes poses unique challenges given the language diversity, low health literacy rates, and limited interest in learning new technologies.41
As with language preferences, food preferences trended toward traditional Hispanic foods, particularly high-fat, calorie-dense foods, among immigrants, regardless of length of time residing in the United States.36 Research continues to find significant barriers to healthy diet-related behaviors in many Hispanic communities, including economic poverty and expected roles of males versus females.42 These researchers have experienced similar obstacles. Feedback from participants of diabetes studies conducted in Starr County have consistently identified improving the quality of their and their family’s food intake as priorities. Individuals wanted to learn how to prepare their favorite cultural foods in more healthy ways. However, simply telling them to limit saturated fats in their diets is woefully inadequate guidance. Study participants requested healthy, simple Hispanic recipes that are Mexican specific; they preferred food preparation demonstrations, either in person or on video. Again, these types of dietary educational tools that accommodate the diversity of Hispanic subgroups are limited.
For Starr County studies, researchers used several strategies, provided in Spanish, to address individuals’ dietary educational needs: (1) group visits to the local grocery store, led by Spanish-speaking dietitians, to learn how to read food labels, locate healthy substitutes for less healthy foods they currently use, taste healthy food options, and identify store aisles to avoid; (2) provision of healthy cultural snacks at weekly/biweekly intervention meetings; (3) group intervention sessions during which participants bring favorite recipes for the dietitian(s) and group members to suggest healthy modifications; and (4) Spanish-language videos of dietitians demonstrating the preparation of simple, healthy Mexican American recipes. These strategies have been well received by study participants, but they are time-consuming for staff and participants as well. So the current ongoing diabetes prevention intervention trial is testing text messaging technology augmented with food demonstration videos and written recipes.
Several limitations of these analyses are noteworthy. Dichotomizing the acculturation variables may have diminished the precision of these measures, and thus, variable relationships may have been undetected. Furthermore, some measures, particularly the acculturation variables, had limited ranges, which may attenuate variable relationships. Self-reported dietary information is subject to potential bias; training of data collectors and the use of models and pictures to standardize portion sizes were used to minimize discrepancies in dietary intake estimates. Multiple analyses that were conducted raises the potential for a Type I error rate (ie, finding statistical significance by chance), so a conservative approach was employed by setting the level of statistical significance at .01. Regardless of these limitations, the importance of language preference—English versus Spanish—remained and was significantly related to many of the dietary factors and macronutrients that were measured.
Dietary-related information presented here is important for the design of culturally tailored weight loss programs that target Mexican Americans and that are aimed at diabetes prevention. Indeed, dietary changes represent one of the key targets to alter the course of transition from normal glycemia to prediabetes and diabetes. Although descriptive/correlational analyses such as these cannot determine causal connections between acculturation factors and key diabetes outcomes, these researchers add their voices to the calls for diabetes prevention strategies designed to accommodate the diversity among Hispanic subgroups. Researchers should explore strategies that go beyond merely telling individuals to change dietary food habits. A disturbing dietary recommendation that continues is the notion that Mexican Americans and other Hispanic subgroups should eliminate their cultural foods for more healthy American foods. As these researchers have stated in the past, this recommendation is not only culturally insensitive; it is factually wrong. Healthy Hispanic diets are attainable, but individuals need to be taught how to modify cultural food preferences, both foods prepared at home and those that are eaten in restaurants, so that recipes are acceptable to family members as well. Otherwise, dietary strategies will continue to be ineffective.
The authors wish to express their gratitude to the study participants who so generously agreed to be in the diabetes prevention project, especially given their personal challenges imposed by the COVID-19 pandemic. The authors also wish to acknowledge the nurses, dietitians, and research staff for their assistance with and commitment to the past and ongoing research studies conducted in Starr County, Texas.
The authors declare no potential conflicts of interest.
Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health, under Award Nos. R01DK109920 and R01DK116378, and the State of Texas. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Sharon A. Brown https://orcid.org/0000-0001-7325-9599
ClinicalTrials.gov: NCT03208010https://clinicaltrials.gov/ct2/show/NCT03208010
From School of Nursing, The University of Texas at Austin, Austin, Texas (Dr Brown, Dr Becker, Dr García, Ms Winter); School of Social Work, The University of Texas at Austin, Austin, Texas (Dr Velasquez); College of Education, The University of Texas at Austin Department of Kinesiology & Health Education, Austin, Texas (Dr Tanaka); School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas (Dr Perkison, Dr Brown, Dr Hanis); School of Public Health, LSU Health New Orleans School of Medicine, New Orleans, Louisiana (Dr Aguilar).
Corresponding Author:Sharon A. Brown, Joseph H. Blades Centennial Memorial Professor Emerita, School of Nursing, The University of Texas at Austin, 1710 Red River Street, Austin, TX 78712, USA.Email: sabrown@mail.utexas.edu
