Evaluation of the Southwest Food Frequency Questionnaire

mHealth-Supported Gender- and Culturally Sensitive Weight Loss Intervention for Hispanic Men With Overweight and Obesity: Single-Arm Pilot Study

BACKGROUND

Hispanic men have disproportionate rates of overweight and obesity compared with other racial and ethnic subpopulations. However, few weight loss interventions have been developed specifically for this high-risk group. Furthermore, the use of mobile health (mHealth) technologies to support lifestyle behavior changes in weight loss interventions for Hispanic men is largely untested.

OBJECTIVE

This single-arm pilot study examined the feasibility and acceptability of integrating mHealth technology into a 12-week gender- and culturally sensitive weight loss intervention (GCSWLI) for Hispanic men with overweight and obesity.

METHODS

A total of 18 Hispanic men (mean age 38, SD 10.9 years; mean BMI 34.3, SD 5.5 kg/m²; 10/18, 56% Spanish monolingual) received a GCSWLI, including weekly in-person individual sessions, a daily calorie goal, and prescription of ≥225 minutes of moderate-intensity physical activity per week. mHealth technology support included tailored SMS text messaging, behavior self-monitoring support using Fitbit Charge 2, and weight tracking using a Fitbit Aria Wi-Fi Smart Scale. Changes in weight from baseline to 12 weeks were estimated using a paired 2-tailed t test. Descriptive analyses characterized the use of Fitbit and smart scales. Semistructured interviews were conducted immediately after intervention to assess the participants' weight loss experiences and perspectives on mHealth technologies.

RESULTS

Of 18 participants, 16 (89%) completed the 12-week assessments; the overall attrition rate was 11.1%. The mean weight loss at week 12 was -4.7 kg (95% CI 7.1 to -2.4 kg; P<.001). Participants wore the Fitbit 71.58% (962/1344) of the intervention days and logged their body weight using the smart scale (410/1344, 30.51% of the intervention days). Participants identified barriers to the use of the technology, such as lack of technological literacy and unreliable internet access for the smart scale.

CONCLUSIONS

Although clinically significant weight loss was achieved by integrating mHealth technology into the GCSWLI, adherence to the prescribed use of technology was modest. Addressing barriers to the use of such technologies identified in our work may help to refine an mHealth intervention approach for Hispanic men.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02783521; https://clinicaltrials.gov/ct2/show/NCT02783521.

A Metabolomic Analysis of the Sex-Dependent Hispanic Paradox

In Mexican Americans, metabolic conditions, such as obesity and type 2 diabetes (T2DM), are not necessarily associated with an increase in mortality; this is the so-called Hispanic paradox. In this cross-sectional analysis, we used a metabolomic analysis to look at the mechanisms behind the Hispanic paradox. To do this, we examined dietary intake and body mass index (BMI; kg/m²) in men and women and their effects on serum metabolomic fingerprints in 70 Mexican Americans (26 men, 44 women). Although having different BMI values, the participants had many similar anthropometric and biochemical parameters, such as systolic and diastolic blood pressure, total cholesterol, and LDL cholesterol, which supported the paradox in these subjects. Plasma metabolomic phenotypes were measured using liquid chromatography tandem mass spectrometry (LC-MS/MS). A two-way ANOVA assessing sex, BMI, and the metabolome revealed 23 significant metabolites, such as 2-pyrrolidinone (p = 0.007), TMAO (p = 0.014), 2-aminoadipic acid (p = 0.019), and kynurenine (p = 0.032). Pathway and enrichment analyses discovered several significant metabolic pathways between men and women, including lysine degradation, tyrosine metabolism, and branch-chained amino acid (BCAA) degradation and biosynthesis. A log-transformed OPLS-DA model was employed and demonstrated a difference due to BMI in the metabolomes of both sexes. When stratified for caloric intake (<2200 kcal/d vs. >2200 kcal/d), a separate OPLS-DA model showed clear separation in men, while females remained relatively unchanged. After accounting for caloric intake and BMI status, the female metabolome showed substantial resistance to alteration. Therefore, we provide a better understanding of the Mexican-American metabolome, which may help demonstrate how this population—particularly women—possesses a longer life expectancy despite several comorbidities, and reveal the underlying mechanisms of the Hispanic paradox.

Dietary Patterns with Healthy and Unhealthy Traits Among Overweight/Obese Hispanic Women with or at High Risk for Type 2 Diabetes

Hispanic women are at high risk for type 2 diabetes (T2D), with obesity and unhealthy eating being important contributing factors. A cross-sectional design was used in this study to identify dietary patterns and their associations with diabetes risk factors. Participants completed a culturally adapted Food Frequency Questionnaire capturing intake over the prior 3 months. Overweight/obese Hispanic women (n = 191) with or at risk for T2D were recruited from a community clinic into a weight loss intervention. Only baseline data was used for this analysis. Dietary patterns and their association with diabetes risk factors (age, body mass index, abdominal obesity, elevated fasting blood glucose [FBG], and hemoglobin A1c). An exploratory factor analysis of dietary data adjusted for energy intake was used to identify eating patterns, and Pearson correlation coefficient (r) to assess the association of the eating patterns with the diabetes risk factors. Six meaningful patterns with healthful and unhealthful traits emerged: (1) sugar and fat-laden, (2) plant foods and fish, (3) soups and starchy dishes, (4) meats and snacks, (5) beans and grains, and (6) eggs and dairy. Scores for the "sugar and fat-laden" and "meats and snacks" patterns were negatively associated with age (r = - 0.230, p = 0.001 and r = - 0.298, p < 0.001, respectively). Scores for "plant foods and fish" were positively associated with FBG (r = 0.152, p = 0.037). Being younger may be an important risk factor for a diet rich in sugar and fat; this highlights the need to assess dietary patterns among younger Hispanic women to identify traits potentially detrimental for their health.

Feasibility and Acceptability of a Type 2 Diabetes Prevention Intervention for Mothers and Children at a Federally Qualified Healthcare Center

BACKGROUND

Maternal obesity and gestational diabetes mellitus (GDM) contribute to increased risk for type 2 diabetes mellitus (T2DM) among both mothers and their offspring. Randomized trials demonstrated T2DM risk reduction in adults following lifestyle behavior change and modest weight loss; the evidence base for at-risk children remains limited.

PURPOSE

Evaluate the feasibility, acceptability, and preliminary efficacy of a T2DM prevention intervention for mother-child dyads delivered by Federally Qualified Health Center staff.

METHODS

A group randomized design tested the effects of a behavioral lifestyle intervention on T2DM risk factors in women with a history of GDM and their 8- to 12-year-old children. Mother-child dyads were recruited and randomized to intervention or wait-listed control conditions. Intervention participants completed the 13-week intervention; control participants received standard of care. Baseline and 13-week measures assessed program acceptability and feasibility, and explored effects on body weight, waist circumference, hemoglobin A1c, and lifestyle behaviors.

RESULTS

Forty-two dyads were randomized and 35 (83%) completed pre-/post-measurements. Participants and program leaders positively rated content and engagement. Nearly all strongly agreed that activities were enjoyable (97%), applicable (96%), useful (97%), and motivational (96%). Attendance averaged 65% across 2 cohorts; delivery costs were approximately $225/dyad. There were no significant differences in body weight, BMI (or BMI z-score), waist circumference, hemoglobin A1c, diet quality, physical activity, sleep, or home environment changes between intervention and control groups.

CONCLUSIONS

A family T2DM prevention program was feasibly delivered by FQHC staff, and acceptable to mothers and children. Program efficacy will be evaluated in an adequately powered clinical trial.

Lessons Learned From a Program to Reduce Diabetes Risk Among Low-Income Hispanic Women in a Community Health Clinic

BACKGROUND

The Diabetes Prevention Program (DPP) and Look AHEAD studies demonstrated that modest weight loss and increased physical activity can significantly reduce the incidence of diabetes among overweight individuals with prediabetes. However, these studies involved costly interventions, all of which are beyond the reach of most real-world settings serving high-risk, low-income populations. Our project, De Por Vida, implemented a diabetes risk-reduction intervention for Hispanic women in a Federally Qualified Health Center and assessed the program's efficacy. This report describes the methodology used to develop and implement De Por Vida, the cultural adaptations made, the community-academic partnership formed to carry out this program, and the barriers and challenges encountered through the implementation process.

METHODS

Our goal was to translate the DPP and Look AHEAD programs into an intervention to prevent diabetes and reduce diabetes complications among high-risk Hispanic women at a federally qualified health center in Hillsboro, Oregon, where more than half of clinic patients are Spanish-speaking, and nearly all live in poverty. This randomized clinical trial targeted overweight Spanish-speaking women at risk for, or diagnosed with, type 2 diabetes. We developed a 12-month behavioral diabetes risk-reduction intervention that was responsive to the cultural practices of the Hispanic population and that could be implemented in low-income clinical settings. Study planning and implementation involved close collaboration among the clinic leadership, a research team from the Kaiser Permanente Center for Health Research, and Arizona State University.

DISCUSSION

Creating a fully informed partnership between research and clinical institutions is the first step in successful cooperative research projects. The adoption of a bidirectional, rather than a top-down, approach to communication between researchers and health-care providers, and between clinic management and the clinic frontline staff, gave the research study team crucial information about barriers, constraints, and needs that clinic staff experienced in implementing the program. This allowed clinic management and front-line clinic staff to play an active role in study implementation, identifying problem areas, and collaborating in finding practical solutions.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov, NCT03113916.

Feasibility and acceptability of a beverage intervention for Hispanic adults: results from a pilot randomized controlled trial

OBJECTIVE

To assess the feasibility and acceptability of a beverage intervention in Hispanic adults.

DESIGN

Eligible individuals identified as Hispanic, were 18-64 years old and had BMI 30·0-50·0 kg/m2. Participants were randomized 2:2:1 to one of three beverages: Mediterranean lemonade (ML), green tea (GT) or flavoured water control (FW). After a 2-week washout period, participants were asked to consume 32 oz (946 ml) of study beverage daily for 6 weeks and avoid other sources of tea, citrus, juice and sweetened beverages; water was permissible. Fasting blood samples were collected at baseline and 8 weeks to assess primary and secondary efficacy outcomes.

SETTING

Tucson, AZ, USA.ParticipantsFifty-two participants were recruited over 6 months; fifty were randomized (twenty-one ML, nineteen GT, ten FW). Study population mean (sd) age 44·6 (sd 10·2) years, BMI 35·9 (4·6) kg/m2; 78 % female.

RESULTS

Forty-four (88 %) completed the 8-week assessment. Self-reported adherence was high. No significant change (95 % CI) in total cholesterol (mg/dl) from baseline was shown -1·7 (-14·2, 10·9), -3·9 (-17·2, 9·4) and -13·2 (-30·2, 3·8) for ML, GT and FW, respectively. Mean change in HDL-cholesterol (mg/dl) -2·3 (-5·3, 0·7; ML), -1·0 (-4·2, 2·2; GT), -3·9 (-8·0, 0·2; FW) and LDL-cholesterol (mg/dl) 0·2 (-11·3, 11·8; ML), 0·5 (-11·4, 12·4; GT), -9·8 (-25·0, 5·4; FW) were also non-significant. Fasting glucose (mg/dl) increased significantly by 5·2 (2·6, 7·9; ML) and 3·3 (0·58, 6·4; GT). No significant change in HbA1c was demonstrated. Due to the small sample size, potential confounders and effect modifiers were not investigated.

CONCLUSIONS

Recruitment and retention figures indicate that a larger-scale trial is feasible; however, favourable changes in cardiometabolic biomarkers were not demonstrated.

A gender- and culturally-sensitive weight loss intervention for Hispanic males: The ANIMO randomized controlled trial pilot study protocol and recruitment methods

Hispanic men have the highest rates of overweight and obesity when compared to men of other racial/ethnic groups, placing them at increased risk for obesity-related disease. Yet, Hispanic men are grossly underrepresented in weight loss research. Tailored intervention strategies to improve obesity treatment programs for this vulnerable racial/ethnic subgroup are needed. This manuscript describes recruitment strategies, methodology, and participant characteristics of the ANIMO study, a 24-week randomized controlled pilot trial testing the effects of a gender- and culturally-sensitive weight loss intervention (GCSWLI) on body weight in Hispanic men compared to a wait-list control condition. The ANIMO study included two phases. The first phase was a 12-week GCSWLI. Participants attended weekly in-person individual sessions guided by a trained bilingual Hispanic male lifestyle coach, were prescribed a daily reduced calorie goal, and 225 min of moderate-intensity physical activity per week. In the second phase, GCSWLI participants received bi-weekly phone calls across a 12-week follow-up. Wait-list control (WLC) participants from phase 1 received the GCSWLI plus mobile health technology support. Recruitment strategies included face-to-face efforts at a swap meet (outdoor marketplace), family/friend referrals, printed advertisements and social media. Recruitment, screening, and participant enrollment occurred over three months. Overall, 143 men expressed interest in participation. Of these, 115 were screened and 78% (n = 90) were eligible to participate; 45% of enrolled participants (n = 52) completed baseline assessments and 43% (n = 50) were randomized (mean age of 43.3 ± 11.4 years; BMI: 34.1 ± 5.3 kg/m²; 58% Spanish monolingual). Parameter estimates from ANIMO will support future adequately powered trials for this health disparate population.

Trial registration

ClinicalTrials.gov: NCT02783521.

Feasibility and acceptability of a beverage intervention for Hispanic adults: a protocol for a pilot randomized controlled trial

BACKGROUND

In the U.S., Hispanics have among the highest rates of overweight and obesity when compared to other racial/ethnic groups placing them at a greater risk for obesity-related disease. Identifying intervention strategies to reduce caloric intake and/or improve cardiometabolic health in Hispanics is critical to reducing morbidity and mortality among this large and growing population. Evidence exists to support diet-specific behavioral interventions, including beverage modifications, in reducing obesity-related health risks. However, the acceptability and feasibility of a beverage intervention in obese Hispanic adults has not been robustly evaluated.

METHODS

The objective of this pilot study is to assess the feasibility and acceptability of a randomized, controlled beverage intervention in 50 obese Hispanic adults ages 18-64 over 8-weeks. Eligible participants were obese (30-50.0 kg/m2), between the ages 18-64, self-identified as Hispanic, and were able to speak, read, and write in either English and/or Spanish. Study recruitment was completed August 2017. Upon the completion of baseline assessments, participants will be randomized to either Mediterranean lemonade, Green Tea, or flavored water control. After completing a 2-week washout period, participants will be asked to consume 32 oz. per day of study beverage for 6-weeks while avoiding all other sources of tea, lemonade, citrus, juice, and other sweetened beverages; water is permissible. Primary outcomes will be recruitment, retention, and acceptability of the intervention strategies. Our study will also evaluate participant-reported tolerance and as an exploratory aim, assess safety/toxicity-related to renal and/or liver function. Fasting blood samples will be collected at baseline and 8-weeks to assess the primary efficacy outcomes: total cholesterol, high-density lipoprotein (HDL), and low-density lipoprotein (LDL). Secondary outcomes include fasting glucose, hemoglobin A1c (HbA1c), and high-sensitivity C-reactive protein (hs-CRP).

DISCUSSION

This pilot study will provide important feasibility, safety, and early efficacy data necessary to design a larger, adequately-powered randomized controlled trial.

TRIAL REGISTRATION

NCT02911753 ( ClinicalTrials.gov ). Registered September 19, 2016. Last updated November 1, 2017.

Invited Commentary: The Contribution to the Field of Nutritional Epidemiology of the Landmark 1985 Publication by Willett et al

The semiquantitative food frequency questionnaire (FFQ) has been the primary source of dietary exposure data in epidemiology for decades. Although frequency instruments had been evaluated before the 1985 publication "Reproducibility and Validity of a Semiquantitative Food Frequency Questionnaire" by Willett et al. (Am J Epidemiol. 1985;122(1):51-65), that paper was the prototype for the development and validation of what was then a highly innovative method for collecting dietary data. This approach was adopted in nearly all subsequent cohort studies of diet and disease. The paper also catalyzed an extended scientific discourse regarding methods for validation, energy adjustment, and measurement error. It is now well established that data from FFQs and other self-reported dietary assessment instruments have both value and error and that this error should be considered in the analysis and interpretation of findings, including sensitivity analyses in which adjustment for measurement error is explored. Advances in technology make it feasible to consider collecting multiple granular short-term instruments such as recalls or records over time in addition to FFQs among all participants in large cohort studies; both provide valuable information. Without a doubt, the 1985 publication by Willett et al. provided the foundation that propelled the field of nutritional epidemiology forward, and it continues to be relevant today.

Development and Validation of a Mediterranean Oriented Culture-Specific Semi-Quantitative Food Frequency Questionnaire

The objectives were to develop a Mediterranean oriented semi-quantitative food frequency questionnaire (FFQ) and evaluate its validity in measuring energy and nutrient intakes. For FFQ development, the main challenge was to merge food items and practices reflecting cultural Mediterranean preferences with other food choices ensuing from diet transition to more westernized dietary patterns. FFQ validity was evaluated by comparing nutrient intakes against the average of two 24-h dietary recalls for 179 pregnant women. Although the mean intake values for most nutrients and energy tended to be higher when determined by the FFQ, the Cohen's d was below 0.3. Bland-Altman plots confirmed the agreement between the two methods. Positive significant correlations ranged from 0.35 to 0.77. The proportion of women classified correctly was between 73.2% and 92.2%, whereas gross misclassification was low. Weighted kappa values were between 0.31 and 0.78, while intraclass correlation coefficients were between 0.49 and 0.89. Our methodological approach for the development and validation of this FFQ provides reliable measurements of energy, macro- and micronutrient intakes. Overall, our culture-specific FFQ could serve as a useful assessment tool in studies aiming at monitoring dietary intakes, especially in the Mediterranean region, where countries share common cultural dietary habits.

Weight-loss interventions for Hispanic populations: the role of culture

In the United States, ethnic minorities are overrepresented among the overweight and obese population, with Hispanic individuals being among the groups most at risk for obesity and obesity-related disease and disability. Most weight-loss interventions designed for the general population have been less successful with individuals from ethnic minorities and there is a pressing need to develop more effective interventions for these groups. This paper examines the importance of culture in the development of "culturally competent" weight-loss interventions for ethnic minority populations, and discusses specific culturally mediated factors that should be considered in the design and implementation of treatment interventions. While specifically focusing on Hispanic populations, we also address issues of relevance to other multiethnic societies.

En Balance participants decrease dietary fat and cholesterol intake as part of a culturally sensitive Hispanic diabetes education program

PURPOSE

The purpose of this study was to assess dietary intake habits of Mexican American Hispanic adults participating in the En Balance diabetes education program.

METHODS

En Balance is a 3-month culturally sensitive diabetes education intervention for Spanish-speaking Hispanics. Of the 46 participants enrolled, 39 mainly Mexican American Hispanic adults with type 2 diabetes completed the En Balance program. Participants lived in the Riverside and San Bernardino counties of California, and all participants completed the program by June 2008. Dietary intake was assessed at baseline and at 3 months using the validated Southwest Food Frequency Questionnaire.

RESULTS

Clinically important decreases in glycemic control and serum lipid levels were observed at the end of the 3-month program. The baseline diet was characterized by a high intake of energy (2478 ± 1140 kcal), total fat (87 ± 44 g/day), saturated fat (28 ± 15 g/day), dietary cholesterol (338 ± 217 mg/day), and sodium (4236 ± 2055 mg/day). At 3 months, the En Balance group mean intake of dietary fat (P = .045) and dietary cholesterol (P = .033) decreased significantly. Low dietary intakes of docosahexaenoic acid, eicosapentaenoic acid, and vitamin E were also observed in these adults with type 2 diabetes.

CONCLUSIONS

The En Balance program improved glycemic control and lipid profiles in a group of Hispanic diabetic participants. En Balance also promoted decreases in dietary fat and dietary cholesterol intake.

Comparison between dietary assessment methods for determining associations between nutrient intakes and bone mineral density in postmenopausal women

It is important to identify the role of nutrition in the treatment and prevention of osteoporosis. The goal of this study was to compare the equivalency of nutrient intakes assessed by diet records and the Arizona Food Frequency Questionnaire and the associations of these nutrients with bone mineral density (BMD). This is a secondary analysis of cross-sectional data that was analyzed from six cohorts (fall 1995 to fall 1997) of postmenopausal women (n=244; 55.7+/-4.6 years) participating in a 12-month, block-randomized, clinical trial. One-year dietary intakes were assessed using 8 days of diet records and the Arizona Food Frequency Questionnaire. Participants' BMD was measured at the lumbar spine (L2-L4), femur trochanter, femur neck, Ward's triangle, and total body using dual-energy x-ray absorptiometry. Linear regression analyses (P< or =0.05) were adjusted for the effects of exercise, hormone therapy use, body weight at 1 year, years post menopause, and total energy intake. Significant correlations (r=0.30 to 0.70, P< or =0.05) between dietary assessment methods were found with all dietary intake variables. Iron and magnesium were consistently and significantly positively associated with BMD at all bone sites regardless of the dietary assessment method. Zinc, dietary calcium, phosphorous, potassium, total calcium, and fiber intakes were positively associated with BMD at three or more of the same bone sites regardless of the dietary assessment method. Protein, alcohol, caffeine, sodium, and vitamin E did not have any similar BMD associations. Diet records and the Arizona Food Frequency Questionnaire are acceptable dietary tools used to determine the associations of particular nutrients and BMD sites in healthy postmenopausal women.

Plasma vitamin B-12 concentrations in an elderly latino population are predicted by serum gastrin concentrations and crystalline vitamin B-12 intake

The prevalence of vitamin B-12 deficiency increases with age, probably resulting from malabsorption of food-bound B-12 secondary to gastric atrophy. On the basis of this assumption, the Institute of Medicine (IOM) recommends those aged >50 y consume crystalline vitamin B-12. There is limited information on the prevalence of gastric atrophy in the elderly and whether the IOM recommendation would be effective. The objective of this study was to assess predictors of vitamin B-12 status and their interactions in free-living elderly. Individuals (n = 57) with deficient plasma vitamin B-12 (p-B12 < 148 pmol/L) were compared with 68 individuals with marginal p-B12 (148-221 pmol/L) and 52 with normal p-B12 (>221 pmol/L) in a cross-sectional sample (n = 1546) of elderly (>60 y) Latinos in California. Associations were examined among p-B12 and serum gastrin, vitamin B-12 intake from food and crystalline sources, and medications that putatively affect vitamin B-12 absorption. Serum gastrin was elevated, indicating gastric atrophy, in 48% of participants with deficient p-B12, 23% with marginal p-B12 and 21% of normal p-B12 participants, and was a significant predictor of deficient p-B12 and high plasma homocysteine (p-tHcy). Median total vitamin B-12 intake exceeded recommendations and was similar among status groups. Crystalline vitamin B-12 intake in the normal p-B12 group was higher than in the deficient p-B12 group (P < 0.01), and tended to be higher than the marginal group (P = 0.07). When serum gastrin was elevated, p-B12 was predicted by crystalline vitamin B-12, but not by intake of vitamin B-12 from food. Elevated serum gastrin was highly prevalent and predicted vitamin B-12 depletion. Crystalline vitamin B-12 intake predicted p-B12 in individuals with elevated serum gastrin, supporting IOM recommendations to increase consumption of crystalline vitamin B-12.