Diabetes Among Latinas in Hartford: Key Findings & Recommended Actions Latinos are twice as likely as non-Hispanic whites of similar age to have diabetes. …

Diabetes Among Latinas in Hartford: Key Findings Recommended Actions

Rafael Pérez-Escamilla1, PhD, Grace Damio2, MS, CD/N, Nurgul
Fitzgerald1, PhD Candidate, RD, Sofia Segura-Pérez2, MS, RD, Yu-
Kuei Peng2, MPH

1Department of Nutritional Sciences and Cooperative Extension System

, University of Connecticut

rafaelperez-escamilla@uconnedu

Storrs CT 06269-4017

2Center for Community Nutrition

, Hispanic Health Council

graced@hispanichealthcom

Hartford CT

Six DraftTechnical Report: April 128, 2004

For internal discussion among authors only

Suggested reference: Pérez-Escamilla R, Damio G, Fitzgerald N, Segura-Pérez
S, Peng YK Diabetes Among Latinas in Hartford: Key Findings Recommended
Actions University of Connecticut and The Hispanic Health Council, Storrs
and Hartford CT: Technical Report, March 9, 2004

EXECUTIVE SUMMARY

Key Findings

Hispanic or Latinos have become the largest
minority group in the USA
representing 13 of the USA population According to the recent data from
the Centers for Disease Control and Prevention CDC, during the year 2000
diabetes was the sixth leading cause of death in the United States during
the year 2000 Diabetes is a costly disease;, its total direct and
indirect cost in the year 2002 in the USA was estimated at 132 billion
dollars for 2002 In this country, this disease affects 182 million people
of whom an estimated 52 million have undiagnosed diabetes Over 90 of
people diagnosed with diabetes have type 2 diabetes Latinos are twice as
likely as non-Hispanic whites of similar age to have diabetes Two million
Latinos, representing 82 of all Latinos aged 20 years and older, have
diabetes representing 82 of all Latinos aged 20 years and older Our
previous studies in Hartford show that Puerto Ricans and other Latino
groups are heavily affected both by obesity and type 2 diabetes Because
little is known about the characteristics of Puerto Ricans with diabetes
diabetics and the main challenges they face managing this disease, Tthe
University of Connecticut Department of Nutritional Sciences, Tthe
Cooperative Extension System, and
Tthe Hispanic Health Council joined
forces to examine these issues through the Diabetes Prevention Among
Latinos DIPAL case-control study Because in addition to therapeutic
drugs if necessary, type 2 diabetes management relies heavily on diet and
physical activity the study emphasized these aspects

The main objectives of DIPAL were to better understand the needs among
Latinos with type 2 diabetesLatino diabetics with regards to their: aA
Nnutrition knowledge, attitudes, behaviors and self-efficacy, Bb
Pphysical activity knowledge, attitudes, behaviors and self-efficacy, Cc
Hhousehold food insecurity,
Dd Ddiabetes knowledge and self-management, Ee Hhealth status, and fF
Hhealth care coverage and access DIPAL was designed as a case-control
study that included 100 Puerto Rican adults who self-reporteding to have
type 2 diabetesic cases and 101 individuals who reporteding not having
this condition controls A valid 30-page questionnaire was specifically
developed for this study and applied in the language and at the place of
participants choice Most of the participants preferred to be interviewed
in Spanish, and at their homes to the great majority of participants mostly
in their
homes Participants were mostly recruited mostly through street
outreach, the telephonephone book directory, and referrals from the
Hispanic Health Council Participants had to meet the following criteria to
be eligible for the study: aA Hispanic Ffemale, bB Lliving in the
Hartford area, cC Bbetween the ages of 35-60 years old, Dd Nnot being
pregnant or breastfeeding, eE Wwithout HIV or cancer, fF Ccases needed
to be free of serious diabetes-related complications, and Gg Ccases must
have not been using insulin continuously since the time of diagnosis

The percentage of individuals with at least high school education was
similar among cases and controls 340 vs 386 Likewise, there were no
between-group differences in the percent being employed 260 vs 307
or receiving food stamps 510 vs 455 Controls tended towere more
likely to be bilingual; however, both groups mostly preferred much more to
speak only in Spanish at home 8090 cases vs 733 controls, p0438
Even though, and aAs expected, persons with diabetesdiabetics were more
likely to have a close relative with diabetes, but it is remarkable that
this was also true for over 80 of controls An overwhelming 90 of persons
with diabetes
and 83 of controls were either overweight or obese, with 80
of them having the high risk central obesity pattern Cases were
significantly more likely to have type 2 diabetes-associated symptoms such
as: high risk central obesity, excessive urination, excessive thirst,
extreme hunger, increased fatigue, blurry vision, high blood pressure, and
high blood cholesterol However, a high number about one-third of controls
that experienced at least some of these symptoms Rafael: Can we come up
with a percentage?, GDThis implies that a potentially higher number of
individuals hadwith diabetes without knowing it that are undetected and
has reached the level of clinical symptoms

Only 642 of respondents had ever heard about the Food Guide Pyramid FGP
with no significant differences p0407 found between cases 670
614 and controls 670614 The percentage of cases and controls
who knew the correct number of the food group daily recommended servings
for each food group was distributed as follows: breads and cereals 45
vs 81, p0480399, vegetables 20912 vs 290, p0285307, fruits
403394 vs 419, p0850770, dairy 507761 vs 613758,
p0228967, meat and other protein sourcesalternates 3103 vs
339344, p0760620
After being shown the sample food label, The
majority of the cases and controls indicated, after being shown the sample
food label, that they were familiar with it, but although surprisingly,
participants with diabeticsdiabetes were less likely to be so 770 vs
871, p0061 Among respondents who were familiar with food labels
n1656, only 37785 of cases and 307 of controls reported to use them
often to select healthier foods Among those who were familiar with food
labels, 5139 of casesdiabetics and 511 of controls never used them to
select foods low in saturated fat It is indeed remarkable that, among
those who were familiar with food labels, 4628 of casesdiabetics and
511 of controls never used food labels to choose foods low in sodium
Among food label users, Pparticipants with type 2 diabetesDiabetics were
much less likely than controls to report never using food labels to choose
foods low in sugar 1697 vs 500, p0001 It is remarkable thatBy
contrast, over 60 of each group 61003 vs 648 reported never using
food labels to select such foods Likewise, over half of each group
51306 vs 568 reported never using food labels to look at total
carbohydrate content

The majority of cases and
controls were familiar with the term fiber
750 vs 822, p0215 However, among those who were familiar with it
n158, very few cases and controls were able to choose the right
definition from a list of options 133 vs 134, p097588
Surprisingly, only 514 of casesdiabetics and 598 of controls agreed
with the statement that people should increase their fiber intake for
better health p0713291

The vast majority of cases and controls reported that they usually cooked
meals at home 900 vs 950, p0173 However, persons with
diabetesdiabetics were less likely than controls to be the food shopper
810 vs 941, p0005 All but one of the 201 participants ate Puerto
Rican or other Hispanic foods, and 602 of them participants ate them
every day Even though cases were more likely than controls to eat
breakfast every day 6657 vs 406, p00001, it is disturbing that
more than a third of them skipped breakfast at least once per week Less
than half of casesdiabetics and controls ate lunch every day 450 vs
366, p0228 Dinner was the meal that was most likely to be consumed
every day by cases and controls 830 vs 750, p0123 Lack of
appetite and not feeling hungry wasere the major reasons given by both
groups for
skipping meals Fast food consumption was widespread among both
groups However, participants with diabetesdiabetics were less likely than
controls to report eating fast foods at least once per month 68790 vs
818919, p002501 The daily frequency of intake of fruits and
vegetables was very low in relationship to the recommendation of at least 5
servings per day

Four out of every ten study participants consumed nutritional supplements,
most of them containing multivitamins and minerals Only one-third of
participants reported doing regular exercise, and cases with diabetics
being were more likely than controls to do so 420 vs 290, p0055
About one-third of the participants thought exercising wais difficult, and
about 308 of them did not feel confident in their ability to exercise
regularly

One out of every four respondents were current cigarette smokers and almost
half indicated that they had been smokers at some point in their lives
There were no differences between diabeticscases and controls with regards
to the prevalence of being a current 260 vs 257, p0967 or
formerever 480 vs 436, p0528 smokersmoking

Household food security is defined as access, at all times for all
household
members, to a diet of sufficient quantity and quality through
socially acceptable means that leads to an active and healthy life Based
on the 6-item USDA food insecurity scale, only 433 of households were
considered to be food secure, 289 attended food pantries, and 483 were
receiving food stamps Because 706 were receiving either food stamps or
accessing food pantries, results indicate that a substantial proportion of
participants not enrolled in food stamps were alsoquite food insecure
Among those with food insecurity, participants with type 2
diabetesDiabetics were almost twice as likely as controls to live in
households experiencing hunger 448260 vs 250139, p002731

Cases were significantly more likely than controls to know that there are
two main different types of diabetes, type 1 and type 2 910 vs 760,
p0006 DiabeticsThey were also more likely to know: that a fasting blood
sugar level of 210 is too high 920 vs 700, p0001, what gestational
diabetes is 720 vs 580, p0041, that shaking and sweating are not
signs of high blood sugar 240 vs 90, p0001, that diabetes can
damage the kidneys 980 vs 820, p0001, the meaning of a
glycosylated hemoglobin test 602 vs 386, p0008, that people
with
diabetesdiabetics should check their blood sugar before meals and at
bedtime 940 vs832, p0001, that persons with diabetesdiabetics need
to monitor their blood sugar daily even if their doctor did a hemoglobin
A1c test 540 vs 386, p0011 However, the above percentages
revealed significant numbers of people with diabetes who lack key
information necessary for effective management of the disease Only 120
of casesdiabetics and 59 of controls were familiar with the dietary
exchange system p0133

Only 130 of participants self-assessed their health as either very good
or excellent As expected, participants with type 2 diabetes werediabetics
were significantly more likely than controls to report their health status
as either fair or poor 700 vs 486, p0003 Participants with
diabetesDiabetics were less likely than controls to behave been without
medical insurance during the year preceding the survey 140 vs 277,
p0017 Among those who had insurance, Mmedical insurance coverage was
provided mainly by Medicaid 723 For 867 of the persons with
diabetesdiabetics n100, their diabetes care was provided by a a family
physician generalist The prevalence of visits to health care
specialists by
casesdiabetics during the 12 months preceding the survey
was: optometrist 680, podiatrist 270, diabetes educator 333,
and dietician 300 The main reason given by respondent for not having
seen a dietician during the previous years was that she was not referred by
a doctor

Recommended Actions

Findings call for the following actions:

Nutrition and Diabetes Education

Provide nutrition education about:
a FGP, especifically about recommended servings of food groups
Emphasize: a1 fruit and vegetable intake, a2 Total fat, saturated
fat, carbohydrates, fiber, and sodium, including their sources, and
importance for disease prevention and management
b Food label use, and its importance for selecting healthier foods
Emphasize: b1 daily value to figure out if a particular product is
high, medium or low for any given nutrient
o Because of the likely presence of
o external locus of control in selecting healthier foods, families of
targeted individuals should be encouraged to attend intervention
sessions Overcoming possible barriers within the family or work
environment should be explored
o Knowledge- and skill-building
o interventions are
critically needed for those with type 2 diabetes
However, considering that this is an at risk population, only about
29 people do not have any of the symptoms of type 2 diabetes,
controls and persons with and without type 2 diabetesdiabetics are
similar in their nutrition knowledge and behaviors, and also for the
primary prevention purposes, targeting both groupsdiabetics with or
without diabetes and non-diabetics is seems more appropriate
o Health literacy skills and health
empowerment should be improved among this population
Develop a network of well trained bilingual and bicultural community
health promoters/promotoras to provide support in attaining these
nutrition education goals

Food Security

The conditions of persons with diabetes appear to be compounded by a more
severe level of food insecurity It is essential to understand why only
half of the impoverished individuals participating in the study were
enrolled in the food stamp program
It is important to work with food pantries and other emergency food
assistance providers to ensure that they understand the types of foods
more appropriate for persons
with diabetes It is also important that
their personnel know where they can refer people with diabetes to receive
support and adequate treatment Rafael: Do we have food security
recommended action to be inserted here?, GD
Develop a network of well trained bilingual and bicultural community
health promoters/promotoras to provide support in attaining these food
security goals

Physical Activity Promotion

Encourage regular physical activity 150 minutes/week in both groups,
since majority of the both groups58 to 71 reported no regular exercise
Physical activity interventions should focus on:
o Increasing the knowledge and awareness about the benefits, and the
process of exercising
o Overcoming barriers by providing guidance in:such as becoming familiar
with the exercise process, time management, cold weather options,
increasing activities in the house, options at work
o Building social support eg, neighborhood walking activities
o Develop a network of well
o trained bilingual and bicultural community health promoters/
promotoras to attain these physical activity goals
Extremely high rates of overweight/
obesity in both groups, and the
positive association between obesityweight and diabetes call for
intervention for weight control
Confidence building, overcoming barriers ie resisting food
temptations, and dealing with previous failed attempts should be
addressed within the intervention
Weight control intervention should include both dietary and physical
activity aspects, since other studies support the higher effectiveness of
a combined approach rather than dietary control alone
Develop a network of well
trained bilingual and bicultural community health promoters/promotoras
to attain these weight management goals

Improve Overall Well-Being

The poor health conditions of persons with diabetesdiabetics appeareds to
be compounded by a more severe level of food insecurity in addition to
greater rates of self-reported hypertension and high blood cholesterol
levels High depression levels may be related to food insecurity and
other socioeconomic factors analyses not shown, and these potential
barriers should be considered in future interventions
Low alcohol intake among those with diabetesdiabetics should be
supported, since it can
complicate the blood glucose control However,
how to deal with alcohol intake should also be incorporated into
nutrition education interventions for diabetics
At about 26, the cigarette smoking rate in this study is higher than
national rates for Hispanic/Latino women 124, from Health, United
States 2002, and closer to the national rates for non-Hispanic white
women 234 Interventions should increase the awareness about the
health risks of cigarette smoking, and inform the communitypopulation
about available smoking cessation programs However, potential risk of
weight gain upon cessation should be considered and discussed, and
incorporated into weight control programs
High rates of hypertension provide support for including sodium intake
monitoring in the diet-related interventions
Develop a network of well
trained bilingual and bicultural community health promoters/promotoras to
attain these health improvement goals

Health Care Access

The strong reliance on Medicareaid by this diabetic community indicates
that any further cuts into this program are likely to affect enormously
the well- being of Laatinos with type 2
diabetesics
Referral to a dietitcian should be seen as a priority among programs that
treat diabetics Furthermore, once the patient has had an initial
consultation with the dietictians, regular follow ups should also be a
priority until the patient shows enough confidence in following his/her
prescribed diet
It is crucial to incorporate community health promoters/promotoras that
serve as liaisons within the health care system to improve access and
quality of care tofor Latinos with diabetes diabetics Toward this end,
iIt is essential to identify community members whothat have been
successful at managing their diabetes and fully understand the barriers
that need to be overcome, so they can serve as role models and provide
support for their peers to followbe able to do so

Conclusion

Introduction

Hispanic or Latinos have become the largest minority group in the USA
representing 13 of the USA population This ethnic group experiences high
poverty rates and poorer health outcomes than non-Hispanic whites
According to recent data from the Centers for Disease Control and
Prevention CDC, Dduring the year 2000 Ddiabetes was listed as the sixth
leading cause of death in United States during the year 2000 It is a
disease that affects 182 million people of whom an estimated 52 million
have undiagnosed diabetes Over 90 of people diagnosed with diabetes have
type 2 diabetes In the year 2002 alone, there was were 13 million of
newly diagnosed cases Populations with a higher risk for diabetes are the
elderly, with a prevalence for this
disease of 183 ofamong people 60
years and older had been diagnosed with diabetes; and Mminority
populations such as the Latinos, population among whom are at increased
risk for this disease; 20 million of whom them, representing 82 of all
Latinos aged 20 years and older, haved diabetes representing 82 of all
Latinos aged 20 years and older Mexican Americans, the largest Hispanic
subgroup in the United States, areis twice as likely as non-Hispanic whites
of similar age to have diabetes as non-Hispanic whites of similar age
while Likewise, Puerto Ricans living in the Ccontinental USA residents are
18 times more likely to have diagnosed diabetes than their US non-
Hispanic whites counterparts The major rRisk factors for type 2 diabetes
type 2 are family history of diabetes, obesity and physical inactivity
being overweight and not being physically active Hispanics in the United
States have high rates of allare heavily affected ofby these risk factors
Uncontrolled hyperglycemia in diabeteshigh blood sugar leads to
complications affecting many organs in the body, causing disability and
premature death According to the CDCs most recent latest statistics,
diabetes is the leading
cause for end –stage renal disease 44 of the
new cases, and more than 60 of non-traumatic lower-limb amputations
Diabetes complications are also higher among Hispanics Diabetes is a
costly disease;;, the its total direct and indirect cost in the year 2002
for diabetes was estimated at 132 billion dollars

Our previous studies in Hartford show that Puerto Ricans and other Latino
groups are heavily affected both by obesity and type 2 diabetes Because
little is known about the characteristics of Puerto Ricans with diabetes
diabetics and the main challenges they face managing this disease, The the
University of Connecticut Department of Nutritional Sciences, Tthe
Cooperative Extension System, and tTthe Hispanic Health Council joined
forces to examine these issues through the Diabetes Prevention Among
Latinos DIPAL case-control study Because, in addition to therapeutic
drugs if necessary, type 2 diabetes management relies heavily on diet and
physical activity the study emphasized these aspectsBecause type 2
diabetes management relies heavily on diet, therapeutic drugs if
necessary and physical activity the study emphasized these aspects

CHAPTER 1

Study
Design

Objectives

The main objectives of DIPAL were to better understand the needs among type
2 Latinos with type 2 diabetes diabetics with in regards to their:

Nutrition knowledge, attitudes, behaviors and self- efficacy
Physical activity knowledge, attitudes, behaviors and self- efficacy
Household food insecurity
Diabetes knowledge and self-management
Health status
Health care coverage and access

Methodss

The DIPAL study was conducted between June 24, 2002 and September 4, 2003
and approved by the Human Subjects Iinstitutional Review Boards from the
University of Connecticut and The the Hispanic Health Council and aAll
subjects signed an informed consent form before agreeing to participate in
the study DIPAL was designed as a case-control study that included 100
Puerto Rican adults self-reporteding to have type 2 diabetesic cases and
101 individuals who reporteding not having this condition controls After
obtaining their informed consent, respondents who met the study criteria
were scheduled for an interview at the time and location of their choice
The
overwhelming majority 955 of the interviews took place at the
respondents homes and 861 chose to be interviewed in Spanish

Recruitment strategies
Participants were recruited through sStreet outreach 320317
, pPhone book directory 2056
, The Hispanic Health Council Rreferrals 131140
, lLists of participants from previous HHC studies 125120
, hHealth fairs/bulletin boards 75
, WIC office Ooutreach 55
, and through oOther 8096 sources To be included in the study,
participants had to meet the following inclusion criteria: Rafael: I did
not include the 1 missing value in these s, I also combined the radio
and TV with HHC because they were done by HHC

Selection criteria

Hispanic fFemale
Living in the Hartford area
Between the ages of 35-60 years old
Not being pregnant or breastfeeding
Without HIV or cancer
Cases must had been diagnosed with diabetes by a doctor within the 5
years preceding the study
Cases needed to be free of serious diabetes-related complications such
as: glaucoma, kidney failure, heart disease, stroke, gangrene or
amputations due to poor blood circulation
Cases must have not been using insulin continuously since the
time of
diagnosis

Survey instrustment

After obtaining their informed consent, respondents who met the study
criteria were scheduled for an interview at the time and location of their
choice The overwhelming majority 955 of the interviews took place at
the respondents homes and 861 chose to be interviewed in Spanish ThA e
30-page questionnaire that was specifically developed for this study, and
it included the following sections:

Demographic and socio-economic characteristics
Household food insecurity and hunger
Acculturation
Nutrition knowledge
Self-efficacy, stages of change, and locus of control for healthy
lifestyle behaviors
Dietary assessmenthabits
Cigarette smoking and alcohol consumption
Physical activity
Depression
Diabetes care-related knowledge, attitudes, self-efficacy, and locus of
control
Diabetes care
Health status and access to health care
Anthropometric assessment: weight, height, waist circumference, and hip
circumference
CHAPTER 2
A Description of the Environment and Project Participants

Results

Socio-economic and demographic characteristics

Participants ages ranged from 35 to 610 years, and with cases
werebeing
slightly older than controls 5061 vs 4732 years, respectively The
percentage of individuals with at least high school education was similar
among cases and controls 340 vs 386 Likewise, there were no between-
group differences in the percent being employed 260 vs 307 or
receiving food stamps 510 vs 455 There were no significant between-
group differences in ethnicity p0878 The majority of respondents
identified themselves as Puerto Rican 780752 of cases vs 75278 of
controls, followed by Hispanic or Latino 90119 vs 11990,
Puerto Rican American 7089 vs 8970, American 1 of both groups
and other 530 vs 350 However The percentage of individuals who
could speak only Spanish was higher among participants with diabetes than
controls cases were significantly more likely to be Spanish-only speakers
590 vs 455 Interestingly, even though controls were more likely to
be bilingual, but Spanish was the preferred language spoken at home by most
of the participants in both groups preferred much more to speak only in
Spanish at home 8009 cases vs 733 controls, p0438 Participants
with Ddiabetesics were moreless likely than controls to have grown up in
Puerto Rico 810110 vs 644208, p003
There was no significant
difference in the number of years that cases and controls had been residing
in the continental USA 194 1298 years vs 219140 years, p0190
Although not statistically significant, diabetics tended to be less
acculturated when measured by other language and migration variables
Because all the others, but 1, are covered already The percent of
individuals with at least high school education was similar among cases and
controls 340 vs 386 Likewise, there were no between-group
differences in the percent being employed 260 vs 307 or receiving
food stamps 510 vs 455

Those who grew up in Puerto Rico were more likely to have diabetes than
participants who grew up in other Latino countries or USA p003
Although not statistically significant, diabetics tended to be less
acculturated when measured by other language and migration variables

These findings have several implications:
First,First, aany effort designed to deal with type 2 diabetes
management or prevention among Latinos in Hartford needs to have highly
qualified bilingual staff
Second, because the educationalschooling level of individuals with
diabetes diabetics and the community at large is
likely to be low, it is
important to take their literacy level into account when designing cost-
effective interventions
Third, cases and controls were quite similar in their socio-economic and
demographic characteristics indicating that the research design is quite
appropriate to identify risk factors for type 2 diabetes in the sample
examined

Diabetes risk factors and symptoms

Cases were significantly more likely than controls to have a close relative
with diabetes 910 vs 802, p0012 Cases had a significantly
p001 higher body mass index than controls 34658693 kg/m2 vs
3123821 kg/m2, p0004, a higher waist-to-hip circumference ratio
089007 vs 085005, p00001, and waist circumference 40656 vs
37169 inches, p0001 than controls , and Indeed, an overwhelming 90
of persons with diabetes and 83 of controls were either overweight or
obese, with 80 of them having the high risk central obesity pattern

About half of the participants were confident/very confident in their
ability to achieve a healthy weight About two-thirds of the participants
tried within the past 6 months, and were planning to lose weight within
the next 6 months Among those who had tried to lose
weight, about 34
concluded that their attempt was not successful

Participants with diabetes were significantly more likely to have the
following type 2 diabetes-associated symptoms: high blood pressure 600
vs 356, p0001, high blood cholesterol 620 vs 218, p0001,
excessive urination 680 vs 317, p0001, excessive thirst 540 vs
267, p0001, extreme hunger 460 vs 178, p0001, increased
fatigue 520 vs 356, p0019, and blurry vision 610 vs 406,
p0004 Cases were also more likely to have high blood pressure 600
vs 356, p0001, and high blood cholesterol 620 vs 218, p0001

Summary

On the one hand, Tthese results confirm: a that obesity is a major risk
factor for type 2 diabetes, b that central obesity ie, the type of
obesity more strongly associated with cardiovascular disease is more
likely among people with diabetesdiabetics based on a higher waist-to-hip
circumference ratio and waist circumference values, and c the
appropriateness of the control group as they had a much lower probability
than cases to experience typical type 2 diabetes symptoms Even though, and
as expected, participants with diabetes diabetics were more likely to have
a close relative with diabetes, it is remarkable
that this was also true
for over 80 of controls Indeed, type 2 diabetes is a major health burden
in this community Furthermore, On the other hand, the fact that the
average BMI of controls fell within the obesity range and that about a
third of controls reported experiencing symptoms suggestiveindicative of
type 2 diabetes; this strongly suggests that there were individuals in the
control group with type 2 diabetes that had never been diagnosed by a
doctor This finding is not surprising as in the USA, 350 of individuals
with type 2 diabetes are not aware that they have the disease

Less than half of the participants 40-48 were confident/very confident
in their ability to achieve healthy weight About two-thirds of the
participants tried within the past 6 months, and were planning to lose
weight within the next 6 months Among those who tried to lose weight,
about 34 think concluded that they their attempt werewas not successful

CHAPTER 3

Nutrition Knowledge

The US government strongly endorses the US Department of Agriculture USDA
Food Guide Pyramid and the Food and Drug Administration FDA food labels
as the key tools to allow consumers to make healthy food choices based
on
current scientific knowledge In addition, researchers have identified
these tools as crucial for improving the glucose control among people with
type 2 diabetesdiabetics Thus, it is essential to understand the level of
nutrition knowledge among cases and controls, particularly, and in
particular their specific understanding of the Food Guide Pyramid and the
food labels This section presents the key results and summarizes their
implications

USDA Food Guide Pyramid

Only 642 of respondents had heard about the Food Guide Pyramid, and there
were with no significant differences p0407 found between cases 670
614 and controls 614 670 Among those who had heard about it
n129, 821 of cases and 869855 of controls p066102 correctly
defined it as a Daily guide for healthy eating

The percentage of cases and controls who knew the correct number of
the food group daily recommended servings for each food group was
distributed as follows: breads and cereals 45 vs 81, p0480399,
vegetables 209212 vs 290, p0285307, fruits 403394 vs 419,
p0850770, dairy 507761 vs 613758, p0228967, meat and other
protein sourcesalternates 3103 vs 339344, p0760620

FDA Food Label

After being shown a sample
food label, tThe majority of cases and controls
indicated, after being shown a sample food label, that they were familiar
with food labelsit, although surprisingly, those with diabetesdiabetics
were less familiar with themlikely to be so 770 vs 871, p0061
Among respondents familiar with food labels n1656, only 377385 of
cases and 307 of controls reported to use them often to select healthier
foods Participants with diabetesDiabetics were less likely than controls
to report never using food labels to make healthier food choices 1952
vs 318

Among cases, 481474 reported never looking at serving size information
inon food labels, and the same was true for 534 of controls Participants
with diabetesDiabetics were more likely to look often for serving size
information when compared with controls 286295 vs 182, p0279
Among those who were familiar with food labels, the percentage of cases and
controls who could recognize were familiar with the food label term daily
value was exceedingly low 156121 vs 148129

Surprisingly, 2995 of participants with diabetesdiabetics and 386 of
controls reported never using food labels to select foods low in fat and
only 416423 of cases and 352 of controls
reported using itdoing so
often For saturated fat, the situation was even worste; as, among those
who were familiar with food labels, 5193 of casesdiabetics and 511 of
controls never used them to select food s low in this nutrient A slightly
higher percentage of cases reported using food labels often to select foods
low in saturated fat when compared to controls 247256 vs 193 With
regards to cholesterol, 312308 of cases who were familiar with food
labels never used them to chose foods low in this compound The percentages
of individuals with diabetesdiabetics and controls who reportinged using
food labels often to choose foods low in cholesterol wasere very similar
364372 vs 386

There was a strong contrast between groups with regards to the frequent use
of food labels to choose foods low in sugar 6759 among casesdiabetics
vs 341 among controls, p0001 Consistent with this, among those who
were familiar with food labels, persons with diabetes diabetics were much
less likely than controls to report never using food labels to choose foods
low in sugar 1697 vs 500, p0001 By contrast, only 221231 of
casesdiabetics and 148 of controls used food labels often to select foods
high in fiber
Over 60 of each group 610603 vs 648 reported never
using food labels to select such foods Likewise, only 289299 of
casesdiabetics and 159 of controls used food labels often to look at the
total carbohydrate content of the food product In fact, over half of each
group 513506 vs 568 reported never using food labels to look at
total carbohydrate content

Only 3907 of participants with diabetesdiabetics and 443 of controls
used food labels often to find out about the caloric content of the food
product About a third in each group never used the food label to look at
calories 3383 vs 375 Likewise, only 364359 of cases and
341344 of controls used food labels often to select food slow in sodium
or salt It is indeed remarkable that, among those who were familiar with
food labels, 4682 of casesdiabetics and 511 of controls never used food
labels to choose foods low in sodium

The proportion looking of participants who looked at the list of
ingredients often was quite low in both cases and controls 312321 vs
227 A lower percentage of casesdiabetics than controls reported never
looking at the food ingredient list 338321 vs 489227
Surprisingly, respondents did not pay a lot of attention to
food label
health food claims as only 429436 of casesdiabetics and 375 of
controls reported doing so often In fact, 2475 of cases and 364 of
controls reported never paying attention to them

Overall, only about 55 of the participants felt confident or very
confident in their ability to use food labels in selecting healthier foods,
while about 64 to 7360-70 of them were confident/very confident about
their ability to reduce total fat, animal fat and cholesterol

Fat, saturated fat, and cholesterol

The overwhelming majority of cases 980 and controls 990 indicated
that people should decrease their fat intake for better health Also, the
great majority correctly stated that reducing fat intake can decrease the
risk of heart disease, and with cases being were more likely to report so
than controls 939 vs 860, respectively, p0063 When given a list
of options, almost all cases 930 and controls 960 were able to
identify French fried potatoes as the food with the highest amount of fat
p0343

A relatively low percentage of cases 390 and controls 406 had heard
about were familiar with the term saturated fat p0817 Among those
who had heard about it n80, cases were significantly more likely
than
controls to select bacon from a list of options as the highest source of
saturated fat 949 vs 780, p004829 However, both groups were as
likely to recognize the fact that animal products usually contain more
saturated fat thanas likely to recognize the fact that animal products
usually contain more saturated fat than vegetable oils 744 vs 683,
p0600549

In cContrasting withto the saturated fat findings, the vast majority of
cases and controls were familiar with the term cholesterol 920 vs
950, p0379 Among those who were familiar with this term n188,
891 of cases and 906 of controls were aware that high fat intake may
raise blood cholesterol levels p0985734 The proportion of study
participants who could correctly that was bable to identify choose
correctly the highest food item with highest source of cholesterol content
from a list of options was slightly higher greater among cases than among
controls 848 vs 792, p0157317

Fiber and carbohydrates

Only 560 of cases and 525 of controls were familiar with the term
carbohydrate p0878 Among those who were familiar with this term
n109, only about half of cases 482 and controls 509 were able
to correctly identify rice from a list
of options as being the closest to
viandas ie, traditional starchy root/tuber vegetables in terms of its
carbohydrate content p0182776 Among those who were familiar with the
term carbohydrate, Tthe percentproportions of individuals who could were
able to correctly identify the indicated foods as either good or poor
sources of carbohydrates wasere distributed as follows among cases vsand
controls: fruits 643 vs 660, p0848, vegetables 143714 vs
189660, p0520544, fruit juices 429 vs 453, p0799, legumes
750 vs 83, p0305, bread rice 618 vs 698, p0382, milk
625 vs 642, p0858, meat 364 vs 415, p0583

The majority of cases and controls were familiar with the term fiber
750 vs 822, p0215 However, among those who were familiar with it
n158, very few cases and controls were able to choose the right
definition type of carbohydrate that cannot be absorbed by the body from
a list of options 133 vs 134, p097588 Surprisingly, only 514 of
casesdiabetics and 598 of controls agreed with the statement that people
should increase their fiber intake for better health p0713291

Summary

Findings presented in this section clearly indicateshow the need for
community-based nutrition education
appropriate for low low-income Latinos
with low literacy levels

First of all, the understanding and level of use of the two key national
tools to make sound food choices ie, The Food Guide Pyramid and the FDA
food labels is very low For example, they were unaware of the daily
recommended servings for most of the food groups, and the overwhelming
majority weremajority was unfamiliar with the daily value term/concept
Thus, it is not surprising that even though the participants in this study
were aware of some nutrition terms such as cholesterol and the importance
of reducing fat intake in the diet, they were unable to demonstrate the
knowledge needed to be able to make wise food choices This indicates the
need ofor effective hands-on food label reading and nutrition education

Second, participants were unaware of specialized terms such as saturated
fat, fiber and carbohydrates This is worrisome as special attention
needs to be paid to these nutrients when designing effective type 2
diabetes prevention and management interventions

Third, there were few differences between participants with
diabetesdiabetics and controls with respect to their nutrition knowledge
This is remarkable
given the necessity forexpectation that persons with
diabetesdiabetics toshould have received culturally competent nutrition
education as part of their disease management program Unfortunately, and
as shown in a subsequent section in this report, this is not the case An
interesting difference between groups was related to the fact that
individuals with diabetesdiabetics appear to concentrate a lot of their
attention on the sugar content of food products However, they are not
paying attention to the total carbohydrate and fiber content This is not
surprising given the fact that few have heard or understanood the meaning
of these terms

Finally, it is disturbing that both casesdiabetics and controls hardly used
the food labels to choose foods low in sodium This is a disturbing finding
because This is unexpected as many of them also reported to have are
hypertensionve or know someone who is

CHAPTER 4

Dietary IntakeFood Consumtion, Meal Consumption, Nutrition Supplements and
Herbal Remedies, and Physical Activity, and Smokingother Lifestyle
Behaviors

Dietary Intake Patterns

Non parametric statistical testing indicated that there were no differences
in the median daily intake
of the following foods when comparing diabetics
with controls: fruit 10 vs 071 times/day, legumes 057 vs 042
t/d, viandas 014 vs 014 t/d, green leafy vegetables 042 vs 042
t/d, milk 100 vs 100 t/d, cheese and yogurt 032 vs 028 t/d,
meats chicken, beef, pork, ham 100 vs 100 t/d, fish and shellfish
007 vs 014 t/d, eggs 014 vs 021 t/d, pasta, breads, and cereals
200 vs 200 t/d, 100 fruit juices 029 vs 050 t/d, artificial non-
carbonated drinks sunny delight, tang, kool aid 014 vs 028 t/d, high
fat/high sodium snacks potato chips, nachos 005 vs 007 t/d

Diabetics had a significantly lower median intake than controls of regular
soft drinks 003 vs 036 t/d, p0001, regular sweets and desserts 003
vs 014 t/d, p0001, and
tomatoes and other vegetables 036 vs050 t/d, p0019

Meal Consumption

The vast majority of cases and controls reported that they usually cooked
meals at home 900 vs 950, p0173 However, casesdiabetics were less
likely than controls to be the food shopper 810 vs 941, p0005 All
but one of the 201 participants ate Puerto Rican or other Hispanic foods,
and 602 of them the participants ate them every day Even though cases
were more likely than controls to eat breakfast every
day 66570 vs
406, p00001, it is disturbing that more than a third of them skipped
breakfast at least once per week Two major reasons that participants with
diabetesdiabetics gave for skipping breakfast wasere lack of appetite and
not feeling wellhungry Less than half of casesdiabetics and controls ate
lunch every day 450 vs 366, p0228 with lack of appetite being
the major reason given by both groups for skipping lunch at least once per
week Dinner was the meal that was most likely to be consumed every day by
cases and controls 8340 vs 750, p012315, and with lack of
appetite, being once again, was the main reason for skipping this meal

Participants with diabetesDiabetics were somewhat less likely to sometimes
eat away from home ie, in restaurants than controls 596 vs 6893,
p0151 Among those who ate out, diabetics tended to eat out less
frequently than controls 20 22 times/month vs 28 41 times/month,
p0173 Overall, they were less likely than controls to eat at fast
food restaurants more frequently at least once a month 680 vs 818,
p0025, but this difference was not significant among fast food consumers
n170; 890 vs 861, p0562 When asked directly how often they ate at
fast
food restaurants, diabetics were less likely than controls to report
eating fast foods at least once per month 790 vs 919, p001 Among
fast food consumers n170, there was no difference in the frequency of
monthly consumption between cases and controls 3869 times/month vs
3639 times/month, p0761 The most popular fast food outlets were
those serving Chinese food, pizza, and hamburgers Thus, it appears as if
most of the Hispanic food consumption takes place at home

Dietary Intake Patterns

Non parametric statistical testing indicated that there were no differences
in the median daily intake of the following foods when comparing
participants with diabetesdiabetics towith controls: fruit 10 vs 071
times/day, legumes 04357 vs 05742 t/d, viandas 014 vs 014 t/d,
green leafy vegetables 0432 vs 0432 t/d, milk 100 vs 100 t/d,
cheese and yogurt 032 vs 0298 t/d, meats chicken, beef, pork, ham
100 vs 100 t/d, fish and shellfish 007 vs 014 t/d, eggs 014
vs 021 t/d, pasta, breads, and cereals 200 vs 200 t/d, 100 fruit
juices 029 vs 050 t/d, artificial non-carbonated drinks sunny
delight, tang, kool aid 014 vs 0289 t/d, high fat/high sodium snacks
potato chips, nachos 005 vs 0075
t/d

Participants with diabetesDiabetics had a significantly lower median intake
than controls of regular soft drinks 003 vs 036 t/d, p0001, regular
sweets and desserts 003 vs 014 t/d, p0001, and
tomatoes and other vegetables other than starchy root and green leafy
types 036 vs050 t/d, p0019 than controls Rafael: Did you leave the
artificially sweetened beverages and desserts out on purpose?

Nutrition Supplements Herbal Remedies

Four out of every ten study participants consumed nutritional supplements,
most of them containing multivitamins and minerals There was no
significant difference between diabeticscases and controls with regards to
their probability of consumption of nutritional supplements 390 vs
416, p0709
One out of every three respondents took herbal remedies such as herbal
teas, ginger, cats clawuña de gato and others There was no significant
difference between casesdiabetics and controls with regards to their
probability of consumption of herbal remedies 263 vs 337, p0253

Physical Activity and Smoking

In this study regular exercise was defined as performing physical
activities such as brisk walking, aerobics, and jogging from 3-5 times per
week for at least
20-60 minutes per day Only one-third of participants
reported doing regular exercise, and cases with diabetics being were more
likely than controls to do so 420 vs 290, p0055 However,
participants with diabetes had lower Metabolic Energy Equivalent MET
levels, which was significantly different when housework ie, cleaning
the house or job-related activities are included in the measure
Regardless of other activities, cases had lower levels of moderate
walking, dance, exercising at home and heavy climbing stairs, exercising
at a gym, jogging type physical activity METs

However, diabetics had lower Metabolic Energy Equivalents MET levels,
which was significantly different when housework type activities ie
cleaning the house are included in the measure Exclusion of housework
activities result in indifference for the total and light activity MET
levels Regardless of the housework activities, diabetics have lower
levels of moderate walking, dance, exercising at home and heavy climbing
stairs, exercising at a gym, jogging type physical activity METs

A worrisome finding is that when participants were classified according to
their stages of preparedeness for change in physical activity,
only 1715
were in the maintenance stage and 1810 in the action stage The rest were
either in the preparation 1265, contemplation 1956 or more likely,
the precontemplation 3265 stage

Furthermore, about one-third of the participants thoughtink that exercising
iwas difficult, and about 308 of the participantsthem dido not feel
confident in their abilityies to exercise regularly A variety of reasons
were given for not exercising: Percentages are of those who do not
exercise, and they are shown for cases vs controls vs casesdiabetics
Differences are not statistically significant
Health problems: 190 vs 109 vs 16

Busy/do not have time for it: 40 vs 1319 vs 4
Work: 30 vs 50 vs 3
I feel lazy: 90 vs 1099 vs 9
Family obligationsCaretaker for a family member, cannot leave house: 10
vs 50 vs1
Cold wWeather: 20 vs 869 vs 3
No desire/motivation/do not feel need for itDo not like it/no motivation
or desire: 40 vs 670 vs 4
No appropriate environment to do it: 0 vs 20 vs 0
Get tired easily/shortness of breath: 60 vs 10 vs5
No companion to exercise with: 30 vs 120 vs 3
Do not need any more exercise than the current level: 3 vs3

One out of every four respondents
indicated that they were current smokers
and almost half indicated that they had been smokers at some point in their
lives There were no differences between diabeticscases and controls with
regards to the prevalence of being a current 260 vs 257, p0967 or
everformer 480 vs 436, p0528 smokering

Summary

The documented dietary intake patterns strongly suggest a suboptimal diet
among both diabeticsparticipants with diabetes and controls For example,
the daily frequency of intake of fruits and vegetables iswas very low in
relationship to the official recommendation of at least 5 daily servings of
a variety of fruits and vegetables per day It is indeed very worrisome
that the daily intake frequency of consumption of tomatoes and other of
vegetables other than starchy root or green leafy types was lower among
individuals with diabetesdiabetics Consistent with their food label
behaviors, it appears as if the only dietary message that people with
diabetesdiabetics are more aware of than controls is related to sugar
consumption as reflected by their lower median frequency of intake
frequency of soft drinks, sweets, and desserts Thus, it is imperative that
the community receives more
detailed and appropriate information related to
carbohydrates and fiber, and not just onto refined sugar consumption
Because all but one of the 201 participants consumed Puerto Rican or other
Hispanic foods and 602 of them consumed them every day, it is imperative
that this information be provided in a culturally appropriate manner that
is inclusive of Puerto Rican/Hispanic foods The use of community
paraprofessionals to support such efforts is recommendedessential that
culturally competent community paraprofessionals get involved with these
efforts Likewise, fast food consumption is widespread; thus, it is also
very important to work with fast food outlets to improve the food choices
available to the target community Lack of appetite and not feeling hungry
wasere consistently mentioned by both groups as a reasons for skipping
breakfast, lunch, and/or dinner This may reflect in part the large
prevalence of depression symptoms data not shown in this report45 of
study participants had symptoms suggestive of clinical depression
Rafael: why data not shown?, GD and calls for providing nutrition and
health education and support within a system that must include community-
based and
culturally appropriate psycho-social support As shown in the
previous and subsequent sections, this this refers to what? Skipping
meals or depression?the need for a strong and efficient network of type 2
diabetes community health promoters/promotoras is an inference that
constantly comes out from the data presented in this report Skipping meals
is a serious concern among the general population but it is even a bigger
concern among people with diabetesdiabetics whose blood sugar levels may be
negatively impacted by prolonged fasting periods

Findings call for the absolute need to coordinate dietary with physical
activity counseling As with dietary advisce, it is imperative that we
understand the types of cognitive, infrastructural, and cultural barriers
that will need to be addressed to convince the community to improve their
fitness and health through physical activity The sSmoking rate in this
community is quite high and also deservesmust to be addressed through
culturally competent cost-effective interventions

Findings also indicate that health care providers need to be aware of the
types of nutritional supplements and herbal remedies used by this community
and their reasons for
doing so Once again, this effort will require strong
participation from key community informants

CHAPTER 5
Food Insecurity

According to the World Health Organization and The US Department of
Agriculture, Hhousehold food security is defined as access, at all times
for all household members, to a diet of sufficient quantity and quality
through socially acceptable means that leads to an active and healthy
life Reference? In this study, we measured household food insecurity
using the 6-item USDA food security/hunger scale This scale includes
questions related to scarcity of food and/or consumption of diets of poor
nutritional quality during the 12 months preceding the survey because of
lack of money The scale also probes for hunger by asking participants if
during the previous 12 months they ever went hungry because they could not
afford enough food Households with participants who answered positively to
none or 1 question were classified as food secure Those who answered
positively to 2 to 4 questions were classified as food insecure without
hunger, and those with a total score of 5 or 6 as food insecure with hunger
ie, the most extreme case of food insecurity Only 433 of
households
were considered food secure, 289 attended food pantries, and 483 were
receiving food stamps Because 706 were receiving either food stamps or
accessing food pantries, results indicate that a substantial proportion of
participants not enrolled in these programs were also food insecure Among
those with food insecurity n114, participants with diabetes were almost
twice as likely as controls to live in households experiencing hunger
260 vs 139, p0027

Summary

A high proportion of participants lived in food insecure households and
relied on food stamps and/or food pantries for their food needs A
substantial proportion of participants not enrolled in food stamps were
also food insecure as they had to access food pantries These findings call
for efforts to improve access to a healthy diet by this community These
efforts need to involve strategies to help understand why in such an
impoverished community almost half of participants were not receiving food
stamps The increased likelihood of hunger among people with diabetes is
very worrisome and needs to be fully addressed as these very vulnerable
individuals are experiencing the burden of serious food insecurity
These
community -wide efforts need to be implemented in full partnership with
government and non-government food assistance programs

CHAPTER 56

Diabetes Knowledge

Biomedical and disease management

Cases were significantly more likely than controls to know that there are
two main different types of diabetes known, type 1 and type 2 910 vs
760, p0006 CasesDiabetics were also more likely to know: that a
fasting blood sugar level of 210 is too high 920 vs 700, p0001,
what gestational diabetes is 720 vs 580, p0041, that shaking and
sweating are not signs of high blood sugar 240 vs 90, p0001, that
diabetes can damage the kidneys 980 vs 820, p0001, the meaning of
a glycosylated hemoglobin test 602 vs 386, p0008, that people with
diabetesdiabetics should check their blood sugar before meals and at
bedtime 940 vs832, p0001, that people with diabetesdiabetics need
to monitor their blood sugar daily even if their doctor did a hemoglobin
A1c test 540 vs 386, p0011

CasesDiabetics and controls were equally likely to know that diabetes risk:
is higher among minority groups 740 in both groups, and is higher for
children of people with diabetesdiabetics than for children of
people
without diabetesnon-diabetics 919 vs 910, p0357 Cases were also
as likely as controls to disagree with the statement that diabetes
complications cannot can not be prevented 660310 vs 584347,
p0328 Cases were less likely than controls to respond that they didnt
know when asked if it was true that both, type 1 and type 2 diabetes can be
cured 20 vs 170, p0001 However, they were not significantly more
likely to provide the correct answer 760 vs 680

Exchange System

The dietary exchange system was created by the American Dietetic
Association and the American Diabetes Association Its original intention
was to help diabetics and people with diabetes and other chronic illnesses
to properly manage their diseases Since then, the principles of the
exchange system have also been used for weight reduction programs This
system is based on categorizing foods into groups, depending on their
carbohydrate, protein and fat content, and then, allowing the exchange of
foods with similar nutrient levels the principle that it is important to
teach individuals the caloric FYI:the system is actually based on 3
macronutrients, not just calories For instance, equivalency of foods
within a group
eg, bread, rice, viandas and among groups eg, corn is
often times listed as a vegetable but because it has almost as much
carbohydrate as white rice, in this system, it becomes a bread/starch
exchange The number of daily exchanges allowed depends on the
individuals caloric needs and desired caloric breakdown from protein, fat,
and carbohydrates Thus, this system can benefit patients by allowing more
variety in their diets; at the same time, that they learn to monitor their
caloric intake by learning how to measure portion sizes and the amounts of
calories in different foods derived from protein, fat and carbohydrates
Not surprisingly, DIPAL documented that only 120 of casesdiabetics and
59 of controls were familiar with the exchange system p0133 Because
of the high prevalence of obesity in both groups and the relevance of
adequate dietary management of type 2 diabetes patients, it is important to
develop culturally-competent counseling services that teach Latinos how to
measure portion sizes and how to determine the number and types of
exchangesfoods that they should consume daily to meet the diet recommended
by their health providers Obviously, this is a major challenge as this
has
to happen within the context of severe socio-economic, literacy, language,
and health care access constraints Undoubtedly, this effort will require
multi-institutional partnerships with strong representation and
participation from the target community

Summary

The results presented in this section show on the one hand that
participants with diabetesdiabetics tend to have more knowledge than
controls with respect to specific biomedical and disease management issues
related to this disease This, of course is not surprising However, even
among those with diabetesdiabetics, this knowledge is far from universal
see section xx, , a situation that is strongly indicative of the
inadequate level of lack of adequate counseling and care that these
individuals have had Because type 2 diabetes is so endemic in this
community, as illustrated by the exceedingly high percentage of controls
who have a close relative with diabetes, it is important to educate the
public at large and not only the ones with diabetesdiabetics on these very
relevant topics

CHAPTER 6

Dietary Intake, Meal Consumption, Nutrition Supplements and Herbal
Remedies, and Physical Activity and Smoking

Dietary
Intake

Non parametric statistical testing indicated that there were no differences
in the median daily intake of the following foods when comparing diabetics
with controls: fruit 10 vs 071 times/day, legumes 057 vs 042
t/d, viandas 014 vs 014 t/d, green leafy vegetables 042 vs 042
t/d, milk 100 vs 100 t/d, cheese and yogurt 032 vs 028 t/d,
meats chicken, beef, pork, ham 100 vs 100 t/d, fish and shellfish
007 vs 014 t/d, eggs 014 vs 021 t/d, pasta, breads, and cereals
200 vs 200 t/d, 100 fruit juices 029 vs 050 t/d, artificial non-
carbonated drinks sunny delight, tang, kool aid 014 vs 028 t/d, high
fat/high sodium snacks potato chips, nachos 005 vs 007 t/d

Meal Consumption

The vast majority of cases and controls reported that they usually cooked
meals at home 90 vs 950, p0173 However diabetics were less likely
than controls to be the food shopper 810 vs 941, p0005 All but
one of the 201 participants ate Puerto Rican or other Hispanic foods and
602 of them ate
them every day Even though cases were more likely than
controls to eat breakfast every day 657 vs 406, p00001 it is
disturbing that more than a third of them skipped breakfast at least once
per week Two major reasons that diabetics gave for skipping breakfast was
lack of appetite and not feeling well Less than half of diabetics and
controls ate lunch every day 450 vs 366, p0228 with lack of
appetite being the major reason given by both groups for skipping lunch at
least once per week Dinner was the meal that was most likely to be
consumed every day by cases and controls 830 vs 750, p0123 with
lack of appetite being once again the main reason for skipping this meal

Diabetics were somewhat less likely to sometimes eat away from home than
controls 596 vs 693, p0151 Among those who ate out, diabetics
tended to eat out less frequently than controls 20 22 times/month vs
28 41 times/month, p0173 When asked directly how often they ate at
fast food restaurants, diabetics were less likely than controls to report
eating fast foods at least once per month 790 vs 919, p001 Among
fast food consumers n170, there was no difference in the frequency of
monthly consumption between cases and
controls 3869 times/month vs
3639 times/month, p0761 The most popular fast food outlets were
those serving Chinese food, pizza, and hamburgers Thus, it appears as if
most of the Hispanic food consumption takes place at home

Nutrition Supplements Herbal Remedies

One out of every three respondents took herbal remedies such as herbal
teas, uña de gato and others There was no significant difference between
diabetics and controls with regards to their probability of consumption of
herbal remedies 263 vs 337, p0253

Physical Activity and Smoking

In this study regular exercise was defined as physical activities such as
brisk walking, aerobics, jogging from 3-5 times per week for at least 20-60
minutes per day Only one-third of participants reported doing regular
exercise with diabetics being more likely than controls to do so 420 vs
290, p0055 However, diabetics had lower MET levels, which
was
significantly different when housework type activities ie cleaning the
house are included in the measure Exclusion of housework activities
result in indifference for the total and light activity MET levels
Regardless of the housework activities, diabetics have lower levels of
moderate walking, dance, exercising at home and heavy climbing stairs,
exercising at a gym, jogging type physical activity METs

A worrisome finding is that when participants were classified according to
their stages of prepardeness for change in physical activity, only 171
were in the maintenance stage and 181 in the action stage The rest were
either in the preparation 126, contemplation 196or more likely, the
precontemplation 327 stage Furthermore, about one-third of the
participants think exercising is difficult, and about 30 of the
participants do not feel confident in their abilities to exercise
regularly

A variety of reasons were given for not exercising: Percentages are of
those who do not exercise, and they are shown for controls vs diabetics
Differences are not statistically significant
o Health problems: 10 vs 16
o Busy/do not have time for it: 13 vs 4
o Work: 5 vs 3
o I
feel lazy: 10 vs 9
o Caretaker for a family member, cannot leave house: 5 vs1
o Cold weather: 8 vs 3
o Do not like it/no motivation or desire: 6 vs 4
o No appropriate environment to do it: 2 vs 0
o Get tired easily/shortness of breath: 1 vs5
o No companion to exercise with: 1 vs 3
o Do not need any more exercise than the current level: 3 vs3

One out of every four respondents indicated that they were current smokers
and almost half indicated that they had been smokers at some point in their
lives There were no differences between diabetics and controls with
regards to the prevalence of current 260 vs 257, p0967 or ever
480 vs 436, p0528 smoking

Summary

The documented dietary intake patterns strongly suggest a suboptimal diet
among both diabetics and controls For example, the daily frequency of
intake of fruits and vegetables is very low in relationship to
recommendation of at least 5 servings of a variety of fruits and vegetables
per day It is indeed very worrisome that the daily frequency of
consumption of tomatoes and other vegetables was lower among diabetics
Consistent with their food label behaviors, it appears as if the
only
dietary message that diabetics are more aware of than controls is related
to sugar consumption as reflected by their lower median frequency of intake
of soft drinks, sweets, and desserts Thus, it is imperative that the
community receives more detailed and appropriate information related to
carbohydrates and fiber and not just on refined sugar consumption Because
all but one of the 201 participants consumed Puerto Rican or other Hispanic
foods and 602 of them consumed them every day, it is essential that
culturally competent community paraprofessionals get involved with these
efforts Likewise, fast food consumption is widespread thus it is also very
important to work with fast food outlets to improve the food choices
available to the target community Lack of appetite was consistently
mentioned by both groups as a reason for skipping breakfast, lunch, and/or
dinner This may reflect in part the large prevalence of depression
symptoms data not shown in this report and calls for providing nutrition
and health education and support within a system that must include
community-based and culturally appropriate psycho-social support As shown
in previous and subsequent sections, this is
an inference that constantly
comes out from the data presented in this report Skipping meals is a
serious concern among the general population but its even a bigger concern
among diabetics whose blood sugar levels may be negatively impacted by
prolonged fasting periods

Findings call for the absolute need to coordinate dietary with physical
activity counseling As with dietary advise, it is imperative that we
understand the type of cognitive, infrastructural, and cultural barriers
that will need to be address to convince the community to improve their
fitness and health through physical activity The smoking rate in this
community is quite high and also deserves to be addressed through
culturally competent cost-effective interventions

Findings also indicate that health care providers need to be aware of the
types of nutritional supplements and herbal remedies used by this community
and their reasons for doing so Once again, this effort will require strong
participation from key community informants

Food Insecurity {Yu-Kuei/Sofia: Move this chapter before Diabetes Knoweldge
Chapter 5}

Household Ffood security is defined as access, at all times for all
household members, to a diet
of sufficient quantity and quality through
socially acceptable means that leads to an active productive and healthy
life Reference? In this study, we measured household food insecurity
using the 6-item USDA food security/hunger scale Thise scale includes
questions related to scarcity of food and/or consumption of diets of poor
nutritional quality during the 12 months preceding the survey because of
lack of money The Sscale also probes for hunger by asking participants if
during the previous 12 months they ever went hungry because they could
notnt afford enough food Households with participants who answered
positively to none or 1 question were classified as food secure Those who
answered positively to 2 orto 34 questions were classified as food insecure
without hunger, and those with a total score of 5 or 6 as food insecure
with hunger ie, the most extreme case of food insecurity Only 433 of
households were considered food secure, 289 attended food pantries, and
483 were receiving food stamps Because 706 were receiving either food
stamps or accessing food pantries, results indicate that a substantial
proportion of participants not enrolled in these programsfood stamps were
were
alsoindeed quite food insecure Among those with food insecurity
n114, participants with diabetesDiabetics were almost twicetwice as
likely as controls to live in households experiencing hunger 448260 vs
250139, p003127

Summary

A high proportion of participants lived in food insecure households and a
substantial proportion relied on food stamps and/or food pantries for their
food needs A substantial proportion of participants not enrolled in food
stamps were alsoindeed quite food insecure as they had to access food
pantries These findings call for efforts to improve access to a healthy
diet by this community These efforts need to help understand why in such
an impoverished community almost half of participants were not receiving
food stamps The increased likelihood of hunger among people with
diabetesdiabetics is very worrisome and needs to be fully addressed as
these very vulnerable individuals are experiencing the burden of serious
food insecurity These community wide efforts need to be implemented in
full partnership with government and non-government food assistance
programs

CHAPTER 7

Health Perception, Health Insurance and Access to Health Care

Only 130 of participants
self-assessed their health as either very good
or excellent As expected, participants with diabetesdiabetics were
significantly more likely than controls to report their health status as
either fair or poor 700 vs 486, p0003 Consistent with this,
casesdiabetics were also morel likely to report that they required
hospitalization with overnight stay at least once during the year preceding
the interview 130 vs 50, p0046 Cases Diabetics were less likely
than controls to have been without medical insurance during the year
preceding the survey 140 vs 277, p0017 Among those who had
insurance, Mmedical insurance coverage was provided mainly by Medicaid
723, with Medicare covering only 88 of participants

Diabetes Health Care

For 867 of casesdiabetics n100, their diabetes care was provided by a
family physician generalist The prevalence of visits to health care
specialists by participants with diabetesdiabetics during the 12 months
preceding the survey was as follows: optometrist 680, podiatrist
270, diabetes educator 333, and dietician 30055654 The main
reason given by respondent for not having seen a dietician during the
previous years was that she was not referred by a doctor

In
terms of diabetes care follow-up during the year preceding the survey,
results indicated that: 6106 received a hemoglobin-aA1c test, 91009 a
blood cholesterol test, and 94039 a urine analysis Almost 760 of
casesdiabetics indicated that they check their feet daily, and 880
reported that they monitored their blood glucose; however, 263 of
participants with diabetes did not check their blood glucose dailyalthough
209 did not do it daily during the previous week

An overwhelming majority of the participants percent 930 felt that
diabetes care could be better for most people

Summary

Findings indicate that these low-income Latinos with type 2
diabetesdiabetics have little access to specialized health care
professionals such as podiatrists, diabetes educators, and dieticians Our
experience strongly suggests that this is not due to lack of interest from
affected individuals but rather to their lack of economic resources and
health insurance coverage to access these vital services and/or lack of
referrals by general physicians The strong reliance on Medicaidare by this
diabetic community indicates that any further cuts into this program are
likely to affect enormously the well- being of
people with type 2
diabetesics It is crucial to incorporate community paraprofessionals
thatwho serve as liaisons within the health care system to improve access
and quality of care to Latinos with diabetes diabetics In aiming toward
thisToward this goalend, it is essential to identify the community members
whothat have been successful at managing their diabetes and fully
understand the barriers that need to be overcome, so they can be role
models and provide support for their peers to followbe able to do so

CHAPTER 8

Conclusions and Recommendations

Nutrition Knowledge and Behaviors

Nutrition knowledge about Food Guide Pyramid FGP, macronutrients and food
labels are not significantly different between controls and diabetics
Only about half of the participants could recognize what the FGP is for,
and the vast majority of them did not know the recommended servings of
food groups
Average intake frequency of fruits and vegetables including starchy
vegetables and fruit juice is about 236 per day, while the FGP
recommendation is 5 to 9 servings per day
The Mmajority of the study participants recognized that decreasing total
fat intake is better for health and
heart health in particular Among
the types of fats, they knew about cholesterol most 75 to 95
However, most majority of the participants did not know about saturated
fat, carbohydrates and fiber
Food label: Although statistically not significant, less number of
dDiabetics knew what theIindividuals with diabetes tended to be less
familiar with food labels is for 770 vs 870 Among those who were
who knew food labelfamiliar with them:
o About 17 to 65 of the participants never used them
o Persons with diabetesDiabetics tended to use food labels more than
controls, but the difference was significant only for selecting low
sugar foods 675833 vs 34150
o The Vvast majority of the participants did not know what daily
value is
Only about 55 of the participants felt confident or very confident in
their ability to use food labels in selecting healthier foods, while
about 640-730 of them were confident/very confident about their ability
to reduce their intakes of total fat, animal fat and cholesterol
Nutrition knowledge about the Food Guide Pyramid FGP, macronutrients
and food labels were not significantly different between
controls and
casesdiabetics
The Vvast majority of persons with diabetesdiabetics are were planning to
lower their fat, animal fat, cholesterol and sodium intakes within the
next 6 months
Although about 99 of the them respondents agreed to the answered, yes
to the statement It is in my control to select can control selecting
foods that are good for my health, about 34 to 43over one-third of them
also agreed to the statement It is up to others for me to eat
healthier

Recommendations

Provide education about
o FGP, specifically about recommended servings of food groups
Emphasize fruit and vegetable intake
o Total fat, saturated fat, carbohydrates, fiber, and sodium, including
their sources, and importance for disease prevention and management
o How to use food labels, and the importance of using them to select
healthier foods Trying to figure out if the absolute amounts are
high, medium or low for any given nutrient may be too complicated for
people with lower education levels With the current food labels, use
of daily value section should be encouraged because it provides
measures easier to
calculate ie, using an analogy for 100 DV and
having 100 dollars to spend each day for that nutrient
Because of the likely presence of external locus of control in selecting
healthier foods, families of targeted individuals should be encouraged to
attend intervention sessions Overcoming possible barriers within the
family or work environment should be explored
Knowledge- and skill-building interventions are critically needed for
those with type 2 diabetes However, considering that this is an at risk
population only about 29 people dido not have any of the major symptoms
of type 2 diabetes, controls and persons with diabetesdiabetics are
similar in their nutrition knowledge and behaviors, and also for the
primary prevention purposes, targeting people with and without
diabetesboth diabetics and non-diabetics seemsis more appropriate
Health literacy skills and health empowerment should be improved among
this population
Develop a network of well trained community health promoters/promotoras
to attain these goals

Physical Activity

Although a greater proportion of casesdiabetics vs controls 42 vs29
said that they exercised
regularly according to our definition, analysis
of their individual activities point otherwise Participants with
diabetesDiabetics had lower MET levels, which was significantly different
when housework or job-relatedtype activities ie cleaning the house
are included in the measure Exclusion of housework activities result in
indifference for the total and light activity MET levels Regardless of
the other housework activities, persons with diabetesdiabetics haved
lower levels of METs for moderate walking, dance, exercising at home
and heavy climbing stairs, exercising at a gym, jogging leisure-time
type physical activitiesy METs
Stages of change, perception of difficulty, and self-efficacy are were
not statistically different between groups About one-third1/3 of the
participants thinkhougth exercising wais difficult About 17 to 4038 of
the participants doid not feel confident in their abilities to regularly
exercise Only about 38 of the participants were in Diabetics tend to
be more in the action andor maintenance stages, while controls tend to be
more in the earlier stages About 18 of both groups said that they
tried to
exercise regularly within the past 6 months, but they were not
successful
AIndividuals who did not regularly exercise, reported variety of
barriers reasons such as health problems, time constraints, family or
job-related obligations, lack of motivation, and absence of suitable
environment or a companion to exercisewere given for not exercising:
Percentages are of those who do not exercise, and they are shown for
controls vs diabetics Differences are not statistically
significant
o Health problems: 10 vs 16
o Busy/do not have time for it: 13 vs 4
o Work: 5 vs 3
o I feel lazy: 10 vs 9
o Caretaker for a family member, cannot leave house: 5 vs1
o Cold weather: 8 vs 3
o Do not like it/no motivation or desire: 6 vs 4
o No appropriate environment to do it: 2 vs 0
Get tired easily/shortness of breath: 1 vs 5
No companion to exercise with: 1 vs 3
o Do not need any more exercise than the current level: 3 vs3

Recommendations

Regular physical activity 150 minutes/week should be encouraged in both
groups, since majority of the participants58 to 71 of them reported no
regular exercise

Physical activity interventions should focus on:
o Increasing the knowledge and awareness about the benefits and the
process of exercising
o Overcoming barriers by providing guidance in:such as becoming familiar
with the exercise process especially for those who think getting
tired easily as a barrier, time management, other options in cold
weather, increasing activities in the house, options at work
o Building social support eg, neighborhood walking activities

Weight Control

Persons with diabetesDiabetics have had greater overall BMI and central
obesity measures [waist-to-hip ratio WHR, waist circumference WC],
all statistically significant
About Between 83 control andto 9089 diabetic of participants are
were overweight or obese by BMI More than 80About 66 to 91 of them
have had th e high risk central obesity measured by either WHR or WC
About Less than half of the participants 40-48 were confident/very
confident in their ability to achieve a healthy weight, and
Aalmostbout two-thirds of the participants tried within the past 6
months, and were planning to lose weight within the next 6 months
Among those who
tried to lose weight, close toabout 34 thoughtink that
they were not successful

Recommendations

Extremely high rates of overweight/obesity in both groups, and the
positive association between obesityweight and diabetes call for
intervention for weight control
Confidence- building, overcoming barriers ie resisting food
temptations, and dealing with previous failed attempts should be
addressed within the intervention
Weight control intervention should include both dietary and physical
activity aspects, since other literature studies support the higher
effectiveness of a combined approach rather than dietary control alone

Acculturation

Recommendations

Materials should be appropriate for Puerto Rican culture, and be available
in both languages, English and Spanish
Community paraprofessionals/peer counselors are
needed to address these
issues

Food Security

Persons with diabetesDiabetics were more likely to be severely food
insecure than controls

Depression

Although data was not shown in this report, controls and casesdiabetics
showed similar rates of mild to moderate 11-12 and major depression
symptoms 45

Alcohol Intake Aand Cigarette Smoking

Whereas participants with diabetesdiabetics were significantly less
likely than controls to consume alcohol, smoking rates were similar, at
about 26, for both groups

Hypertension Aand High Blood Cholesterol

Persons with type 2 diabetesDiabetics had significantly higher rates of
hypertension 600 vs 360 in controls and high blood cholesterol
620 vs 220 in controls

Recommendations

The conditions of persons with diabetesdiabetics appear to be compounded
by a more severe level of food insecurity in addition to greater rates of
self-reported hypertension and high blood cholesterol levels High
depression levels may be related to food insecurity and other
socioeconomic factors analyses not shown, and these potential barriers
should be considered in future interventions
Low alcohol intake
among persons with diabetesdiabetics should be
supported, since it can complicate the blood glucose control However,
how to deal with alcohol intake should be incorporated into nutrition
education interventions for diabetics
At about 26, the smoking rates in this population study appears isto be
higher than national rates for Hispanic/Latino women 124, from Health,
United States 2002, and closer to the national rates for non-Hispanic
white women 234 Interventions should increase the awareness about
the health risks of cigarette smoking, and inform the population about
available smoking cessation programs However, potential risk of weight
gain upon cessation should be considered and discussed, and incorporated
into weight control programs
High rates of hypertension provide support for including sodium intake
monitoring in the diet-related interventions
The role of the family and kin networks in the management of type 2
diabetes needs to be emphasized This is because only 39 of people with
diabetes reported receiving a lot of support from their immediate family

Access to Health Care

For the vast majority of the persons with type 2
diabetes, 867 of
diabetics n100, their diabetes care was provided by a family physician
generalist The prevalence of visits to health care specialists by
those with diabetesdiabetics during the 12 months preceding the survey
was as follows: optometrist 680, podiatrist 270, diabetes
educator 333, and dietician 300
Diabetics should also have higher access to qualified dieticians and
diabetes educators One of the major reasons for never seeingen a
dietitcian was not being referred by the health care providertheir
doctors

Recommendations

The strong reliance on Medicareaid by this diabetic community indicates
that any further cuts into this program are likely to affect enormously
the well being of persons with type 2 diabetesics It is crucial to
incorporate community paraprofessionals that serve as liaisons within the
health care system to improve access and quality of care to Latino
diabetics Toward this end, it is essential to identify community members
that have been successful at managing their diabetes and fully understand
the barriers that need to be overcome for their peers to be able to do
so

The strong reliance on
Medicaid by this community indicates that any
further cuts into this program are likely to affect enormously the well
-being of persons with type 2 diabetes
Referral to a dietictian should be seen as a priority among programs that
treat people with diabetesdiabetics Furthermore, once the patient has
had an initial consultation with the dietictians, regular follow ups
should also be a priority until the patient shows enough confidence in
following his/her prescribed diet
It is crucial to incorporate community paraprofessionals whothat can
serve as liaisons within the health care system to improve access and
quality of care to Latinos with diabetes diabetics Toward this end, For
this reason, it is essential to identify community members whothat have
been successful at managing their diabetes and fully understand the
barriers that need to be overcome, so they can be role models and provide
support for their peers to to followbe able to do so

Conclusion

Findings from this study demand an integrated response, from healthcare
institutions, legislators and community based service providers, with full
participation from community members in
planning and implementing solutions
to this
serious public health problem Findings from this studyspecifically call
for the establishment of a network of bilingual/bicultural type 2 diabetes
community health promoters/promotoras peer counselors in the Ccity of
Hartford that work within the health care system and serve as key
community liaisonssettings Establishing such a network requires addressing
the complex issues of training, certification, and supervision of health
care community paraprofessionals A network such as this one can only
succeed at a citywide level if it involves the participation and
coordination among all key actors including but not limited to: health care
providers, community agencies and institutions, relevant advocacy groups
and task forces, and the state legislature This social capital
enhancement effort should emphasize the potential role of the family and
kin networks in the management of type 2 diabetes