Predictors of fruit and vegetable consumption in older mostly Hispanic women in Arizona
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Link to Item http://hdl.handle.net/10150/280548 PREDICTORS OF FRUIT AND VEGETABLE CONSUMPTION IN OLDER
MOSTLY HISPANIC WOMEN IN ARIZONA.
by
Karen Yannice Gregory-Mercado
Copyright © Karen Yannice Gregory-Mercado 2004
A Dissertation Submitted to the Faculty of the
GRADUATE INTERDISCIPLINARY PROGRAM IN NUTRITIONAL SCIENCES
In Partial Fulfillment of the Requirements For the Degree of
DOCTOR OF PHILOSOPHY
In the Graduate College
THE UNIVERSITY OF ARIZONA
2004 UMI Number: 3132224
Copyright 2004 by Gregory-Mercado, Karen Yannice
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entitled Predictors of Fruit and Vegetable Consumption in Older Mostly Hispanic
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SIGNED: 4 ACKNOWLEDGMENTS
This dissertation scripts the end of what was once just a hope and a dream in my mind. It marks the milestone of exciting professional possibilities. This task would have not have been possible if the many people who encouraged this venture had not been part of my life. I will like to give my thanks to the members of my committee for their continuous guidance, support, and encouragement throughout ali the "stages of dissertation" my major advisor, true mentor, and friend, Lisa Staten, Ph.D. who lent valuable expertise, supported my ideas, trusted me, and kept me focused. I also want to thank Cynthia Thomson, Ph.D. and Anna Giuliano, Ph.D.whose nutrition knowledge provided valuable research guidance. And a debt of gratitude to the other members of my committee Stuart Cohen, Ph.D., Sheila Parker, Ph.D. 1 also need to thank James Ranger-Moore. Ph.D. who has a magnificent working knowledge of statistics, and provided precious investigation assistance. I will like to thank Jim Marshall, Ph.D., Earl Ford, Ph.D. and Julie Will, Ph.D., whom acted as co-authors in my manuscripts and gave me their editorial assistance. I will like to give special thanks Jose Guillen whose words of support and friendship, together with his imiate ability to make statistics appear less complicated, help me throughout the entire process. I would like to thank the Behavioral Measurement Shared Service Core of the Arizona Cancer Center, particularly Vcrn Hartz and Robin Whitacre, whose patiencc and availability were important in the compilation of my nutritional data. Special thanks to all the WISEWOMAN project participants who willingly gave part of their precious time to the study. I want to give special thanks to all those close family members and old friends whose continuous support, long distance calls, and sporadic visits to "get me out of my routine" added that true zest to my daily routine. Thanks to Edwin, my first and everlasting mentor, who helped to start me off on this educational journey with his recommendation letters and continuous support words. A lifetime of gratitude goes to my old best friends Edgardo, Luis. Totie, and Elvin whose calls and support has been the best means of genuine support. Thanks to my special friends Roberto, William, Lizary, and Corey whose closeness and sense of humor were vital in my day-to-day. Finally, 1 am most grateful and dedicate this work to my parents, Ana and Efren, my sister, Lorna, my brother Chiqui, my sister in law Vero, my grandmother. Carmen, my uncle, Panchi, my cousin Zory, and my niece and nephews Anibal, Adriana, and Jay for their incessant encouragement, support, unconditional love, and for their help in keeping my life balanced during this process. They enrich my life with wittiness, and intellect. They have supported my dreams since the beginning and longed for the day to come when this dissertation was completed. 5
DEDICATION
I want to dedicate this dissertation to the two people that have made this
possible: my dad and my mom. Efren Gregory-Ramirez and Ana Mercado-Sorrentini,
whom planted a seed of ceaseless and perpetual curiosity in my mind, whom always
encouraged me to do the best I could, and always believed in me.
My parents with whom I constantly shared my happiest and worrisome moments and whose kind and loving outlook and wisdom always helped me to go inward and try
to focus on the big picture.
I love you too much, you arc my blessing.
Thanlc You 6
TABLE OF CONTENTS
LIST OF FIGURES 10 LIST OF TABLES 11 ABSTRACT .....12 INTRODUCTION 14 Explanation of the Problem and Its CoHtext 14 Overview 14 Hypothesis and Specific Aims 16 BACKGROUND AND LITERATURE REVIEW 18 Sociodemographics, Health, and Diet ofU.S. Hispanics 18 Sociodemographic and Health Characteristics 18 Acculturation Among Mexican Americans 22 Hispanics Patterns of Health Risk...... 26 Hispanic Mortality...... 27 Hispanic Morbidity 29 Diet profiles ....30 Fruit and Vegetable Consumption 34 Frait and Vegetable Consumption, Sociodemographic, and Acculturation Factors 36 Fruit and Vegetable Consumption and Behavioral Factors ...... 41 Stages of Changes and Diet Behavior 43 Summary...... 46 OVERVIEW OF CARDIOVASCULAR DISEASE AND DIABETES AND ASSOCIATED RISK FACTORS...... 47 Cardiovascular Disease 48 Cardiovascular Disease Epidemiology in Mexican Americans 48 Cardiovascular Disease and Risk Factors 49 Cardiovascular Disease and Dietary Modifiable Factors .....51 . Cardiovascular Disease and Fruit and Vegetables .53 Hypertension (HTN) 56 Hypertension and Dietary Modifiable Factors .57 Diabetes 59 Diabetes Epidemiology in Mexican Americans 60 Diabetes Contributing Risk Factors 62 Diabetes Genetic Risk Factors 62 Diabetes and Physiological Risk Factors 64 Metabolic Syndrome and Insulin Function 65 Diabetes and Behavioral Factors 65 Diabetes and Dietary Modifiable Factors .67 7
TABLE OF CONTENTS Continued
Diabetes and Glycemic Index 68 Diabetes and Fniit and Vegetables 70 SunimarA^...... 71 MECHANISMS BY WHICH FRUIT AND VEGETABLE INTAKE ALTERS PATHOGENESIS OF CARDIOVASCULAR DISEASE AND DIABETES...... 73 Pliytociiemicals 73 Cardiovascular Disease and its Pathogenesis 79 Modulation of Key Heart Disease Biological Mechanisms via Plant Constituents 83 Antioxidant Activity. 84 Decrease Platelet Aggregation and Vasodilation 92 Capillar}'' and Vascular Protection. 93 Alteration of Cholesterol Metabolism 94 Blood Pressure Reduction 98 Summary.. 100 Diabetes and its Pathogenesis 101 Modulation of Key Diabetes Biological Mechanisms via Plant Constituents ...... 103 Reducing Cholesterol, Glucose, and Aldose Reductase.... 103 Preventing Pancreas Damage and Promoting Insulin Action 107 Protecting the Heart...... 108 Hypoglycemic Agents in Plants and Spices 109 Summary ...Ill Explanation of Dissertation Format 114 PRESENT STUDY. ..117 Introduction 117 Methods 117 AZ VvTSEWOM AN Study Population 117 Recruitment 118 Intervention Description 119 Fruit and Vegetable Intervention 120 Assessment Measures 121 Data collection 121 ADHS Wellwoman Healthcheck Questionnaire and AZ WISEWOMAN Health Assessment 122 Project Questiomiaires 122 Psychosocial Factors in AZ WISEWOMAN Questionnaires.. 122 Measurements of Acculturation, Stages of Change, and Self-Efficacy 123 Acculturation 123 8
TABLE OF CONTENTS Continued
Stage of Change 124 Self-Efficacy 125 Dietary Data: 24-houi- recalls 127 Estimation of Fruit and Vegetable Intake... 128 Data from National Health and Nutrition Examination Survey III (1988-1994).. 130 Introduction... 130 NHANES III Study Population.. 130 Etlinicity Determination 131 Dietary Intake and Fruit and Vegetable Detemiination.. 131 Data Management and Analyses .131 AZ WISEWOMAN Data Management 131 Statistical analyses 132 RESULTS AND DISCUSSION 141 PAPER 1: DIETARY PROFILES OF ARIZONA AZ WISEWOMAN PARTICIPANTS INDICATE NUTRIENT INADEQUACIES. 141 Introduction..... 141 Synopsis of methods 141 Primary Findings.. 142 PAPER 2: ACCULTURATION AND FRUIT AND VEGETABLE CONSUMPTION OF OLDER MEXICAN AMERICAN WOMEN. 144 Introduction 144 Synopsis of methods 144 Primary Findings 145 PAPER 3: OLDER WOMEN'S SELF REPORTED CHANGES IN FRUIT ANT) VEGETABLE CONSUMPTION: ANALYSES FROM A STAGES OF CHANGE APPROACH ...... 146 Introduction 146 Synopsis of methods 146 Primaiy Findings 147 SUMMARY AND FUTURE DIRECTIONS 149 WORKS CITED 154 APPENDICES 206 APPENDIX A: DIETARY PROFILES OF ARIZONA WISEWOMAN PARTICIPANTS MICATE NUTRIENT INADEQUACIES 206 APPENDIX B: ACCULTURATION AND FRUTT AND VEGETABLE CONSUMPTION OF OLDER MEXICAN AMERICAN WOMEN. 226 9
TABLE OF CONTENTS Continued
APPENDIX C: OLDER WOMEN'S SELF REPORTED CHANGES IN FRUIT ANT) VEGETABLE CONSLMPTION; ANALYSES FROM A STAGES OF CHANGE APPROACH 246 APPENDIX D: SUPPLEMENTAL TABLES ...... 267 Table D.L Demographic characteristics of older AZ WISEWOMAN participants compared to NHANESIII participants with similar demographic characteristics by ethnicity .267 Table D.2. AZ WISEWOMAN participants compared to NHANESIII participants by ethnicity.... 268 Table D.3. Mean Dietary Intake of macronutrients, by ethnicity in AZ WISEWOMAN and NHANES III 269 Table D.4. Mean dietary Intake of micronutrients by ethnicity for women participating in WISEWOMAN and NHANES III .270 Table D.5. Mean dietary intake of minerals by ethnicity for women participating in WISEWOMAN and NHANES IIL 271 Table D.6. Mean dietary intake of fruits, vegetables and legumes by ethnicity for women participating in AZ WISEWOMAN and NHANESIII 272 10
LIST OF FIGURES
Figure 1. Proposed role of LDL oxidation in the initiation of fatty streak lesions 80
Figure 2. Potential cardiovascular benefits of many plant constituents. 84
Figure 3. WISE WOMAN study schematic representation of intervention, diet, and outcomes 116 11
LIST OF TABLES
Table 1. Summary of CVD Risk Factors. .50
Table. 2. Phytochemicals and their proposed biological mechanisms. ...76
Table. 3. Intervention components for provider counseling, health education, and community health worker groups 120
Table 4. Stages of Dietary Change Questions for Fruit and Vegetable Consumption.. 125
Table 5. Items to measure psychological factors: self-efficacy, social support, and weight control motivation. ....126
Table 6. Analysis of variance of macronutrients and their mean values before collapsing 24-hour recalls by participants and their visits 134
Table 7, Analysis of variance of macronutrients and their mean values after collapsing 24-hour recalls by participants 134
Table 8. Analysis of variance of macronutrients, their mean values, and comparison between amounts of 24-hour recalls before collapsing 24-hour recalls by participants and their visits 135 12
ABSTRACT
Recent U.S. statistics indicate continued increased incidence of many chronic diseases. The prevalence of these chronic diseases could be reduced if Americans would modify their eating habits to increase fruit and vegetable (FV) intake to the minimum recommended level of five servings daily. Educational strategies to change eating behavior would benefit from a greater understanding of sociodemographic and psychological factors related to dietary behavior.
A secondary analysis of data collected from 361 older uninsured women participating in a controlled trial of diet and physical activity change conducted Jrom
1998 to 2000 was completed to assess differences between Mexican Americans (MA) and non-Hispanic whites (NHW) in overall nutrient intake. Acculturation and the ability to accurately identify stage of change were examined and related to FV intake.
Significant differences in energy, total fat, total carbohydrate, total protein, alcohol, total monounsaturated fatty acids, total polyunsaturated fatty acids, soluble dietary fiber, thiamin, riboflavin, niacin, folate, pantothenic acid, total vitamin E, calcium, potassium, sodium, magnesium, phosphorus, zinc, copper, selenium, and legume sei-vings a day were found between MA and NHW. Low acculturated MA and NHW had a comparable intake of FV. In contrast, more acculturated MA had a significantly lower intake of FV. Acculturation, education, smoking status, and stages of changes were the most significant predictors of baseline FV intake while only acculturation and backward movement through stages of change predicted change in FV consumption over time based on repeated measure analyses. The imphcations of these research findings are that nutrition interventions to increase FV consumption should be aimed at factors that are predictive of behavior change. In particular the differences by acculturation and stage of change underscore the need for tailoring educational intervention for greater impact.
Given the small sample of our study, the findings need to be interpreted with caution. Policy inference can be suggested jfrom this research, but further research is needed before implementation and changes in nutrition policy recommendations are made. 14
INTRODUCTION
Explanation of the Problem and Its Context
Overview
Increasingly, Americans are being told to eat more plant foods, specifically more fruits and vegetables (FV). Consuming a diet rich in such plant foods will provide a variety of phytochcmicals that have protective effects and specifically, the capacity to reduce chronic diseases (1-9). At present there is a nationwide campaign to increase FV intake: "The 5-a-day for better health program" (10,11). In fact, Americans on average, are eating significantly less than the suggested amounts of 5-9 servings of FV a day (12-
14). Understanding the complexities of numerous factors related to FV consumption and the changes related to food intake will aid in the development of enlianced nutritional messages thus, improving national dietary profiles of Americans, particularly those at increased risk of chronic diseases.
There are several population groups in the U.S. (mainly children and pregnant women) that have benefited from the "5-a Day" message and made behavior changes.
Yet, older and minority women are considered less frequently in the 5-a Day message interventions (15). Minority older populations have been described as being at increased risk of health disparities and as having inappropriate diets (16). Poor diet is a key factor that influences morbidity and premature mortality among older women (17).
Coupled with the trend towards lower income and access to health care services, disease risks may be higher among older women. Many factors including lifestyle, socioeconomic (SES), and psychological characteristics have been shown to 15 significantly influence FV intake. Older adults (50+) have reported deficient daily energy intake and often their dietary habits slip and they fail to eat balanced meals regularly (18). This pattern indicates that not only age may play a significant role in food access or intalce but also, various sociodemograpMc and psychological factors may be playing a synergistic role.
The effects of demographic factors on the demand for fresh FV have been investigated. Shifts in income and other demographic factors contribute to increased
FV intake. Several studies (13,19-21) have demonstrated that most of the variation in
FV consumption has been explained by demographic variables (mainly income and education) and little has been explained by taste (i.e. FV flavor, consistency, etc.) or knowledge. Nevertheless, research suggests that FV demands will increase mainly through increasing awareness of the recommendation to eat five FV a day (13,19-21).
Among others, factors such as acculturation measurements and stages of change (SOC) model classification have been related to changes in food patterns among different populations (22-26). These above factors have been examined less frequently specifically, related to FV consumption in older uninsured low-income minority populations.
Existing information about FV consumption and factors associated with its consumption continue to have limitations inlierent to the methods of data collection, brief food frequency questionnaires, acculturation scales that use a single question, and a SOC model that has been used less fi-equently in older uninsured mostly Hispanic women. The motivation for this study is to identify limitations and barriers related to 16 increased intalce of FV (27,28) and to understand why attempts at behavior change have been ineffective, especially when they have been directed at low-income and minority groups (29-31). By further understanding factors influencing food choices, more effective nntrition intervention programs and media campaigns can be designed.
Investigation of the nature, magnitude, and variability associated with FV consumption are important nutrition and public health issues.
Hypothesis and Specific Aims
The overall purpose of this study was to investigate the association between various sociodemographic (e.g. acculturation), and psychological (e.g. SOC model) factors, and usual dietary intake of FV. Few studies have assessed dietary intake and FV consumption patterns among older (50+ years) uninsured, mostly Hispanic, women. In order to determine dietary profiles and to address how acculturation and the SOC model arc related to FV consumption, data from a comprehensive one-year randomized controlled trial (AZ WISEWOMAN (Well-Integrated Screening and Evaluation for
Women Across the Nation)) were used.
Primary Hypotheses:
Hypothesis 1: There will be no significant difference on the dietary intake and health profile of low income uninsured Arizona Hispanic women, age 50+ years and a national sample of Hispanic women of similar sociodemographic characteristics participating in National Health and Nutrition Examination Survey III (1988-1994).
Hypothesis 2: Acculturation is significantly negatively associated with total FV consumption in low-income older Hispanic uninsured women. 17
Hypothesis 3: Stages of change classification for FV consumption will be no significantly different than actual FV consumption recalled from 24-hour recalls in
Hispanic older, low income, uninsured women.
Specific Aims;
Using data collected from a recently completed randomized controlled trial:
Specific Aim #1. Present energy, nutrient. FV intake and relevant health dietary risks of AZ WISEWOMAN participants by ethnicity, and compare the obtained diet profile to a similar demographic group in the National Health and Nutrition
Examination Survey (NHANES).
Specific Aim #2. Determine the relationship between acculturation and FV consumption in a low income, uninsured, older, predominantly Hispanic female population.
Specific Aim #3. Determine the relationship between baseline SOC and recall based FV consumption in a low income, uninsured, older, predominantly Hispanic female population and determine how initial stage predicts final FV consumption. BACKGROUND ANB LITERATURE REVIEW
Soeiodemographies, Health, and Diet of U.S. Hispanics
The following sections of the introduction include a description of sociodemographic characteristics of the U.S. Hispanic population that are pertinent to health and FV intake. This section is followed by a brief report of chronic disease prevalence. The final section discusses diet (more specifically FV) in relationship to sociodemographic and behavioral factors. In nearly all sections Hispanic data will be presented and compared to NHW and when available specific data from MA and
Arizona will be provided as well. Subsequent sections provide a detailed review of the most prevalent chronic diseases among Hispanics, including biological mechanisms of action, and suggested mechanisms for protection via FV.
Sociodemographic and Health Characteristics
The 2000 U.S. Bureau of the Census defined a "Hispanic" as: "A person of Cuban,
Mexican, Puerto Rican, South or Central American, or other Spanish Culture or origin, regardless of race. Hispanics constituted 13% (38 million) of the entire U.S. population and accounted for 40% of the increase in the nation's total population in the year 2000.
Almost 58%) of all Hispanics and 8% of the entire U.S. population are of Mexican descent (32).
Fifteen percent (42 million) of the U.S. population are women 50+ years and 2.6 million of those women are of Hispanic descent. The older Hispanic population is expected to grow 4% per year from 1990 to 2050 (32-34). Although no projections of older population by ethnic subgroups were found, it is expected that the Hispanic older 19 population will surpass the Afiican American population in that age category (35).
Moreover, by 2025, NHW will comprise 57.5% of Arizona's population, down from current 69.6 % while persons of Hispanic origin are projected to increase from 25% in
2000 to 32.2 % in 2025. This growth rate ranks Arizona's Hispanic population change as the 5^^ largest gain in the U.S. (35). Similar to older groups and other minority ethnic groups, Hispanic older populations include more women than men. There are smaller proportions of older MA men and women in the older age categories when compared to other ethnic groups in the U.S. indicating that even though the life expectancy among
Hispanics is higher than for NHW (79.1 vs. 75.4 years), when independent age categories are considered a smaller proportion of Hispanics are seen in older categories
(36). The increasing rate of low income MA immigrants to the Southwest intensifies nutrition and health issues (18,37-39). Numerous factors that serve as predictors of socioeconomic status (SES) arc closely related to health disparities among minority groups (16,40).
Minority women are disproportionately poor with an increased chronic disease risk compared to white women (14). Twenty-five percent of all Hispanic families in the
U.S. live below the poverty level as compared to 10% NHW (41). Older Hispanic women participate less frequently in the labor force (approximately 15% compared to
NHW 17%). MA tend to hold occupations in the skilled blue collar and unskilled labor positions (41,42). Main sources of income for older Hispanics are private pensions, retirement incomes, and Social Security (42). Some older people have not had occupations that allow them sufficient retirement pensions therefore they continue to 20 work to supplement their income, in addition they are less likely to have graduated from high school and as a result have low paying jobs (42). Women, in general, tend to experience more poverty than men, 27% compared to 19.6%. This poses a serious threat to the quality of hfe for older women and suggests they may struggle economically in their older age and may also place them in a disadvantaged position for getting adequate nutrition. Indeed, it has been shown that as education and income levels increase, the diets of minority women improve (13,21,43). Many other SES characteristics in Hispanics differ from those of NH W.
Hispanic families are generally larger in number than other families in the U.S. and
32% of the families are uninsured (41). One of the most common characteristics of
Hispanic populations is the maintenance of the Spanish language. More than 21% of
Hispanics in the U.S. do not speak English proficiently or at all, despite the fact that the majority of adult American Hispanics were born in the U.S. (44,45). Many factors influence the English language proficiency such as immigration or nativity history, cohort effects, education level, economic background, residence, and geographic area.
Limited English proficiency has been reported as a barrier to accessing medical and social services (46,47). Hispanics who speak English poorly or not at all tend to live in geographically concentrated areas. These linguistic isolations can pose barriers to heath access. MA, bom in the U.S., who speak primarily Spanish, have demonstrated markedly increased levels of risk factors for chronic disease compared to their counterparts who spoke predominantly English (38). What is more, differing interpretations of words may correspond to national origins. An example of this is the 21 cultural norm that influence responses to subjective measures of individual health status, such as "good", "fair", or "poor," which may have very culturally based meanings (41). Hispanics are more likely to report fair or poor health than NHW, despite controlling for illness and SES factors. Leading researchers conclude that self- rated health assessment may be dependent on cultural values and not reflective of objective health measures, particularly among traditional Hispanics (48,49).
Hispanic women of recent migration status are less likely to use health care services than those with earlier immigration status (50). Older MA and recent immigrants are in need of targeted health initiatives because they are often linguistically inaccessible, of low SES (13,51), and their lifestyles choices may increase their morbidity (52). Furthermore, older Hispanics have the least number of education years when compared to other ethnic/racial groups. Understanding and knowledge of beneficial behavior is less hkely to occur with high levels of illiteracy, therefore this population is at increased risk of chronic disease (44,45). Low English proficiency and no education can become barriers for accessing health education information and accessing needed care.
Another SES factor of considerable importance among Hispanics is marital status.
Marital status is one of the 31 key indicators of quality of life of older adults and their families. Marital status affects a person's emotional and economic well being because of living arrangements and caregiver availability. Data from the Hispanic
Epidemiological Studies of the Elderly (H-EPESE), a large multistage probability sample of MA 65+ residing in the Southwestern states of Texas, California, New 22
Mexico, and Arizona (53) indicated that foreign bom MA were more likely to live with others and be married, while native bom MA were more hkely to be head of the household and live alone. It has been argued in the literature whether more elder
Hispanics live with family as a result of health or economic necessity or because of culturally bound expectations governed by norms of mutual reciprocity among families
(53). Also, in the H-EPESE study it was determined that more foreign bom elders tend to live within the family environment because they provide adult children with financial or child care assistance (42). SES factors such as low income, fewer years of education, limited employment opportunities, large family size, and lack of health insurance may affect the health status of the H ispanic population in the U.S. (44). Another important sociodeniographic factor, which plays a significant role in Hispanic health behavior, is acculturation.
Acculturation Among Mexican Americans
Risk status and behavior among Hispanics have been commonly explained by their adoption of attitudes, values, and behaviors of the mainstream culture, this concept is called acculturation (54). Assimilation of one cultural group into another may be evidenced by changes in language preference, adoption of common attitudes and values, membership in common social groups and institutions, and loss of separate political or ethnic identification. Di fferent measures of acculturation are used, including language preference and place of birth, and more complex scales that measure several dimensions of acculturation. 23
Acculturation was once viewed as a one-dimensional continuum, i.e. from belonging to the origin culture to belonging to the host culture, the process now is considered multidimensional. Although assessing language use and preferences has been found to be a reliable measure of acculturation for Hispanics (55), others believe that cultural values, attitudes, and behaviors related to family, peer associations, media use, preference for ethnic food, parental occupation, and length of stay in U.S. should be used to assess levels of acculturation (54,56). Cuellar, Harris and Jasso's (1980)
Acculturation Rating Scale for MA (ARSMA) (54) is frequently used for measuring the process of acculturation. The ARSMA, a Likert-type scale, assesses the acculturation process by measuring movement of cultural orientation from a Mexican culture at one extreme to a U.S. culture to the other extreme (54). The ARSMA is a linear model from identification with the original culture to the assimilation of a new culture. ARSMA measures assimilation rather that integration. Assimilation occurs when an individual has a cultural shift or adopts the language, behaviors, practices, and values of the majority group, while integration takes place when an individual successfully incorporates aspects of both groups and readily identifies and feels a sense of comfort with both groups (54,56,57). Many factors impact the acculturation process: SES, social and emplo3Ament skills, education, gender, and age, among others. As suggested by Berry and colleagues Hispanic females tend to have more difficulty in the process of acculturation than Hispanic males because of the vast differences in treatment of females in the American and Hispanic cultures (58). 24
Evidence of increased health related risk factors as a generation assimilates suggests that environmental factors influence chronic disease risk. Acculturation has been studied in relation to prevalence of chronic illnesses and utilization of health services. Aspects of the lifestyle of particular cultural groups (e.g. dietary habits, patterns of physical activity) may affect the development of specific diseases.
Acculturation may affect the attitudes, beliefs, and values as well as the preferred learning style of individuals (56,59). Acculturation may have an impact on the way
Hispanics view and react to health concerns (59). Beliefs about causes, treatment, and prevention of illnesses may affect the utilization of health services or health behavior modification; these may be affccted by acculturation. Hispanics may hold culturally fatalistic beliefs and attitudes that they have little or no ability to impact their health status by changing health care behaviors (60). Traditionally it has been described that
Hispanics may hold more fatalistic attitudes and beliefs of divine intervention than highly acculturated Hispanics (60). Some other culturally derived beliefs and attitudes are: personalismo, preference for information gathering through person-to-person communication, instead of media or other sources (61); respeto, a premium placed on knowledge of elders and professionals (62); and familialism customary values where family needs supercede the desires of a single person (59,62,63). As a result of these cultural beliefs Hispanics may miss important infomiation or may be reluctant to ask questions regarding their health, or tradition may have precedence over the needs of the individual. These culturally derived health behefs and attitudes may impact dietary 25 practices, weight control, and initiative in increasing health information awareness and use of health care services.
In most studies, acculturation is strongly associated with SES variables, such as education and income (64-66). When adjustments are made for SES, the relationship between dimensions of acculturation and health status or health behavior weakens or disappears altogether. Because acculturation and SES may be closely related in a particular community, research studies must be reviewed carefully to distinguish acculturation effects from those that can be linked to income and education (64-66). As an example, low accuiturated Hispanics have demonstrated low understanding on the importance of diet, exercise, and blood glucose monitoring for prevention, treatment and management of diabetes (65,67,68). Systematized acculturation scales must be incorporated. More than a few acculturation scales have been used to learn about
Hispanics' behavior, mostly with MA. Superior acculturation scalcs allow scientists to segment study populations for intra-ethnic and cross ethnic comparisons, that allow for understanding of the cultural learning and behavioral adaptation that takes place among individuals when exposed to a new culture. This is a complex concept to measure, particularly across cultures and languages. However, when studying a single ethnic group complex acculturation scales can be modified and simplified for convenience and used as a quick instrument to plan culturally appropriate health education or promotion programs (54,55,57). Understanding how acculturation affects food intake is a key concept for diet modification particularly among immigrant groups. 26
U.S. dietary patterns tend to be high in fat and low in FV, this represents a concern when immigrants start to change their traditional eating habits to a dietary pattern that may increase fat and decreased FV intake and thus increase their risks for chronic disease. The effects of acculturation on beliefs, attitudes, and values of Hispanics in the
U.S. are reflected on their health behaviors. Support for the evidence that acculturation to U.S. culture explains a significant portion of health behavior among Hispanics' food and FV consumption is lacking. Further, there has been limited recognition of the role that acculturation may play in studies when examining its influence of health behaviors.
Health related behaviors and lifestyle choices are closely related to the clironic diseases that frequently affect Hispanic populations.
Hispanics Patterns of Health Risk
Behavioral and lifestyle risk factors account for 40-70% of all premature deaths, a third (30-33%) of all cases of acute disability, and two thirds (66%) of all cases of chronic disability (69.70). Hispanic women are less likely than white women to know that being overweight, smoking, physical inactivity, high cholesterol, and a family history of heart disease increase their heart disease risk (71).
The San Luis Valley Health and Aging Study compared self-rated health in
Hispanics and NHW in southern Colorado (49). Illness indicators were strongly correlated with self-rated health in both ethnic groups, Hispanics remained much more likely to report fair or poor health as opposed to excellent or good health than NHW
(OR 3.6; 95% CI 2.4-5.3). Adjustments for SES factors accounted for a portion of the
Hispanic's lower health rating, the strongest explanatory factor was acculturation (49). 27
Hispanic Mortality
For people older than 50, the all-cause mortahty rates are about one-third lower in
Hispanics than for NHW. National surveys conducted by the U.S. Bureau of Census
(32,34) were matched to the National Death Index over a 9-year follow-up period;
40,000 Hispanics were included in the 700,000 respondents, age 25 and older.
Hispanics were shown to have a lower mortality from all causes compared to the mortality rate of NHW (72). Moreover, age-adjusted total mortality rated per 100,000 person years were 1,581 for Hispanic women and 1,897 for NHW women (73).
For example, when broken down by specific diseases, the CVD death rate is lower among Hispanics than NHW. Results from the National Health Interview Survey and the National Center for Health Statistics showed that mortality rates for CHD and sudden cardiac death are lower among Hispanics than NHW. Heart disease accounts for 26.6% of deaths in Hispanic women (74,75). Despite their adverse risk profiles,
MA frequently have lower reported mortality rales from CHD, the so-called "Hispanic paradox". According to the American Heart Association, African-American and MA women have more CVD risk factors than white women of similar SES (76). These results are in agreement with Mosca's report which indicated higher prevalence rates of high blood pressure (HBP), obesity, physical inactivity, diabetes and metabolic s3mdrome in Hispanics and African-Americans than white women (71).
Contrary to the prediction of the "Hispanic paradox," in the San Antonio Heart
Study, Hunt and colleagues argued against the "Hispanic paradox" indicating that MA were at greater risk of all-cause, cardiovascular, and coronary heart disease mortality than were NHW (77). Also, Espino and colleagues indicated that mortality rates among
MA were higher than those of NHW from death caused by diabetes, congestive heart failure, and multiple systemic diseases (30). Ethnic misclassification and incomplete ascertainment of death, via population data aggregation, may explain previous reports favoring the "Hispanic paradox (77)." Mortality rates calculated from cohort studies in which mortality is ascertained over follow-up period, or mortality rates calculated by linking vital registration data to census populations counts may lead to wrong mortality estimates (78). Also conflicting results related to mortality rates among Hispanics may be explained by population differences and differences in the definition of outcomes of interest.
The relative risk of stroke death among Hispanics is about 1.3 times higher compared to NHW at ages 35-64, slightly lower at ages 65-74 and about half that at age
75 or older (76). The Corpus Christi Heart Project reported that among women, definite
CHD mortality was 40% greater among MA (RR. 1.43, 95% CI, 1.12 to 1.82), as was all CHD mortality (RR, 1.32, 95% CI: 1.08 to 1.63) compared to NHW (79).
Cerebrovascular disease is consistently lower in MA versus NWH (76).
Diabetes is twice as common among MA adults compared with NHW (80,81). The diabetes-related mortality rate for Hispanic Americans, as for African Americans and
American Indians, is higher than that for whites (82). Higher rates of diabetes complications have been documented in studies of MA, whereas lower rates of myocardial infarctions have been found (80,81). Regardless of ethnicity, the risk of 29
CHD mortality has been shown to increase in both diabetic and non-diabetic persons
(82).
Hispanic Morbidity
After controlling for age, BMI, diabetes status, cigarette smoking, education, and for prevalence of CVD in MA in the San Antonio Study it was demonstrated that MA are at greater risk of diabetes and renal failure than their NHW counterparts (36).
Incidence and prevalence rates of CVD among NHW were compared to a unique
Hispanic population of the San Luis Valley in Colorado and there was no evidence of lower incidence, prevalence, or mortality due to CHD among Hispanics without diabetes. However, the risk for CHD among diabetic Hispanics was approximately
50% lower than among diabetic NHW (83,84).
Among Mexican woman age 20 and older, 30% have HBP, 45% have total blood cholesterol levels of 200 mg/dL or higher, 42% have low density lipoprotein (LDL) cholesterol levels of 130 mg/dL or higher, and 12% had a BMI of 25 kg/m and higher
(85,86). Of all M A, women whose primary language is Spanish have the highest prevalence of physical inactivity (58%)).
As stated previously, Hispanics are about 1.9 times more likely to have diabetes than are NHW of similar age. Diabetes is more common among middle age and older
Hispanics. For those aged 50+, estimates are that 25-30%) have either undiagnosed or diagnosed diabetes (81). The prevalence of type 2 diagnosed diabetes in a population from Arizona (Nogales and Tucson) (n=4,774), was documented as 22 % among 30 individuals 40 and older (87). Prevalence of physician-diagnosed diabetes among MA aged 20+ is 11.4% with estimates of 3.9% having undiagnosed diabetes.
The metabolic syndrome is defined by the Adult Treatment Panel III (ATP III) as three or more of the following deviations in women: waist circumference greater than
88 cm (35 inches), serum triglyceride level of 150 mg/dL or higher, high density lipoprotein (HDL) level less than 50 mg/dL, blood pressure of 130/85 mm Hg or higher, fasting glucose level of 110 mg/dL or higher (88). Using 2000 census data, about 47 million U.S. residents have the metabolic syndrome. The unadjusted and age-adjusted prevalences of the metabolic syndrome are 21.8% and 23.7%, respectively. MA have the highest age-adjusted prevalence of the metabolic syndrome (31.9%) (89.90). These morbidities and mortalities are highly associated with lifestyle choices, particularly with food intake behaviors. National nutritional monitoring activities that focus on food intake patterns and choices are done to understand and further relate food intake to chronic diseases.
Diet profiles
Historically within the U.S., analyses of national dietary surveys have generated estimates of nutritional profiles and nutritional risks of Hispanics, including MA, Puerto
Ricans and Cubans (91). These profiles traditionally were based on the Continuing
Survey of Food Intakes by Individuals (CSFII), the Diet and Health Knowledge Survey
(DHKS), Behavioral Risk Factor Surveillance System (BRFSS) (92) and Third National
Health and Nutrition Examination Survey, 1988-1994 (NHANES) data. Each of these surveys provides a surveillance system of dietary intakes, health knowledge and 31 outcomes (93-95). CSFII includes questions about knowledge and attitudes toward recommended dietary change, DHKS includes individual's knowledge and attitudes, while the BRFSS gathers information about the lifestyle and health habits of adults aged
18 +. NHANES and the Hispanic Health and Nutrition Examination Surv^ey
(HHANES) provide a comprehensive assessment of biological relationships via collection of self reported data, physical examination and biological specimen collections. Data from these surveillance systems are used to help plan and evaluate health promotion, disease prevention, and monitor progress towards the National
Healthy People Objectives (96.97).
Tlirough these systems, food intake patterns and food choices can be described, FV intervention programs may be developed, and FV intake prevalence may be determined, identification and comparisons of frequently consumed foods among ethnic groups can be accomplished as well. With the information compiled from these surveillance systems, interventions have been developed to meet the nutritional needs of specific communities. However, these national surveys are limited by the number of days of dietary data collected and other methodological limitations. They can provide estimates of usual intakes by individuals, but there are differing opinions about the accuracy of these estimates (29,98).
National surveys are used to monitor nutritional status in the U.S. yet, specific guidelines are needed to determine if the reported intake is complementary to healthy physiological nutrient levels. The Dietary Reference Intakes (DRI) were developed to target specific nutrient needs of several at risk groups (99-103), particularly in two older 32 age groups; 51-70 and 70+ years. The Food Guide Pyramid is another way of providing general nutritional recommendations and a Modified Food Guide P>Tamid for older adults-70+ was developed following the increased concern of elder appropriate nutrient intake (18,104). In general, lower SES and uninsured older women have lower adequacy of nutrient intake (86,90) and their mean reported daily energy intake tends to be lower than recommended. For example, for MA and NHW women aged 60-69, have reported energy and carbohydrate intakes lower than recommended (18). While other studies have reported energy intake levels closer to recommended values (105-107).
This phenomenon of underreporting or low-energy reporting is particularly prevalent among older women and overweight persons (108-110). One trend documented by
HHANES is the intake of fat appears to have declined among MA older women
(111,112 ). Food sources for different ethnic groups are different, and the nutritional content of those food sources may vary considerably, adding more diversity to the nutrient sources. Macronutrients such as protein and fat frequently reported as higher than recommended amounts in older populations (16).
Fiber consumption among the U.S. population has been consistently reported below the recommended amount of 21 g/day. Fiber intake of 12 g/day has been previously reported for MA women aged 20 to 74 years in HHANES (113) while NHANES 111 reported 13.7 g/day for MA and 14.6 for NHW women (114). These intakes are significantly lower than recommendations aimed at reducing the risk of heart disease, diabetes, and cancer. 33
Similar to macronutrient intalces, micronutrient intakes of MA have been, reported as marginally at or below the recommended levels of intake (99-101,115), particiilarly among older populations (16, 99-102). A diet adequate in micronutrient intake is essential for disease prevention and health maintenance. Inadequate intakes of vitamin
Bg and folate may lead to elevated serum homocysteine and subsequent risk of CVD
(116-119). Adequate levels of vitamin E have been shown to protect against LDL oxidation (120), while sufficient vitamin D and calcium following the current recommendations are needed for prevention of osteoporosis (120)(97). Low intakes of magnesium and calcium could further increase the risk for CVD and bone health while inadequate intake of zinc has been reported to suppress immune function (121). Proper diets seem to confer health protective effects.
Many older MA fail to meet current recommendations of several of the macro and micro nutrients presented above, thus potentially increasing their risk for chronic diseases. Moreover, since existing national data for Hispanics is not current, accurate nutritional profiles for minority populations are needed for understanding whether nutrition-related disparities exist between populations, to identify individual characteristics that may affect FV consumption, and to detemiine whether the nutritional profile can be generalized to a larger population. Accurately collected nutritional data are needed to achieve accurate nutritional profiles and measured consumption of protective foods such as fhiit and vegetables. 34
Fruit and Vegetable Consumption
Populations in genera! fall short on FV consumption targets. Many adults in the
U.S., and specifically in Arizona, do not eat the recommended number of daily servings of FV (122). Several national educational efforts have been designed to educate consumers about the importance of eating healthy and eating a variety of foods; which include the 5 a Day for Better Health Program (10,11,123), Dietary Guidelines for
Healthy Americans (124), and Food Guide Pyramid (125). The 5 a Day program started in May 1991. when The Produce for Better Health Foundation (PBH) was formed to serve as co-sponsor, with the National Cancer Institute (NCI) of the 5 a Day program.
The program has expanded beyond PBH and NCI to include other key organizations committed to leveraging the reach of "Eat 5 to 9 a Day," which is their most current nutritional message (10). The Food Guide Pyramid helps consumers put the Dietary
Guidelines into practice by recommending the type and quantity of foods to eat from five major food groups. The Dietary Guidelines for Healthy Americans recommends eating at least 5 servings of FV each day. The USDA's Food Guide Pyramid recommends 2-4 servings of fruit and 3-5 servings of vegetables/day. Americans are not meeting this goal, and lower income groups fall particularly short (29,126,127).
Whether qualitative and/or quantitative, barriers that inhibit change are likely to exist.
Several barriers have been identified, among these are SES, food availability, pricing, and lack of knowledge (128).
In more than 150 epidemiological studies, data demonstrated that people who ate five servings of FV daily showed significantly reduced risk of chronic diseases 35 compared to people who ate fewer than two daily servings (2,15,129-136). At present, evidence suggests that the most protective diet for overall health and prevention is one in which FV predominates. This diet would be low in fat (especially saturated fat) and high in dietary fiber (29). In addition, since diabetes and its complications are major sources of morbidity and mortality among minorities in the Southwest region, the optimal diet would also promote foods with low glycemic response that may contribute to reduced diabetes risk (137), thus with an higher emphasis on vegetables than in fruits.
In general only 23% of Americans currently eat 5 or more servings of FV per day, which means that over 140 million (77%) are not eating the minimum daily amount of
FV recommended ( 29,126,127). Nevertheless, prevalence of FV consumption has slightly increased in the past years (122). According to the Arizona prevalence data from BRFSS, only 9% of Arizonans were eating five FV or more a day in 1998, almost
37% in 2000, and the prevalence decreased to 23% in 2002. Nationally 23%) of
Americans consumed more than five FV a day throughout all those years (122). Similar data of FV intake have been reported for MA (122, 123). Yet, MA tend to eat more FV, especially dried beans and peas, than other ethnic groups. Understanding motivations and barriers for dietary consumption changes is important. Food choices are motivated by reasons more complex and sophisticated than health motivation alone. Differences according to age, sex, ethnicity, and social class are likely to be important and are worth ascertaining if specific population-based targets for dietary change are to be achieved
(30,51,138,139). Fruit and Vegetable Consumption, Sociodemographic, and Acculturation Factors
FV consumption varies by gender, age, etlmicity, income, and educational level
(29,139,140). The Southwestern U.S. region has a high proportion of low-income groups with poor diets who have higher rates of diet related diseases such as HBP, stroke, diabetes, and other diseases associated with obesity, than the general population
(141).
Gender plays an important role in FV consumption patterns. NHW men generally consume more food than women in general, but they eat fewer servings of FV (142 ).
Median intake for men is just over three servings per day. compared to almost four for women (5,12,126,143.144). Females in Arizona tend to eat similar amounts of FV than women across the nation (122). FV consumption is higher among females >40 years of age (1.6-1.8 total fhiit and 3.0-3.2 total vegetables) than in younger females (122).
Nonetheless, in other studies Hispanic FV consumption has differed from FV National consumption (92,122). Several individual studies have demonstrated similar total FV consumption quantities among different groups of various sociodemographics characteristics (21.125,139,140,145).
Older adults, 65 years and older, eat nearly four servings per day. In some minority populations the scenario looks similar. Hispanics tend to average about 3 servings of
FV each day, similar to the daily average intake of African Americans (39,122). Krebs-
Smith indicates that Americans have made modest and important improvements in meeting the minimum of five daily FV servings (29,146). Several individual research studies have indicated that low percentages of FV are even more evident in low SES 37 groups, in v/hich the incidence of clironic disease among adults is higher
(4,29,30,139,142,147). It has also been shown that as education and income increase, diets also improve (12,125,148). Furthermore, the lowest levels of education and family income in the United States occur in the Southwest and in the South (39,149). In addition, the increasing diversity of these regions' population intensify nutrition and health issues. Evidence relating SES and health risk effects have provided a direct association: as SES lowers, health status lowers, and consumption of FV lowers as well
(12,125,148).
Economic and social conditions influence the ability of individuals to acquire a healthy diet (29,67). Unemployment and inadequate financial resources reduce the individual capability to meet nutritional goals (51,139,150,151). Moreover, availability of food in grocery stores, in workplaces, and from the food service sector are powerful influences of food choiccs. Lower income populations (<130 percent of poverty threshold) tend to have at least a 1 to 6% lower FV consumption (151-153). Similar results and observations, as seen above for SES, age and ethnic group, have been detennined when monitoring educational level i.e. the higher the educational level the higher the consumption of FV (154). Also, studies have indicated that marital status and number of household members significantly affects diet and food consumption and FV intake (139,155), married persons with fewer household members tend to eat more FV.
Nationally, several programs have been designed to promote increased FV consumption. Adult studies have shown a similar pattern of increased rate of FV consumption from 0.20 to 0.85 servings/day and the strongest effects were seen for 38 daily fruit consumption (128). Studies of worksites in Arizona and Massachusetts demonstrated that traditional worksite plus peer education resulted in higher compliance and success than nutrition educational interventions without peer workers (156). Some of these studies underscore the important role of social systems, such as family members, coworkers, and church members and how all these can assist in improving eating habits. These studies provide compelling evidence of program effectiveness across sex, race, and economic subgroups substantiating the need for further investigation to define factors mediating the effectiveness of interventions in increasing
FV intake.
Improved nutrition education programs at the community and societal levels must be developed with a robust understanding that SES strongly influences nutritional habits at the individual level. Changing consumer demographics, family structures, and lifestyles, coupled with an expanding array of available products have had dramatic impact on food choiccs (21,29). Challenges to overcome economic and physical barriers such as lack of transportation, and work schedules may also limit the availability of food sources and healthier food choices. Assessing age and social class differences in FV intake will help to ascertain specific population based targets, needs, and requirements that require understanding in order to provide affordable nutritional food options. However, besides sociodemographic factors affecting FV consumption, knowledge, attitudes, and self-efficacy also appear to influence FV consumption
(21,29,139,157). 39
Acculturation is an important factor in determining food consumption (23). In order to imderstand the relationship between dietary choices and acculturation two levels of acculturation need to be understood: individuals' SES and dietary acculturati,on (23). SES acculturation occurs at the macro level and is affected by physical, economic, and cultural changes while dietary acculturation is the process by which immigrants adopt mainstream dietary practices (23,158). Acculturated older
Hispanics consume more saturated fat and simple sugars, instead of more complex carbohydrates, than their less acculturated counterparts (22,23,66). Traditionally, the
Hispanic diet is high in fiber, with legumes, vegetables, and whole grains contributing to dietary protein (62). Legume and rice consumption provides most of the fiber which have been suggested as valuable for maintaining health (159). However, Hispanics residing in the U.S. for a longer time tend to have macronutrient profiles that are similar to those of NHW (160). Patterns of alcohol abuse, tobacco use, eating disorders and unhealthy dietary practices are stronger among Hispanics who are more acculturated than those less acculturated (159,161). It has been suggested that acculturation may be associated with 5 a Day program message awareness (13,64) and has been related to positive effects in diet quality and intake. However the literature is conflicting.
Positive associations between acculturation, diet quality, and disease have been found among some ethnic groups (105,157,162-164) while inverse association have been seen in other studies (38,159,165,166).
Research using data from NHANES II, HHAKES, and the NCI compared dietary intakes between first and second generation Mexican and NHW women, and 40 demonstrated that women bom in Mexico or whose parents were outside the U.S. consumed more protein, carbohydrates, folic acid, vitamins A and C, calcium, and iron than second generation MA or NHW (162). Diet quality was reduced as income and education decrease (162). Moreover, diet patterns of second generation women were similar to those of NHW, suggesting that the protective effect of more traditional
Hispanic food patterns is lost. A comparison of Hispanics (without considering generation) with NHW for FV intake, fiber consumption and fat intakes indicated that
NHW reported overall higher vegetable consumption and were more likely to have consumed 3 or more FV daily. As Hispanics became more accultiirated their intake of
FV increased (159), possible because the higher income of NHW may have allowed people to obtain more FV. Another recent study by Neuhouser and colleagues indicated that as a mostly homogenous sample of MA became more acculturated their intake of
FV decreased as much as half a serving per day. In spite of all these differences, some researchers argue that increased frequency of consumption of American food does not necessarily translates to decreased jfrequency of etlmic food consumption (159,167) nor does acculturation necessarily result in unhealthy dietary changes. For example, a reduction of highly saturated fats (e.g. lard) is a healthier diet (105). It is not clear how dietary changes occur within a larger process of sociocultural acculturation.
Multiple studies have reported limitations in the validity of their food frequency questionnaires in minority populations, including Hispanics (112,168,169). Less is known about the specific impact of acculturation on FV consumption in older Hispanic populations and much less in women (170). Moreover, the direction of dietary changes 41 and how acculturation affects FV consumption are unclear. The question of how acculturation, as a social construct, affects FV consumption may be confounded by the heterogeneity in food habits and beliefs about health and diet that exist across different
Hispanic population subgroups. One aim of this study is to explore the relationship between FV consumption and acculturation in a homogenous sample of MA participating in the AZ WISEWOMAN study.
Fruit and Vegetable Consumption and Behavioral Factors
Health behaviors are influenced by those personal attributes such as beliefs, expectations, motives, values, perceptions, and other cognitive elements. These personality characteristics contribute to health maintenance, health restoration, and health improvement (21.160). Prebehavioral determinants of dietary choices including knowledge, attitudes, and beliefs are included in the design and evaluation of many of nutritional interventions. Current health related behaviors including weight control, cooking techniques, fat intake, and FV intake influence the extent of behavior modification.
Several predictors have been utilized to explore consumption of foods. Different profiles of knowledge, beliefs, and attitudes have been used however, several studies have failed to reach statistical significance in establishing a correlation between nutrition knowledge and dietary behavior. A major limitation is the researcher's ability to precisely measure FV consumption (29). Perceptions of serving size, limited access to variety, quality of FV, limited information on preparation techniques, cultural influences for particular nutrient intakes, and recall, all influence the ability to obtain 42 accurate information (21,160). Other limitations include ultimate methods to assess food composition through specific nutrition computation systems, age, gender, intelligence, mood, attention, and consistency of eating patterns (171-173). The importance of understanding the behaviors of people who have been successful in identifying and eliminating barriers to more healthful eating and incorporation of FV in their diet is key (21.160). Identifying these determinants allows for the design of more effective nutritional interventions to increase FV consumption as well as strategies that reduce perceived barriers to consumption of FV and limitations that occur while evaluating food intake.
In order to develop successtul programs that promote increased FV consumption in the U.S., several factors must be considered. Incorporating a message that stresses the importance of increased FV consumption has to be done in a culturally appropriate manner (167,174,175). Although 39% of all American adults know they should eat 5 a
Day, this awareness appears to be much lower for poor minority groups (67,154,176).
An understanding of how food preferences and behaviors are learned is essential.
Behavioral researchers have used several measuring scales, constructs, and psychological models in order to understand and foresee different health behaviors.
Several characteristics, including cultural beliefs and attitudes, of minority populations provide unique directions to behavioral research. At this point it is important to mention a frequently studied psychological mode! and how it has been applied in diet behavior studies. 43
Stages of C hanges and Diet Behavior
Many dietary interventions have been effective in promoting healthful dietary changes when they have been based on an understanding of factors influencing food choices and familiarity with established theory and research on changing health related- behaviors. The constructs of SOC has been examined and found useful in explaining eating habits.
The SOC or Transtheoretical Model is a psychological model of behavior change currently used as the basis of numerous health promotion programs, whether trying to overcome unhealthy behaviors such as smoking or adopting a healthy behavior such as increased physical activity. SOC is perceived as movement through five stages; precontemplation (no participation or intention to begin a specific behavior), contemplation ( no participation but an intention to begin participation in a behavior), preparation (occasional participation in behavior), action (regular participation in a behavior), and maintenance (regular participation in a behavior for 6 months or longer)
(177,178). Assessment of readiness to change may aid in the development of targeted programs, development of specific health education material, and better assessment of program effect (160,179).
Behavioral research, especially on smoking cessation, has used the SOC model to explain how people progress toward cessation (178). In addition, the SOC paradigm has been applied to dietary change (160) focusing on lowering fat intake (26,180,181), milk consumption, and increasing FV intake (69,182-185). Several other psychological models and their constructs have also been used to predict and measure dietary changes. i.e., self-efficacy, cognition, and attitudes. The most popular models and theories include the Health Belief Model (HBM) (186), Social Cognitive (Learning) Theory
(187), the Theory of Reasoned Action (188), and the SOC (178). These models have been used to develop a specific fi'amework in which to examine FV consumption.
Significant differences within food intake and physical activity appear to be only measurable between individuals who are at extreme ranges of the stages, such as precontemplation compared to action and maintenance groups, i.e., people are either not practicing the desired behavior or they are performing the expected behavior.
hi order to address these differences the SOC model has been assessed using algorithmic, continuous methods, or by using single multichoice questions (26). The algorithmic method assigns individuals to a discrete stage for behavior change using a series of branching questions. Algorithms assessing stages of change for food-based and food pattern behaviors, rather than nutrient based behaviors, have been developed.
This system has improved the accuracy of stage classifications (183). For example, a food based staging algorithm for fat consumption instead of asking; "Do you use at least
30% of fat in your diet?" it will gather information on the amount of fat used by probing several questions related to fat use such as, "Do you use butter on your toast?" or "what type of milk do you drink?" among others. The continuous method involves scales measuring attitudes and behaviors relevant to each stage.
Targeting SOC has proven to be effective in several physical activity interventions but findings are less consistent in nutrition intervention studies. Several studies have utilized the SOC model and found it effective in predicting dietary behavior of 45 participants ingesting lower amoimts of dietary unhealthy foods. (25,26,181,189).
Many questions have been raised as to the efficacy of SOC model in minority populations including: is the structure of the model effective in minority populations, and how do diverse populations respond to stage match interventions (160,190).
Classification of participants in SOC has to be done in a carefiil manner because stage classification for a clearly understood behavioral goal such as smoking cessation is a straightforward assessment of behavior stage. On the other hand, a nutritional outcome of multiple behavior changes is extremely difficult to assess (51,180,183,191,192).
What is more, the self-efficacy construct Ixom the HBM has been related to health behaviors and dietary modifications (192-194). Self-efficacy is the self-assurance of an individual to carry out a specific task or behavior to attain a desired result. Self-efficacy maintains that a person's behavior is a result of the individual's personality and their environment, as well as the cognitive and emotional process of the particular individual
(195,196). SOC model has been used together with the self-efficacy construct to assess the stage of change in relation to consumed food groups, but predominantly in NHW male, and young populations. The application of this psychological model has been used less frequently in Hispanic, and low SES populations. Initial cultural appropriateness of this model to address nutritional behavior stages in an older Hispanic population is necessary in order to eventually determine if people are moving forward within this framework. This study provides an ideal setting to examine appropriateness of SOC to reflect the actions of middle-aged mostly Hispanic women to modify FV intake. 46
Snmmary
Poor uninsured low educated minority women are more likely to demonstrate patterns of unhealthy diet behaviors than women with higher income and education.
Not only does SES affect food intake but also, acculturation and the psychological stage of dietary change may play a significant role in the modification of an individuals' diet.
Health professionals commonly suggest diet modification to patients. A dietary change such as increased FV intake is one of the key lifestyle changes that has been suggested to help in decreasing risks of chronic diseases. The benefits fi-om successfully implementing desirable dietary habits will be enormous. Heart disease, cancer, stroke, and diabetes (the four leading causes of death in the U.S.) and also, obesity, hypertension, and osteoporosis, which are all, linked to diet. The medical costs and lost of productivity costs of these conditions are escalating while significant saving may occur through improved nutritional habits. Hispanics, primarily MA, are at a decreased risk for mortality from CVD however, they are 2 times as likely to develop type 2 diabetes as NHW. In the next section, two of the most common chronic diseases in Hispanics, CVD and diabetes, will be presented and later the proposed mechanisms of FV protection against those chronic diseases will be discussed. 47
OVERVIEW OF CARDIOVASCULAR DISEASE AND DIABETES AND
ASSOCIATED RISK FACTORS
According to the CDC the U.S. cannot effectively address escalating health care costs without addressing the problem of chronic diseases. These diseases account for more than 60% of the nation's medical care costs and 70% of all deaths. More than 90 milhon Americans live with clironic illnesses (197,198). In addition, chronic diseases disproportionately affect women and racial minority populations (199,200).
Heart disease is the leading cause of death in the U.S. while diabetes is an increasingly common chronic disease. The prevalence of CVD, diabetes, and hypertension among MA is 27%, 12%, and 23%, respectively (201). Heart disease and diabetes rates among women vary considerably by ethnic group and by region (88).
Hispanic women in the Western U.S. are two times more likely to have diabetes than
NHW women (35). MA women have a 26% higher prevalence of hypertension than
MA men (89). Morbidity from chronic diseases is also greater for Hispanic women than for NHW women (67,86,141). Additionally, age adjusted prevalence of obesity continues to be higher among MA women (39.7%) than among NHW women (30.1%);
69% of MA women are overweight and 36%o of those are obese (202,203).
Three health-related behaviors—tobacco use, lack of physical activity, and poor nutrition or over nutrition—contribute markedly to heart disease and type 2 diabetes.
Because of the higher prevalence of CVD, hypertension, and t3 Hispanic populations in the U.S., this section of the dissertation will focus mainly on those chronic diseases. In this section, cardiovascular disease (CVD) and diabetes will 48 be presented, epidemiological evidence about these diseases will be discussed, and associated risk factors will be described in the context of a female primarily MA population. Cardiovascular Disease CVD encompasses numerous conditions such as: coronary heart disease (CHD), myocardial infarction (MI), stroke, angina, coronary revascularization, congestive heart failure, and peripheral arterial disease. Killing almost a million Americans each year, CVD —^principally in the forms of high blood pressure (HBP), heart disease, and stroke—is the leading cause of death among both men and women, across all racial and ethnic groups, and accounts for more than 40% of all deaths (76). About 58 million Americans live with some form of CVD. CVD costs the nation $274 billion each year in health expenditures and lost productivity (76). A limited number of health-related behaviors are responsible for much of the burden of CVD. Data from NHANES III suggest that women who arc economically disadvantaged, underinsured or uninsured, and who are medically under-served have a worse CVD risk factor profile than women of similar age, with health insurance (204-206). Cardiovascular Disease Epidemiology in Mexican Americans MA women are at the greatest risk for CVD (86). CVD is the leading cause of death for Hispanics living in the U.S., accounting for 27.3% of Hispanic male deaths and 33.1 % of Hispanic female deaths in 2000 (76,207-213). Increased suffering, disability, and rates of premature death from CVD have been reported in ethnic minority women and those with low SES (206,214). Among MA adults, 28.8% of men 49 and 26.6% of women have CVD. Recent studies indicate that MA women are at greater risk for CVD than are NHW women of comparable SES status (77,86,215). On the contrary, data from the National Health Interview Survey 1998 showed that Hispanics (combined women and men) have lower rates of CHD than either NHW or African Americans (76). Among MA aged 20 and older, 7.2% of men and 6.8% of women have CHD (76). The risk of stroke is 1.3 times higher for Hispanics ages 35 to 64 than for non-Hispanics. Among MA aged 20 and older, 2.3% of men and 1.3% of women have had a stroke (76). In 2000, the death rate from CHD was 186.9 per 100,000 for all populations combined, while the death rate for Hispanics was 138.4 (212). CHD mortality rates among Hispanic groups are highest for Puerto Ricans and lowest for MA. Sociocultural factors have been used to explain the so-called "Hispanic paradox" of increased risk factors yet, decreased mortality rate as described in the previous section. Some reports have indicated contradictory findings against the general belief that MA are somehow immune to these factors in the context of CVD, and highlight the need for more observational studies combined with interventions to change unliealthy lifestyles. Cardiovascular Disease and Risk Factors Genetic, metabolic, and lifestyle risk factors have been identified and related to CVD (86,216,217). Genetic and metabolic related risk factors include family history of premature atherosclerotic disease, inborn errors in lipid metabolisms, diabetes mellitus, hypertension, elevated serum lipid levels, and obesity which in turn promote all the above risk factors. These risk factors can be genetically related and at the same time 50 may be influenced by lifestyle and behavior choices. Common behavioral and environmental factors have also been related to increased risk for CVD: cigarette smoking, physical inactivity, and diets rich in saturated fats, cholesterol, and calories. Such diets are believed to promote atherosclerosis. Other related risk factors include demographics and personal factors such as gender, age, and personality type. Table 1 summarizes the major primary (present before developing CVD) and secondary (worsen after CVD is diagnosed) risk factors for CVD. Table 1. Summary of CVD Risk Factors. Personal Factors Disease Relationships Lifestyle/Behavior Patterns family history diabetes" Smoking' gender high blood pressure* diet (high or low-fat) age 0 hyperlipidemia^ overweight® stress level (types II and IV) stress, overwork'^ exercise (low to high) * personality (A) high cholesterol nutrient deficiencies** oveiTVork, time elevated lipoproteins vitamin C® chromium* pressure, etc. high LDL-HDL ratio vitamin * niacin (B3)* overweight' high tiiglycerides selenium'"' fatty acids'- hypothyroidism'' vitamin B6" fiber* magnesium** zinc' potassium** Copper intake of water Substance abuse: sugar, alcohol, caffeine', and other drugs Regular use of: homogenized milk, margarines, and hydrogenated fats "Primary Factors ''Secondary Factors -Qtliers 51 Cardiovascular Disease and Dietary Modifiable Factors Modification of the types and amounts of food has constinously attracted scientific attention as the means to protect the heart. Carbohydrate research have recently focused on semi- and non-digestibie carbohydrates and on how the giycemic index of carbohydrate-rich foods affects risk factors for CVD (218-220). Yet, historically the emphasis of dietary recommendations has been on modifying the types and amounts of fat consumed. Arteriosclerosis, is a complex process involving deposition of plasma lipoproteins and cell proliferation of cellular elements in the artery cell wall, this process will be discussed in more detail in the next main section. An excess of lipids in the blood (i.e., hjperlipidemia) is an important risk factor in developing atherosclerosis and heart disease. Several lipid forms are present in serum: cholesterol, triglycerides, and lipoproteins. Lipoproteins, which are composed of triglycerides, cholesterol, and protein, are classified into different categories: chylomicrons, very low-density lipoproteins (VLDL), LDL, and intermediate-density lipoproteins (IDL). There are also high density lipoprotein (HDL) inversely related to heart disease risk which are therefore known as "antirisk" or protective factors (221). Modification of serum lipids through dietary fat reduction has been a common recommended practice to reduce the risk of CVD. Cholesterol is found in all cells of the body, primarily as a structural component of cell membranes, but it has other vital functions. Stored in the adrenals, testes, and ovaries, it is converted to hormones such as the sex hormones (androgens and 52 estrogens) and the adrenal corticoids (including Cortisol, corticosterone, and aldosterone). In the liver, cholesterol is the precursor of the bile acids which, when secreted into the intestine, aid in the digestion of food, especially fats. Cholesterol has been implicated as a major factor in the development of many CVDs, especially arteriosclerosis. Adaptation and reduction of cholesterol consumption in the diet is a widespread practice to modify risk of heart disease and arteriosclerotic plaque development. Many constituents of food, including fiber and certain types of carbohydrate, have been shown to have an inverse association or protective effect on CVD. Not only difTerent types of fat and cholesterol but also vitamins have been shown to have a positive association with CVD risk. Some dietary patterns also appear to be significant predictors of biomarkers of CVD risk (222). In the Health Professionals Follow-up Study, in which a Western dietary pattern characterized by high intakes of red meat, processed meat, high-fat dairy products, and refined grains was associated with CHD mortality but not with serum lipid concentrations (222). The Lyon Diet Heart Study revealed a strong protective effect of a Mediterranean dietary pattern in the prevention of CHD recurrence, although there were no differences in concentrations of total, HDL, and LDL cholesterol, triacylglycerol, or lipoprotein(a) (Lp(a)) between the control and experimental groups at the beginning or end of the study (223,224). This finding indicated that there are important risk factors other than serum lipids that mediate the relation between diet and CHD. Vitamin B deficiencies are commonly related to congestive heart failure (225). Foods such as caffots, green leafy vegetables, and citrus may provide good sources of B vitamins which in turn may reduce heart disease risk and premature deaths (226,227). Fresh and unaltered foods have more nutrients available and are capable of delivering more homocysteine-lowering vitamins and minerals. Adding nutritional supplements and foods (such as beans, potatoes, bananas, and broccoli) has been demonstrated to reduce elevated homocysteine levels, lowering the risk of heart attack and stroke (228,229). Homocysteine impacts dircctly and indirectly the metabolism of all methyl- and sulfur groups occurring in the body. As increased amounts of this metabolite occur in the cell, impaired methylation reactions occur resulting in dysfunction and halted metabolic pathways (216,230-232). Research has proven that diets deficient in folic acid, and vitamins Bg and B12, are associated with higher blood levels of homocysteine and a higher incidence of heart disease and stroke. Elevations of homocysteine are toxic to the vascular endothelium (229). FV are the major dietary sources of folate and pyridoxine, which play key roles in homocysteine metabolism. Cardiovascular Disease and Fruit and Vegetables FV are carbohydrate rich foods that contain major sources of dietary antioxidants that increase the plasma antioxidant capacity, potentially resulting in inhibition of atherosclerosis-related diseases in humans (233,234). Current epidemiologic and clinical evidence suggests a strong protective role for FV in ameliorating CVD. Most epidemiological studies indicate that dietary antioxidants may be the "protective 54 ingredients" that guard against CVD (235-239). Large prospective studies have identified a significant inverse relationship between FV intake and risk of CVD (2.131,134,240-243). Two comprehensive literature reviews, which focused on foods, rather than nutrients, reported supporting evidence. A Dutch report by Klerk and colleagues reviewed findings from, four ecological, two case-control, and six cohort studies conducted after 1994. Risk reduction for CHD was estimated to be 20-40% for those that consumed greater amounts of FV, and that increased intake of leafy green vegetables and only citrus fruits were protective against heart (238). While Ness and Powles examined findings from 10 ecological, three case-control, and 16 cohort studies, and concluded, but did not quantify, a protective cffect for total FV on CHD (244). FV intakes in the highest quintiles are associated with significantly lower total mortality. Bazzano and colleagues pooled and summarized the relative risks of CVD by comparing the highest and lowest categories of FV intake in several prospective studies (10 studies, some of them presented in this section) and determined an estimated risk of 0.82 (245). Increased daily intake of fresh fruit has been related to 20% to 32% reduction in mortalities from all causes, ischaemic heart disease, and cerebrovascular disease (246,247) while increased vegetable intake has been associated with decreased angina pectoris (248). Also, Ornish and colleagues in a 5-year trial involving 48 participants demonsfrated that a diet rich in FV, grains, and no animal product except nonfat dairy products was associated with a reversal in heart disease (249). Moreover, 55 low daily total intake of FV has been associated with elevated levels of circulating fatty acids (238). A study using survey data from the Nurses' Health Study and the Health Professional's Follow up determined the incidence of ischemic stroke in relation to FV intake (235). These authors were not able to link any component of FV to stroke risk, yet suggested that it is more realistic to expect synergistic effects related to dietary fiber, flavonoids, potassium, folate, and lifestyle than to segregate individual chemicals from food and expect a protective effect. Evidence supporting a protective effect of grape intake against ischemic heart disease in humans is suggestive, but still inconclusive (250). Prospective data from this study also indicated that body weight and weight gain were related to lower consumption of FV. Furthermore, epidemiological studies have related individual FV constituents to the association of the risk of CVD. Ascherio and colleagues, in a recent large study of the relationship between dietary antioxidant intake and risk for ischemic stroke, followed 43,738 men aged 40-75 years over eight years (251). This study found a significant inverse relationship between lutein supplementation and risk for ischemic stroke, but it disappeared when controlled for other dietary factors. This group concluded specific carotenoids supplements (as well as vitamins E and C supplements) did not substantially reduce risk for stroke in the population studied. In contrast, some well- designed, randomized, double-blind, clinical intervention trials found that high doses of P-carotene (Physicians Health Study) (252), P-carotene and/or a-tocopherol (The a- Tocopherol, P-Carotene Cancer Prevention Study Group-ATBC) (253) or P-carotene 56 and pre-formsd vitamin A (CARET or the P-carotene and Retinoi Efficacy Trial) in male smokers ages 50 to 69 (254) are ineffective in reducing risk of cardiovascular disease. From these conflicting results, it has been suggested that other plant-derived compounds may well play a significant synergistic role in health rather than sole dietary supplements, thus supporting protection fom a high FV diet. Hypertension (HTN) HBP is one of the most common health problems in industrialized countries, hi 1995 it was estimated that in the U.S., 25% of the adult population was estimated to suffer from hypertension (255). More recently, prevalence of hypertension is 33% and rates are higher among older women than men. The rates of hypertension increased from 91.7/100,000 among women aged 44 and younger to 591.2/100,000 among women aged 75 and older (207). HBP is one of the most important and common risk factors for atherosclerotic cardiovascular disease and renal disease. Although the treatment of hypertension can reduce morbidity and mortality from CVD, its diagnosis and treatment have been suboptimal for many older adults (256). Up to 50% of MA hypertensives are undiagnosed and 48% of Hispanic women aged 65 years and over have been told that they have hypertension, compared with 33%( of Hispanic men (212). Among Hispanics aged 18 and older, the median percentage who have been told by a health professional that they have HBP is 18.6%). The percentage is higher for MA aged 20 to 74, 24.2% of men and 22.4% of women have HBP or are taking antihypertensive medicine (212), which may indicate different gender pattern for MA compared to Hispanics as a whole. 57 Several landmark clinical trials represented in He's metaiialyses indicated that as blood pressure decreases the risk for CHD and stroke decrease as well (257,258). There is a 37% lower risk of stroke in people receiving active therapy (hypertension medication) vs. placebo. This group indicated that out of the 10 trials the reduction in stroke was statistically significant in six of them. Despite reductions in HTN only one study demonstrated a stalistically significant 28% reduction CHD risk (257). Not only studies of hypertension medication but clinical and observational studies also have demonstrated a significant modification of CVD risk factors while controlling blood pressure level. Diet has been identified as a key factor in controlling/reducing blood pressure. Hypertension and Dietary Modifiable Factors Dietary approaches to lower elevated blood pressure are becoming welcome additions to the arsenal of treatment modalities for hypertension. Beneficial dietary interventions are reducing dietary sodium consumption, avoiding excessive alcohol intake, and restricting calories to reach an optimal weight if overweight. Increasing dietary potassium, calcium, and magnesium may also be useful in the prevention and treatment of hypertension (7,259,260)-(261). In the Nurses Health Study, lower intakes of calcium were related to increased risk of stroke (262) while postmenopausal women with lower intakes of magnesium had heart rhythm abnormalities (263). Increased intakes of potassium (264) and decreased intakes of sodium (265) have effectively lowered systolic and diastolic blood pressure. 58 A potential, more recent addition to this list is that of recommending increased FV intake. A healthy dietary pattern, termed the Dietary Approaches to Stop Hypertension (DASH) diet, effectively lowered blood pressure. Appel and colleagues published results of a clinical trial examining the effects of the DASH diet on blood pressure (7). This group had 459 men and women with blood pressures ranging from normal to mildly hypertensive. Individuals were randomly assigned to consume either the control diet, a diet rich in daily FV intake, or a combination diet rich in fruits, vegetables, and low-fat dairy products with reduced saturated and total fat. The FV and combination diets included 8 to 10 servings of FV a day, and the combination diet also included 2.8 servings per day of low-fat dairy products. Sodium intake and body weights were kept constant throughout the study. After two weeks, the FV diet lowered systolic blood pressure by 2.8 mm Hg and diastolic blood pressure by 1.1 mm Hg in those with normal or high normal blood pressures (7). The combination diet lowered average blood pressures even further, by 5.5 mm Hg systolic blood pressure and 3.0 mm Hg diastolic blood pressure in those with normal or high-normal blood pressure compared to controls (7). Combining a FV rich diet with low-fat dairy products and with reduced saturated and total fat lowered blood pressure to a greater extent. Adoption of the DASH diet could reduce CHD by approximately 15% and stroke by approximately 27% (7). This study showed that a diet rich in FV reduces blood pressure both in individuals with and without hypertension. The DASH study recruited 51% men and 49% women and covered a broad mix of ethnicity (two-thirds were minorities). Participants' 59 baseline blood pressure levels matched 40% of the U.S. adults. The results of DASH are applicable to the general population as the effects observed in all participants were similar. Some risk factors can be modified and subsequently decrease CVD risk. The mechanisms by which some of risk factors are modified through various FV constituents will be presented in the next section. Even though CVD is the primary cause of morbidity and mortality in the U.S., the increased prevalence of diabetes plus the recent escalation in predicted rates among Hispanics compared to that of NHW are alarming. Diabetes Diabetes is a group of metabolic disorders characterized by hyperglycemia. Hyperglycemia is a result of defects in insulin secretion, action, or both. There are two common types of diabetes: type 1 and type 2. Type 1 accounts for approximately 5 to 10% of the diabetes cases and is characterized by a complete inability to produce insulin. This is a heterogeneous and polygenic disorder (266). Type 2 diabetes is a combination of a defect in insulin secretion and insulin resistance at the site of insulin action: muscle, liver, or adipose tissue. Ninety percent of the persons diagnosed with diabetes are classified as having type 2 diabetes (267). The estimated prevalence of total diabetes in the U.S., ail ages, is about 18.2 million people - 6.3% of the population -- from which 13 million people are diagnosed and 5.2 million people are undiagnosed (80). MA are at increased risk of diabetes (80,81). The high costs and increased prevalence of type 2 diabetes have resulted in additional prevention efforts. Lifestyle 60 changes such as exercise and diet modification are the primary non-dmg interventions by virtue of the fact that the majority of type 2 diabetics are ovenveight (267). Other rislc factors for diabetes include family history of diabetes, gestational diabetes, impaired glucose tolerance, hyperinsulinemia, and insulin resistance. Diabetes Epidemiology in Mexican Americans The morbidity associated with diabetes is substantial. Diabetes mellitus in older people is a major public health problem in developed countries worldwide (268) and is associated with increased morbidity, disability, and mortality (269-271). Type 2 diabetes is a growing national concern and chronic disease which particularly affects Hispanic Americans (272). A worldwide t>pe 2 diabetes epidemic has been predicted: increasing from 143 million diabetics in 1997 to 300 million in 2025 (197). According to the World Health Organization data from 2002, the number of U.S. adults with diagnosed diabetes, including women with gestational diabetes (diabetes that develops during pregnancy), has increased 61% since 1991 and is projected to more than double by 2050 (80). In 2000, of the 30 million Hispanic Americans, about 2 million had been diagnosed with diabetes (80,197). Most diabetes studies that focused on Hispanics have been conducted among MA and have found that approximately one out of every 10 persons aged 20 years or older has diabetes (81). Diabetes is twice as common in MA adults as in NHW (81,273). Even though diabetes is the seventh leading cause of death among Americans, diabetes is the leading cause of new cases of blindness, kidney failure, and lower extremity amputations, and it greatly increases a person's risk for heart attack or stroke (80). Higher rates of the diabetes complications of nephropathy (kidney disease), retinopathy (eye disease), and peripheral vascular disease have been documented in studies of MA, whereas lower rates of myocardial infarctions (heart attacks) have been found (268,274,275); diabetic complications are more likely to occur first. Heart disease is the leading cause of diabetes-related deaths. Diabetes is associated with a 2-4 fold increased risk of CHD (276,277) and a 2-3 fold increased risk of ischemic stroke (277). People with diabetes are not only at increased risk for CVD, but also for CHD mortality, as shown in the Multiple Risk Factor Intervention Trial. The general risk of CHD mortality increases in both diabetic and non-diabetic persons as total cholesterol levels increase but, the mortality rate in patients with diabetes far excceds that in non-diabetic patients at each cholesterol level by four to five fold (278). The risk for stroke is two to four times higher among people with diabetes. About 65% of deaths among people with diabetes are due to heart disease and stroke (279). Ruigc and colleagues published a meta-analysis of 12 articles from 17 prospective studies on CVD. Their overall conclusion was that diabetes has a multiplicative interaction with other traditional cerebrovascular and CVD risk factors, resulting in sharp increases in overall vascular risk with each added risk factor to the people with diabetes (280). To prevent stroke in patients with diabetes, risk factor modulation and control are crucial. Different racial and ethnic backgrounds present different prevalence rates for diabetes, suggesting a genetic admixture of ethnicities that may increase the 62 susceptibility to type 2 diabetes or alter responsiveness to lifestyle modification (48,49). Type 2 diabetes becomes complicated by several inherent factors of the disease process; insulin resistance, hyperinsulinemia, impaired insulin secretion, reduced insulin- mediated, and glucose uptake and utilization (281), these mechanisms will be presented in detail in the next main section. Diabetes Contributing Risk Factors Both genetic and nongenetic factors contribute to diabetes development and the actual Diabetes pathogenesis will be discussed in the next main section. This next section will discuss several of the proposed risk factors of diabetes and how those affect the prevalence of diabetes among the U.S. population. Data for MA are presented when available. Diabetes Gcnetic Risk Factors In type 2 diabetes mellitus, it is possible that genetic mutations may account for the disease phenotype in a small number of people. Severe forms of insulin resistance are associated with homozygocity for insulin receptor mutations, but heterozygous people occasionally have more modest degrees of insulin resistance consistent with a diagnosis of tjApe 2 diabetes. Studies suggest that insulin receptor mutations are more important in the rare syndromes of severe insulin resistance than in the more common forms of type 2 diabetes (282-284). Recent studies have shown that the variation in cysteine protease CAPNl 0, the gene encoding calpain-10, affects susceptibility to type 2 diabetes mellitus in MA and in two northern-European populations (282,283). Studies from the University of Chicago 63 and the University of Texas have examined genes whose variation increases susceptibility to type 2 diabetes particularly among MA in Starr County, Texas (285). Their studies indicated that type 2 diabetes in this population results from the action of a gene on chromosome 2, designated NIDDMl, and other genes including a locus on chromosome 15. This finding helped to identify a novel genetical pathway that may lead to type 2 diabetes (282,283). Clinical studies in nondiabetic subjects suggest that calpain-10 is one of the factors affecting the action of insulin on muscle tissue and the secretion of insulin from the pancreatic p-cell. Variation in this gene is associated with a 1.5 to 3 fold increased risk of diabetes in MA. The inheritance of a specific haplot3^e combination defined by three single-nucleotide polymorphisms—SNP-43, -19, and -63—^was found to be associated with a threefold increased risk of diabetes. These polymorphisms are in noncoding regions of CAPNl 0 and are believed to alter risk by affecting the transcriptional regulation of calpain-10 (282). The presence of SNP-43 and an adjacent polymorphism, SNP-44, in an enhancer-like element, as well as the association between the SNP-43 genotype and calpain-10 mllNA levels in skeletal muscle, demonstrated some consistency with this hypothesis (282,286). SNP-43 was also found to be associated with measures of insulin action/presence in Pima Indians with normal glucose tolerance, suggesting that calpain~10 may increase the susceptibility to type 2 diabetes through its effects on the oxidation of glucose in skeletal muscle (286). 64 Diabetes and Physiological Risk Factors Metabolic factors have been shown to be important risk factors for the development of type 2 diabetes. In the disease pathway, both insulin resistance and hyperinsulinemia have been shown to predict type 2 diabetes (details of these pathways will be discussed in the next section). MA have higher rates of hyperinsulinemia and insulin resistance than the general U.S. population (86,201,287,288). The resulting hyperinsulinemia has been shown to be a precursor for the incidence of hypertriglyceridemia, HBP, low HDL cholesterol, and type 2 diabetes (289-291). Each of these factors is associated with CVD risk, and. their combination, at lower than diagnostic levels, also presents a risk. This association between insulin and cardiovascular risk factors was very clearly shown in a cross-sectional analysis from the San Antonio Heart Study (289,292) of almost 3,000 men and women, aged 25-64 years (MA and NHW). Sixty-four percent of the population had one or more risk factor. Insulin concentrations were always higher for subjects with a given risk factor, except in people with type 2 diabetes, in which the 2-h insulin (measurements of insulin after food load) concentration was lower. It appears that hyperinsulinaemia is a precursor of the conditions associated with the insulin resistance syndrome; with the highest risks being associated with type 2 diabetes and hypertriglyceridaemia. Higher levels of insulin resistance have been associated with higher triglycerides, systolic and diastolic blood pressure levels as well as lower levels of HDL-C, but not to LDL-C (293). This association of anomalies was originally described by Reaven (294) and is variously known as syndrome X, the metabolic or piurimetabolic syndrome, and the insulin resistance syndrome. 65 Metabolic Syndrome and Insulin Function Metabolic Syndrome, previously known as Sjmdrome X, is a collection of factors for the development of CHD commonly found in type 2 diabetics (89,90,202,268). The metabolic s3mdrome is present in more than 20% of the U.S. adult population; varies substantially by ethnicity even after adjusting for BMI, age, SES status, and other predictor variables; and is associated with several potentially modifiable lifestyle factors. The National Cholesterol Education Program (NCEP) Adult Treatment Panel III guidelines define five components of the metabolic syndrome; at least three of the five criteria arc required for the diagnosis of the metabolic syndrome (295,296). The NCEP metabolic syndrome guidelines have different criteria for triglycerides and HDL-C, versus the WHO definition which lists high triglycerides and/or low HDL- C as a single factor. Almost all individuals in North America who have the metabolic syndrome have a high waist circumference as one of their criteria (295,296). Other aspects of the definition for the metabolic syndrome vary from NCEP and WHO. The NCEP guidelines do not include obesity and insulin resistance as required features. MA have been identified with an increased rate of the metabolic syndrome, particularly among women (90,297,298). Diabetes and Behavioral Factors Not only genetics and physiological factors are proposed to contribute to the risk for type 2 diabetes, there are many possible lifestyle behaviors that may contribute as well. Health behaviors such as overweight and obesity, poor diet, inadequate awareness 66 of health information, lower levels of health care utilization services, and decreased physical activity may also contribute to an increased prevalence of type 2 diabetes. Obesity is now reaching epidemic proportions in the U.S.. In the decades between 1980 and 1999, the occurrence of obesity increased from a quarter (25%) of the population to over a third (33%) —which is a 40% relative increase (299). Today, at least half the U.S. adult population is somewhat overweight (299) and according to a recent obesity prevalence report trends have continued in 2000 (203). Also this increase in obesity has been seen in younger populations. In addition to the enormous direct health care costs associated with obesity (which approximate $70 billion dollars each year) there are significant social and psychological burdens for obese individuals and their families (300,301). Obesity is a major risk factor for coronary heart disease, hypertension, type 2 diabetes, and lipid abnormalities. MA have a greater tendency for overweight and obesity than NHW in the U.S. (89,302). It has been suggested that the higher prevalence of overweight and obesity and the correspondence to type 2 diabetes may also be an indicator of social, acculturation, cultural, and SES differences (65,166). Excess body fat in the abdomen and waist areas, as opposed to thighs and hip regions, has been associated with higher risks of type 2 diabetes as well (89,272,303). In the San Antonio Health Study, investigators found that MA female participants had higher rates of type 2 diabetes (11.8%) and overweight (BMI=28.9) than in NHW (5.7% and BMI=26.2) (304). Impaired glucose tolerance (IGT) is defined as higher than normal blood glucose levels and may be the early stage in the progression of type 2 diabetes (304-306) (this 67 biological mechanism will be described in the next section), ovenveight and obesity have been connected to IGT. MA tend to have higher levels of fasting plasma glucose than other ethnic groups. In the San Antonio Heart Study, phase II, participants had an increased prevalence of insulin resistance and reduced insulin secretion (289). Treatment approaches for obesity management and diabetes control include lifestyle interventions, such as eating a healthy diet and increasing physical activity (307,308). Diabetes and Dietary Modifiable Factors Diet modification and improvement are the most common treatments for type 2 diabetes. The Diabetes Prevention Program (309,310), in a group of overweight people with normal fasting glucosc and IGT levels, was completed successfully. Subjects in the healthy life-style group (i.e. diet and exercise) significantly decreased their risks of developing type 2 diabetes by an average of 58% when compared to 31% reduction in the only medication group. Moreover, the lifestyle interv-ention succecded as well in men and women and in all the ethnic groups and people age 60 + who have a nearly 20 percent prevalence of diabetes reduced the development of diabetes by 71%. The San Luis Valley Diabetes Study established that high intakes of daily saturated fat, low daily fiber intake were significantly associated with higher fasting insulin concentrations even after controlling for age, gender, ethnicity, BMI, waist circumference, vigorous activity, and total energy intake (68,311). Obese individuals not only have shown increased insulin concentrations and have reported higher intakes of total and saturated fats. Higher intakes of polyunsaturated fatty acids have been inversely related to insulin sensitivity (312-315). Some research 68 indicates that increased levels of dietary fat increases insulin resistance, decreases insulin sensitivity, increases insulin secretion, and aids in the development of IGT (202,293,313,316), further promoting the prevalence of the metabolic syndrome. Membrane lipid unsaturation has been correlated with insulin fimction. The fat composition of muscle membrane phospholipids reflects the combined influences of diet and desaturase/elongase activity, and in turn phospholipid composition affects the binding and action of insulin (317-320). Insulin sensitivity correlates positively with lipid membrane unsaturation and omega-3/omega-6 polyunsaturated fatty acids (PUFA) in phospholipids, and negatively with intramuscular triglyceride and central obesity. Omega-3 PUFA supplementation is recommended for type 2 diabetes, including long- chain PUFA. In general, the more unsaturated (flexible; fluid) the membrane lipid the better glucose is utilized. The more saturation of membrane lipids the more deleterious the effect on insulin efficiency (317-320), therefore diets lower in saturated fatty acids are frequently recommended. Diabetes and Glycemic Index During the past decade, some lines of evidence have provided strong support for a relationship between glycemic content of foods and diabetes incidence. In animals and in short-term human studies, a high intake of carbohydrates with high glycemic index produced greater insulin resistance than did the intake of low-glycemic-index carbohydrates (219.321). The glycemic index is an average of the glycemic responses of many individuals. The speed at which a food is able to increase a person's blood glucose levels is called 69 the glycemic response. The glycemic response is influenced by many factors. Some factors may be the amount of food consumed, how the food is processed or the way the food is prepared. Foods with glycemic indexes that are lower than 100 are commonly recommended. This recommendation follows the rationale that foods that have a giycemic index value greater than 100 turn into sugar more quickly than the ones with lower glycemic indexes. In large prospective epidemiologic studies, both the glycemic index and the glycemic load of the overall diet have been associated with a greater ri sk of type 2 diabetes in both men and women (322-324). In a cohort study of 65,173 U.S. women 40 to 65 years of age the combination of a high glycemic load and a low fiber intake further increased the risk of diabetes when compared with a low glycemic load and high fiber intake (325). In people with diabetes, evidence from medium-term studies suggests that replacing high-glycemic-index carbohydrates with a low-glycemic-index forms (particularly vegetables and unprocessed foods) improved glycemic control. Among persons treated with insulin, this diet reduced hypoglycemic episodes (321), yet the clinical significance of the glycemic index remains the subject of debate. Currently, several investigations are focusing on patterns of consumption of plant- based product and meat-based products. Alexander and colleagues investigated diet patterns of Hispanic Americans ( Hispanic Seventh-Day Adventists) and determined that individuals consuming a plant-based diet exhibited more favorable blood lipid profiles and lower blood pressures (326). In addition these individuals had lower fasting insulin and glucose levels, suggesting lower risks for type 2 diabetes. Controlling glucose 70 levels is very important in the prevention of diabetes complications as is maintaining pancreas health. Foods such as milk, fruit, and vegetable tend to have a lower glycemic index value than common starchy foods such as bread, rice, potatoes and breakfast cereals. Therefore selecting foods with a low glycemic index are suggested as helpful to manage diabetes and in controlling blood glucose levels. However, the most important message is that most low glycemic index foods offer more fibre and are low in fat and that foods that were previously avoided by people with diabetes can now be added to their diet in moderation. Diabetes and Fruit and Vegetables As part of the nutritional approach, FV can play an integral role in diabetes control because of their low fat, low energy contributions to healthy eating. Once people begin to modify their lifestyle behaviors, the advantages of a healthful diet, including eating more FV, and regular physical activity can be recognized not only as components of weight management, but also as key lifestyle choices that promote general health and well-being. Maintaining healthy lifestyle choices is key in the control and prevention of diabetes and in minimizing several of the physiological factors related to this condition. The leading cause of death in diabetic individuals is CVD. Therefore, most of the evidence on the properties of FV that protect against CVD apply to prevention of diabetes related CVD. On the other hand, the evidence for a beneficial effect of a diet rich in FV on diabetes is not as strong as it is for heart disease. The results of a small number of studies suggest that higher intakes of FV are associated with improved 71 control of blood glucose levels and lower risk of developing type 2 diabetes. Functional aspects of FV such as giycemic load and energy density may also play key roles (5,327). In both cross-sectional and prospective studies, FV have been linked to lower risk of type 2 diabetes. Abnormal glucose tolerance in 1,122 middle aged men and women in UK was related to low FV intake (328). In a group of 338 European men (329) and in a cohort of almost 10,000 adults in the U.S. (enrolled in National Health Examination I Follow-up Study), the risk of developing type 2 diabetes over 20 years was approximately 20% lower in those who reported consuming at least five servings/day of FV compared to those who reported consuming none (5). In the Nurses' Health Study an inverse relationship between type 2 diabetes and FV was observed at a 6-year follow-up (330). Another UK cross-sectional study of more than 6.000 nondiabetic adults found that participants with higher FV intakes had significantly lower levels of HbAic (327). It is important to mention that results from prospective studies on FV consumption and the risk of type 2 diabetes are not always positive, some neutral and negative results have been seen (331). Although the relationships between FV intake and diabetes remain to be clarified, the m,ost promising compounds in FV do enhance glucose control include fiber. Siimmaii' This section provided an overview of the epidemiology of CVD and diabetes as well as their associated risk factors. Lately, food intake patterns have been studied and their association to these chronic diseases support that food patterns are acting syiiergistically with physiological and metabolicai bodily fonctions to influence disease risk (332). The elevated risks present in the MA commiinity in the U.S. compared to NHW for both diseases increases the need to understand health, lifestyle choices, and genetic causes that may be directing these tendencies. One area that is of particular promise appears to be targeting increased FV consumption. Some of the proposed underlying protective mechanisms of action of FV and their constituents will be presented in the next section. 73 MECHANISMS BY WHICH FRUIT AND VEGETABLE INTAKE ALTERS PATHOGENESIS OF CARDIOVASCULAR DISEASE AND DIABETES. Identifying the mechanisms by which FV alter biological response is important to our understanding of how they protect against chronic disease. In fact understanding of these mechanisms provides impetus for much of the current nutritional research that is examining foods for their protective and disease preventing potential. In this section, a general description of phj^ochemicals, key components of plants that have been awarded with protective benefits, will be provided. Then the pathogenesis of two main chronic diseases; cardiovascular disease (CVD) and diabetes will be presented. Last, the main focus of the section is on key biological mechanisms of actions within CVD and diabetes and the frequently suggested protective phytochemicals from FV, spices and some plants. Phytochemicals Folk wisdom has long credited plants with medicinal and protective qualities. Fhytochcmicals are naturally occurring compounds that give plants their color, flavor, smell, and texture, and are being investigated for their health-promoting potential (11). Phytochemicals are not considered "essential", nor are they nutrients. Phytochemicals are commonly found in fruits, vegetables, grains, legumes and seeds and in a number of less frequently consumed foods such as licorice, soy, and green tea. The health benefits of these foods are best obtained by eating a varied diet. Phytochemicals have received increased scientific interest because of their potential benefit to the prevention of the onset of chronic diseases. 74 As presented in the previous section, epidemiological evidence has consistently shown that there is a clear, significant, inverse association between intake of FV and rates of heart disease mortality, common cancers, and other degenerative diseases, as well as aging (15,135,333-337). Select chemicals in FV appear to have an effect on health beyond that of essential nutrients like proteins, carbohydrates, fats, minerals, and vitamins. Initially, researchers began looking at the effect of individual macronutrients (i.e. fat, protein and carbohydrate) on normal metabolic activity and health, and more specifically on chronic diseases. Next, researchers examined micronutrients and minerals, such as the different forms of vitamin A and their P-carotenes, folate, vitamins Be, Bi2, C, and E, calcium, potassium, magnesium, copper, and selenium, which have been related to levels of chronic disease risk (338). The plant chemical, phytochemicals, have more recently attracted a great deal of scientific attention focusing on their role in preventing diseases particularly those associated with increased oxidative stress. The evaluation of the efficacy of phytochemicals in the prevention of chronic diseases is limited by the lack of information on the determination of absorption, distribution, and metabolization. Phytochemicals from plants and foods have been studied using several research methodologies. The simple presence of different plant chemicals has been measured, quantified, and the reduction capabilities have been determined in vitro. In vivo studies have addressed how individual food constituents or FV extracts may affect tissue cultures and replicas of biological systems, to more 75 advanced animal studies, mostly with rats and rabbits, and the determination of physiological, physical, and clinical complications at different stages of the disease. Lastly, a paucity of clinical trials have been completed particularly in humans, which has led to uncertainties that in humans these compounds could express physiologic significance (130,339,340). Many studies have used water-soluble and alcohol extracts, dry powder compositions, and medicinal preparations of the phytochemicals of interest and tested them across biological systems. The limitation of many of these in vitro and in vivo studies are evident when trying to consider only one biological system and the application of one chemical to a system (130,339). Because such compounds occur as complex, highly variable mixtures in plant materials, it is difficult to study their bioavailability and physiologic effects accurately when individual phytochemicals are isolated from whole plant (296,340). Nonetheless, many of the health risks and benefits associated with phytochemicals have been elucidated as have the potential mechanisms for modulating those benefits or risks. Studies continue to investigate absorption and metabolism of single ph34ochemicals and are determining that their absorption varies depending on the type of food, their chemical foim, and their interactions with other food substances. FV contain significant levels of biologically active components that impart health benefits beyond basic nutrition (341). Specifically, the next sections will focus on the phytochemicals that have consistently demonstrated a biological and protective mechanism against CVD pathogenesis including carotenoids, flavonoids, and sulfides. 76 among others. Also, Table 2 provides a list of the frequently studied phytochemicals together with their proposed chronic disease protective mechanism. Next, a description of the proposed plaque formation pathogenesis and potential biological modulation points will be descrided. Those biological points will later be related to plant constituents that may modulate the pathogenesis of CVD. Table 2. Phytochemicals and their proposed biological mechanisms. Most Common Class Specific Foods Properties (135,342,343)* Phytochemicals Butyl Phthalide umbelliferous herbs: Butyl celeiy seed, caraway, phthalide/ sedanoli cumin, dill, fennel, protect against cancer, high blood pressure de/ polyacetylenes parsley, anise, coriander and high cholesterol (344) Fiber pickle, soluble: oat bran, legumes, psyllium, nuts, binds to bile acids-cholesterol lowering beans, pectin and various properties, inhibit digestive enzymes, Calcium pectate, FY; insoluble: brans and inhibit active transport of glucose to the soluble and husks of whole grains, intestinal border, delay gastric emptying insoluble fiber, nuts and seeds. (9,135,218,345-353) Capsaicin antibacterial, promotes intestinal activity Capsaicin chilies (342,343) Carotenoids apricots, cantaloupe, carrots, collard greens, fennel, kale, mustard greens, peaches, pumpkin, red pepper, romaine lettuce, spinach, sweet may modulate process I'elated to potatoes, Swiss chard, mutagenesis, cell differentiation, and Beta-carotene winter squash. proliferation (242,354-360) tomato, grapefruit, watermelon, guava, best quenching property, and radical rosehip, red chilies, scavenging protects against heart disease, apricots, guava, mango, cancer, reduces macular degenerative oranges, peaches, papaya, disease, and serum lipid oxidation Lycopene and watennelon (135,355,361) kale, broccoli, spinach, winter squash, Brussels sprouts, celery, dill, leeks, Lutein mustard greens, peas, Zeaxanthin green onions, summer Cataracts protection, inhibit macrophage- Canthaxanthin squash mediated LDL oxidation (362) Glncosinolates (136,363) Dithioithiones reduce risk of cancer detoxifying enzymes, mobilization of Sulfuraphane human's natural cancer fighting resources Isothiocyanates Cruciferous vegetables: cabbage, kale, broccoli, cauliflower, Brussels anticancerous, induce a multiplicity of Indoles sprouts, watercress, radish phase II, enzymes 77 Table 2. Phytochemicals and their proposed biological mechanisms continued Most Common Class Specific Foods Properties (135,342,343)* Phytochemicals Flavonoids dietary antioxidants, inhibit LDL oxidation, inhibit platelet aggregation and adhesion, inhibit (130,135,136,237,296,35 enzymes involved in lipid and lipoprotein metabolism that affect the immune response to 6,364-374) oxidized LDL and their uptake by endothelial macrophages, may induce endothelium- dependent vassorelaxation, and may increase reverse cholesterol transport and decrease total and LDL cholesterol, and cancer protection among others Flavanol Catechin suppress cancer promotion, anti bacterial and antiviral, regulates cholesterol, blood Epicatechin pressure, and blood clotting tendencies, inhibit sodium glucose-co-transporter-1, Epigallocatechin antioxidant, potentiate insulin action, and may be beneficial in the conti'ol of glucose Epicatechin intolerance and diabetes, prevent foam cell gallate tea plant. Camellia formation, and lipid streak development, Epigallocatechin sinensis, cocoa, black and protect cells against oxidative stress, gallate green tea (366,374-380) Flavoiione peel of citrus fruit, reduce fat and cholesterol, interferes with Naringin grapefruit enzymatic activity in the intestines, modulate hepatic cholesterol synthesis, lower incidence of cerebrovascular disease Taxifolin citrus fruit (365,381,382) Isoflavones/ prevent estrogen from attaching to and Phytoestrogens stimulating cells, cancer enzyme inhibitors, antioxidant, immune system enhancers & stimulants, inhibit sodium glucose-co-transporter-1, lower cholesterol Daidzein (296,383-385) estrogens and antiestrogens, cancer enzyme inhibitors, antioxidant, immune system enhancers & stimulants, inhibit sodium glucose-co-transporter-l Genistein (296,383,384,386-388) inhibit a-amylase activity, protect against Luteolin gastric cancer (333,389-391) cancer enzyme inhibitors, antioxidant, immune system enhancers & stimulants Coumesterol (392) Glycitein legumes & soy lessen plasma cholesterol levels (393) Flavonol endive, leek, broccoli, radish, grapefruit, black tea, onion, lettuce, platelet anti-aggregation activity, lower cranberry, apple skin, incidence of cerebrovascular disease, beiTies, olive, tea, red antioxidant and antiproliferative activities Kaempferoi wine (340,365,388,391). prevents the cytotoxicity of oxidized LDL, reduce the risk of death from coronary red and yellow onions, heart disease, reduces the risk of type 2 kale, broccoli, red grapes, diabetes, protect cells agaitist oxidative cherries, French beans, stress, inhibited TOF-alpha production Quercetin apples and cereals (365,380,388,391,394,395) cranberry, grapes, red induce secretion of TNF-alpha, reduces the Myricetin wine risk of type 2 diabetes (365,388,391) Flavone protect cells against oxidative stress, Chrysin fruit skin hypoglycemic effect (380,396) reduce the risk of death from coronary Apigenin celery, parsley heart disease (391) 78 Table 2. Phytochemicals and their proposed biological mechanisms continued Most Common Class Specific Foods Properties (135,342,343f Phytochemicals Proanthocyanidins/ pine bark, hawtlioin free radical scavengers, insulin-like Tannins berries, bilberry, green Procyanidin tea, black tea, lemon tree biological activity(374) bark, hazel nut tree leaves, Prodelphinidin blueberries, cherries, providing nutritional support to reduce cranberries and black capillary permeability and fragility Propelargonidin currant. (364,397) Anthocyanidins Malvadin Cyanidin Delphinidin reduce risk of heart disease, induced TNF- alpha production and acted as modulators Pelargonidin of the immune response in activated red grapes, red wine, macrophages, support the endothelial Peonidin cherry, raspberry, nitric oxide-dependent relaxation Petunidin strawbeny, grapes (365,378,388,391) Other Polypienok stop the growth of cancer cells, protection Compounds or Phenyl com, rice, tomatoes, of LDL against oxidation and inhibition of prunes spinach, cabbage, cell-modified LDL effects on intracellular Propanoiis Ferulic acid asparagus lipid (336,398,399) apple, pears, cherries, prunes, plums, peaches, depresses blood pressure and heart rate , apricots, hemes, antioxidant and antiproliferative activities, Chlorogenic acid tomatoes, anise, coffee inhibit LDL oxidation (340,400,401) Neochlorogenic acid prunes inhibit LDL oxidation (401) TNF-alpha production decrease, inhibit oxidative modification of LDL particles , antiproliferative activities, support the endothelial nitric oxide-dependent Gallic Acid cranbeiTies, wine relaxation (340,378,388,402,403) Other Polyphenoic white grapes, olives, protect cells against oxidative stress, Compounds or Phenyl spinach, cabbage, antiproliferative activities Caffeic acid asparagus, coffee (340,378,380,399,404) PropanoMs Coiit antioxidants, potentiate insulin action, and beneficial control of glucose intolerance and diabetes, endothelial nitric oxide- dependent relaxation, lessen effect on Cinnamic acids cranberries, wine oxidation of lipoproteins (364,378,404) white grapes, wine, cranberries, tomatoes, spinach, cabbage, antioxidant and antiproliferative activities, asparagus, can-ots, induce a multiplicity of phase 11 enzymes Coumarins caraway, celery. (136,340,364,404) Antioxidant, anti-inflammatory, and anti tumor, support the endothelial nitric oxide- strawberries and dependent relaxation, mediating cardiac Ellagic acid raspberries contractile responses (343,399,405) anticarcinogenic and cardio protective, CuTcumin turmeric, ginger scavenge oxygen radicals (406,407) antioxidant inhibitor of cancer cell growth, antiproliferative activities, modulator of Resveratrol wine and peanuts platelet aggregation (340,408,409) antiproliferative, support the endothelial nitric oxide-dependent relaxation, protection against oxidation of LDL Benzoic acid berries (340,378,404) Lipoic acid dark leafy grees: spinach suppression of malignant cell growth, Lipoic acid and broccoli block release of oxygen radicals (261,410- 79 Table 2. Phytochemicals and their proposed biological mechanisms continued Most Common Class Specific Foods Properties (135,342,343)® Phytochemicals 412) Protease Inklbitors Protease reduces tumors, inhibits carcinomas Inhibitors Soy bean, potato, com (135,136) Monoterpenes Mycrene d-Limonene Citrus fruit, peppers, basil, thyme, caraway, whole Carvone grains Diterpenes Carnosol, Rosmarinic acid Oregano, rosemary Triterpenes Glycyrrhizin 6-Gingerol Saponin Citrus fruit, peas, antifungal, antibacterial, lower cholesterol, soybeans, herb, licorice inhibit cancer growth and tumor, inhibit Zingiberene root, legumes sodium glucose-co-transporter-1 (413) Sulfides Blood clotting disorders, reduction of Allyl Garlic, leek, chives, stroke and heart disease, antimicrobial sulfur/Ajoene onion, shallot, cabbage activity (414-422) Cardiovascular Disease and its Pathogenesis Half of the annual mortality in Western society results from heart and blood vessel diseases of which arteriosclerosis, the most common lethal disease, is the chief cause. Arteriosclerosis, Greek for "hardening of the arteries," is a generic term for a number of diseases in which the arterial wall thickens and loses elasticity. Atherosclerosis, the most familiar type of arteriosclerosis, is a disease of the arteries characterized by fatty deposits on the intimal, or inner, lining of the arterial wall. In atherosclerosis the presence of fatty deposits, called plaque, leads to an important loss of arterial elasticity along with narrowing of the artery. This constriction of smooth blood-flow ultimately deprives vital organs of their blood supply. Clots may lodge in arteries supplying the heart, causing myocardial infarction (MI) or heart attack, or the brain, causing stroke. Atherosclerosis may manifest fairly rapidly in diseases in which the concentration of 80 blood fats (lipids) is raised, as in diabetes and hypercholesteronemia (234,423). Serum lipids, low density lipoprotein (LDL) in particular, are related to the risk of CVD. Diets high in fats may translate to high amounts of LDL in blood. LDL is the major carrier of cholesterol and lipids in the blood. LDL crosses the endothelium in a concentration-dependent manner and can become trapped in the extra cellular matrix or infiltrates the intima of lesion-prone arterial sites (see Figure 1). The subendothelium turns into an oxidizing environment, and if the LDL remains trapped for a sufficiently long period of time, it undergoes oxidative changes promoted by oxidants generated by local vascular cells or enzymes (239,358.424-427). Figure 1. Proposed role of LDL oxidation in the initiation of fatty streak lesions. (Adapted from Hercberg et.al. (234)) Circulating monocyte © X-CAM blood macrophage minimally modified -O oxidative Fully oxidized "trapped" Multiple proatherogenic subendotheHujn effects on aiterial cells Mildly oxidized forms of LDL and cytokines contain biologically active phospholipid oxidation products that affect the pattern of gene expression in endothelial cells (ECs). This alteration leads to changes in the expression of monocyte binding molecules (X-CAM) (423,425), cell adhesion molecule-1, monocyte chemotactic protein (MCP-1), and macrophage colony stimulating factors (CSFs) (234), which cause 81 circulating monocytes to adhere to the endothelium and migrate into the artery wall. Nitric oxide (NO) also may act as a mediator of inflammatory processes. It enhances the effect of cyclooxygenases and stimulates the production of pro-inflammatory eiconosoids. These factors in turn promote the recruitment of monocytes and drive their phenotypic differentiation to macrophages in response to the CSFs (234). The oxidized LDL further inhibits the egress of macrophages for the artery wall. The cells recognize and take up the oxidized LDL through scavenger receptors. Further oxidation leads to alterations in apolipoprotein B/E such that LDL particles are recognized and internalized by macrophages, progenitors of the lipid-laden foam cells, a hallmark component of atherosclerosis (428). Marked increases in lipid and cholesterol oxidation products render the LDL particles cytotoxic, leading to further endothelial injury and favoring further entry of LDL and circulating monocytes and thus a continuation of the disease process and formation of the fatty streaks (428). At the same time macrophages may release their fatty load upon self-destruction, thus damaging surrounding cells, attracting other macrophages, and continuing the cycle of inflammation and proliferation. Macrophages may also migrate back into the blood stream by pushing endothelial cells apart and destroying the endothelial cell monolayer. As the final mechanism, lesions called fibrous plaques, cling to the arterial lining and increase in size, thus narrowing the arterial lumen. Fibrous plaques are soon covered with a thick dome of connective tissue with embedded smooth muscle cells that usually overlay a core of lipid and necrotic debris (423,425). With time the plaques become calcified and may undergo further changes leading to a partial reduction or total 82 blockage of the blood's flow through an artery. If blood is unable to flow through the vessels, it cannot nourish the tissues ultimately causing a heart attack or MI. A MI is often the result of a clot that lodges in a coronary artery, resulting in deprivation of oxygen to a portion of the heart muscle and ultimately the death of a portion of the heart muscle. The pathogenesis of this disease is consistent across ethnic groups, and gender thus MA women diagnosed with CVD will manifest similar and consistent physiological and anatomical changes overtime. While LDL oxidation is a key factor to the atherosclerotic fomaation process, it is still uncertain which factors are responsible for the LDL oxidation. Indirect evidence of decreased in vivo oxidation comes from antioxidant supplementation studies in animals that showed reduced lesion formation and reduced LDL oxidation (427). There are several in vitro assays to measure oxidation and cell damage. The oxygen radical absorbance capacity (ORAC) test is a commonly used test to measure hydrophilic antioxidants for their ability to reduce free radicals. Antibodies to aldehyde-modified LDL recognizable epitopes in human plaques (358,429) have been found in vitro. Its peroxidation product, malondialdehyde, and other aldehydes are produced by reaction with thiobarbituric acid (thiobarbituric acid-reactive substances, or TEARS, assay). Together with conjugated dienes these are the most common assays used to determine oxidability, or susceptibility to oxidation, of LDL. F2-isoprostanes, stable markers of lipid oxidation, have been detected in lesions as well (430). F2-isoprostanes (particularly 8-e/>i-prostaglandion ¥20. [8-e/?f-PGF2a]) have been used as specific 83 markers of lipid peroxidation. Prostaglandins are physiologically active substances that modulate the biochemical activity of the tissues in which they are formed. They play an important role in heart disease, lipolysis, glucose metabolism, vasodilatation, vasoconstriction, and many other factors. An increased concentration of prostagladin has been found in in vitro LDL exposed to various types of oxidative stress, in people with diabetes, smokers, and in persons with hypercholesteronemia however, a link between plaque formation, oxidative damage, and chronic disease events still needs to be established. Modulation of Key Heart Disease Biological Mechanisms via Plant Constituents Several mechanisms have been suggested for the prevention of vascular disease, from prevention of oxidation and Mai Hard reactions, inhibition of leukocyte adhesion, antimicrobial activities that prevent inflammation, and estrogenic effects. Modulations of these biological processes have been related to several FV constituents. The studies selected were chosen bccause the effects of phytochemicals were tested on several biological markers associated with disease risk were utilized. The potential cardiovascular benefits of many plant constituents are depicted in Figure 2. The following sections will present how different studies have tried to discern how the most studied phytochemicals may lower the amount of cholesterol in blood, protect against LDL oxidation, and improve heart health markers such as triglycerides, coagulation factor fibrinogen, and platelet aggregation. Also, the increased sensitivity to prostaglandins and plasminogen activator inhibitor, the impaired vascular function and relaxation, decreased hypertension, and the improved vasodilatation, carotid intima- 84 media thickness, brachial arterial diameter, and adhesion of leukocytes to endothelial cells will be presented when available. The majority of the studies presented in these next sections will be positively and null to the association of CVD and some key vitamins, and phytochemicals yet, some relevant studies that have demonstrated an inverse effect to the associations of phytochemicals and CVD will be mentioned as well. Figure 2= Potential cardiovascular benefits of many plant constituents I antioxidant activity X permeability i i platelet - ' - Aggregation Blood vessel V jf I — X inflammation flexibility- \\^ ^1 • Notes; The potential CVD benefits are brought about via several mechanisms in which FV improve vascular health • LDL metabolism • Superoxide quenching • Nitric oxide synthase inducers • Potassium enrichment • Inhibiting cholesterol synthesis • Binding bile acids • Controlling blood pressure Antioxidant Activity Oxidative stress is a result of the release of free oxygen radicals in the body and has been related to a number of disorders, including cardiovascular malfunction and cancers (135,431). Many phytochemicals act as antioxidants, scavenging free radicals and acting as protectors of the cells (237). According to the definition proposed by the Panel on Dietary Antioxidants and Related Compounds of the Food and Nutrition Board "a dietary antioxidant is a substance in foods that significantly decreases the adverse effects of reactive oxygen species (ROS), reactive nitrogen species, or both on normal physiological function in humans"(102). Over the past two decades, convincing evidence has been gathered in support of the hypothesis that free-radical-mediated oxidative processes and its products play a key role in atherogenesis. At the center of this theory are LDLs, which undergo several changes through oxidation that are thought to be proatherogenic, leading to biologically active compounds that affect the functionality of vascular cells. Dietary antioxidants such as vitamin C, E, j3-carotene and selenium have been reported to reduce the oxidation of LDL (339,344.423,432-434), thereby protecting against CVD. These are the four dietary antioxidants recognized and accepted by the U.S. Food and Drug Administration (FDA) (435). Thus, the intake of antioxidant "cocktails" in the form of dietary supplements is a common practice to decrease risk of CVD. Several observational studies have suggested that individuals who cat more FV, which are rich in several antioxidants, have a lower risk of developing arteriosclerotic plaque and have a diminished oxidative process. The identification of LDL oxidation as a key event in atherosclerosis suggests that it may be possible to reduce the risk of atherosclerosis by antioxidant supplementation. Vitamin C is an important water- soluble antioxidant in biological fluids. Vitamin C also acts as a coantioxidant by regenerating a-tocopherol radicals produced via scavenging of lipid soluble radicals (436). Vitamin E is the major naturally occurring antioxidant in human lipoproteins (436). It has been associated with reduced coronary events and atherosclerotic 86 progression, but the evidence from clinical trials is controversial vi'hen using dietary supplements. The most thoroughly investigated dietary components which have been suggested to have antioxidant activity ixom FV are vitamins A, C, and E, selenium, polyphenols, flavonoids, conjugated isomers of linoleic acid, D-limonene, epigallocatechin, gallate, soya protein, isoflavanones, chlorophyllin, alipharin, sulphides, catechin, tetrahydrocurecumin, seasaminol, glutathione, uric acid, indoles, thiocyanates, and protease inhibitors (338). The ability of antioxidants to protect LDL particles from oxidation, and thus lessening their atherogenicity (428,437,438), have motivated many studies in which plant rich diets are studied for their LDL protection capabilities. Carotenoids are a class of natural fat-soluble pigments found principally in plants and arc responsible for many of the red, orange, and yellow hues of plant leaves, fruits, and flowers. Some 600 different carotenoids are known to occur naturally, and new carotenoids continue to be identified, for more details about where to find these phytochemicals please refer to Table 2. P-carotene has been linked to the prevention of heart disease (357). Cell culture, animal, human, and in vivo studies showed that P-carotene is an effective antioxidant (359,439,440) and inhibits cholesterol synthesis (441). Small compounds (including vitamin C, p-carotene, and other carotenoids, and drags such as probucol) can decrease the susceptibility of LDL to oxidation (442-444). The largest fraction of hydrocarbon carotenoids (e.g., a, P-carotene and lycopene) (as well as most vitamin E and other tocopherols) is transported by LDL (445), suggesting that these compounds in particular 87 may play an important role in preventing oxidative modification of this lipoprotein fraction. The supplementation of LDL with 3 jimol/1 P-carotene or lycopene reduced their susceptibility to metal ion-dependent oxidation 37 and 35%, respectively. However, P- carotene may not be the sole protective food constituent given that this inhibitory effect was positively correlated with vitamin E content (441). Dugas and colleagues, in their in vitro study, showed that cell-mediated oxidation of LDL was inhibited by p-carotene, but enhanced by lutein or lycopene by human aortic endothelial cells (EaHy-1) (446). This same research group later reported that dietary (i. e., in vivo) supplementation of 15 mg per day of p-carotene over four weeks resulted in a three to six fold increase in the p-carotene content of LDL. The in vitro tested increase in oxidation resistance of LDL isolated from the subjects was greater than the increase in oxidation resistance seen in LDL emiched in vitro 11 to 12 fold with P-carotene (440). Again, no effect on LDL resistance to oxidation was seen for lycopene supplied as a dietary supplement (440), yet one cellular model study (a macrophage cell line) was able to demonstrate lycopene antioxidant activity (441). Another study found that serum levels of lutein and ciyptoxanthin were twice as high in a French population that had a much lower incidence of CHD than an Irish group, suggesting that such xanthophylls may be useful as antioxidant supplements (447). Another report described an animal (h3/percholesterolemic mice) model in which tomato ingestion over four months was associated with a decrease in plasma lipid peroxide and an induction of vaso-relaxing activity in the aorta by acetylcholine (448), 88 suggesting plasma lipid protection against oxidation. Other studies have reported a significant decrease in serum lipid peroxidation and LDL oxidation after three weeks of lycopene dietary supplementation (355) while in vitro supplementation of P-carotene, canthaxanthin, or zeaxanthin inhibited cell-mediated LDL oxidation (362). Agarwal and Rao reported similar results. They supplemented individuals for one week with tomato juice (about 50 mg/day lycopene), spaghetti sauce (about 39 mg/day lycopene), or tomato oleorcsin (about 75 mg/day lycopene). These researchers showed a significant decrease in lipid peroxidation and LDL oxidation, but observ^ed no change in serum cholesterol levels (355). Also, this group found that lycopene concentration decreased as a result of oxidative stress derived from ingestion of a meal or a glucose solution, and from cigarette smoke. Another study examined the effects of supplementing FV extracts over four weeks. The capsule contained dried fruit juice extracts from oranges, apples, pineapples, papayas, cranberries, and peaches while the vegetable juice extract was from carrots, parsley, beets, broccoli, kale, cabbage. spinach, and tomatoes. During the 1®^ week the serum, lipid peroxide levels decreased from 16.85 to 3.13 |imol/i and were maintained during the remaining study period (449). In an atherosclerosis case-control study (n=231), an inverse association between lutein and zeaxanthin levels and the extent of atherosclerosis was seen (450), suggesting possible antioxidation effects. Carotenoid depletion studies, where well-fed people ate foods low in lycopene and other carotenoids, have demonstrated increases in oxidative damage during depletion (359,451). Most of these depletion studies concluded that for 89 maximal protection against oxidative damage, modest intakes of carotenoids are needed. The flavonoids, a group of more than 4,000 polyphenolic antioxidants, are potential chronic disease preventive components of FV. Flavonoids are broken down into categories, though the issue of how to divide them is not universally agreed upon. One system breaks flavonoids into isoflavones, anthocyanidins, flavans, flavonols, flavones, and flavanones (452), please refer to Table 2. These compounds can act as antioxidants, protect against LDL oxidation, and inhibit platelet aggregation, thereby providing protection against heart disease (237..369,372,404,453-456). A group of elder women fed strawberries, spinach, red wine, or vitamin C supplements demonstrated that intake of foods increased the antioxidant capacity of serum to a greater extent than that of the vitamin C supplements (457). A group of Finnish men 60+ years consumed lOOg of frozen berries, 600 mg of antioxidant vitamins, or a calcium supplement for eight weeks. This study demonstrated that five hours after consuming berries significant decreases in LDL oxidation were not seen but a significant increase in antioxidant activity occurred (458). Catechins are present in high concentrations in tea. Compared to activities of red wine epigallocatechin gallate is the most active inhibitor and peroxyiiitrite scavenger. Tliis suggests a beneficial preventive effect of tea intake on the occurrence of cardiovascular heart disease (379). Oxidation of LDL has been retarded by phenolic compounds, and antioxidant activity of compounds was demonstrated as follow: quercetin > canidin > catechin (394). Also, catechins inhibit LDL oxidation in vitro, in 90 a dose dependent manner, and epigallocatecMn gallate appeared to be more potent than vitamin E (375). Polyphenols from grape extracts inliibit oxidative changes of LDL in vitro (397), while LDL oxidation was inhibited in vivo in those who dranlc wine (370). In vitro, the polyphenol resveratrol, has been reported to have glutathione sparing mechanisms (408). Quercetin is the major flavonol in the Western diet and possesses both tinticarcinogenic activity and the ability to inhibit LDL oxidation, for details on its food sourccs please refer to Table 2 (395,459). Hayek and colleagues fed atherosclerotic apolipoprotein E-deficient mice red wine, quercetin, or catechin in water for 42 days and found that LDL from these mice was more resistant to oxidation than the control ethanol fed mice (459). Proanthocyanidins, a highly specialized group of bioflavonoids, earlier referred to as pycnogenols, also play a role in oxidative stress reduction. Polyphenols have demonstrated superoxide-quenching properties. NO is an important signaling molecule and vasodilator that acts in many tissues to regulate a diverse range of physiological processes (455). Superoxide can destroy NO generated by the vascular endothelium. Polyphenols also protect NO (460). Total antioxidant capacity measured through oxygen radical absorbance capacity (ORAC) values may suggest inhibition of platelet function and superoxide release, as well as the increase in NO, probably as a result of both antioxidant-sparing and/or direct effects of select flavonoids. Blueberry and bilberry ORAC values were correlated with anthocyanidins and total phenols, and their activity increased with the maturity of the plant. Researchers concluded that daily 91 consumption of'A cup (72.5g) of blueberries could raise ORAC values by 1-3.2 mmol (461) while other research concluded that extracts from blackberries, red raspberries, and sweet cherries were more effective than blueberries in preventing LDL oxidation (403). Other flavonoids have been related to heart health. Isoflavones or soy phytoestrogens have been related to benefits in cardiovascular health (462), particularly when administered in a soy protein matrix. Isoflavones antioxidant effect (protecting LDL from oxidation) has been demonstrated (385). Studies by Hertog and colleagues in The Netherlands (391,463) have demonstrated a clear relationship between flavonoid intake, CUD and stroke prevention. The Zutphen study of older men in the Netherlands found that the flavonoid intake was inversely associated with heart disease mortality and incidence of heart attack over a five-year period. Those who had the highest consumption of flavonoids had 60% less mortality from heart disease than the low flavonoid consumers, primarily from tea, onions, and apples (371). Earlier this group found that intake of flavonoids was protective against the risk of CHD in older men (391). In a prospective study of 34,000 postmenopausal women in the mid-western U.S., total flavonoid intake was associated with decreased deaths from CHD (368). It is likely that various polyphenols, including flavonoids, act similar to antioxidants and that collectively they may bestow protection from the development of CVD. 92 Decrease Platelet Aggregation and Vasodilation Since platelet aggregation leads to blood vessel blockage this mechanism has been studied in relationship to vitamins and phytochemical use. Vitamin C dietary levels are lower in people who have both fatal and non-fatal heart attacks. In a Finish prospective study, vitamin C deficient men demonstrated 3.5 times more heart attacks than men who were not deficient (464-466). The evidence for vitamin C use and incorporation from daily intake is substantiated (466,467). A relationship between winter months and increased cardiovascular death rates has been established, together with a relationship between elevated fibrinogen, and C-reactive protein. It was been proposed that the decreased availabihty of vitamin C due to less accessibility of FV may play a significant role in increased CVD (468.469). Furthermore, high levels of p-carotene in serum have been reported to reduce fibrinogen levels in humans and animals (470). While, lycopene and tocotrienols have been described as potentially inducing endothelial nitric oxide (NO) synthesase (enz3Ame that catalyzes the formation of NO). NO is a powerful vasodilator and is stimulated by proanthocyanidin complexes, while producing more endothelial NO synthase and counteracting vasoconstricting effects of the stress hormone adrenaline and diminishing the threat of platelets clumping (372,455,471). A solution of bilberry anthocyanin reduced platelet aggregation in vitro (402), while consumption of cranberry juice and leek flavonoids inhibited aggregation in vivo (472). Some of the protective effects of isoflavones are anti-inflammatory effects (473), anti-thrombotic effect (decrease platelet aggregation) (474), and blood vessel protection 93 (386,474). Pace-Ascialc and colleagues did a study with 24 healthy males. The men consumed 375 mL/d of red or white wine, grape juice with or without resveratrol. They concluded that grape juice with or without resveratrol-supplemented inhibited 50% of the thrombin-induced platelet aggregation. More recently Keevil and colleagues saw a diminished platelet aggregation in 10 subjects drinking grape juice for one week (367). Garlic have demonstrated antioxidant capability, vascular resistance (475), blood coagulation, fibrinolysis (476), and platelet antiaggregatory (477). Ginger has anti inflammatory properties that may interrupt the prostaglandin-leukotriene cascade, blocking damaging prostaglandins but leaving beneficial ones unaffected (478) and to reduce platelet aggregation (479,480). Some studies indicate that these effects may be particularly influenced by curcumins. Capillary and Vascular Protection Carotid intima media thickness was found to be inversely correlated to the levels of lutein and zeaxanthin (xanthophylls) (481). While in a Finnish study of 520 asymptomatic men and women, those who demonstrated low levels of lycopcne had an 18% increase in intima-media thickness compared to those with high levels. This relationship was not seen in women. In the Los Angeles Atherosclerosis study researchers found a relationship between thickening in the carotenoid arteries and blood levels of lutein (482). Participants with the highest lutein intake demonstrated no arteiy wall thickening while those in the lowest percentiles showed sign of wall thickening. Different anthocyanin preparations have been use to measure electrolyte balances and the protection of capillary permeability. Bertuglia and colleagues demonstrated that 94 hamsters given oral doses of commercial 36% bilberry antliocyanosides for two or four weeks, demonstrated better capillary perfusion and fewer sticking leukocytes (483). Anthocyanin has been proposed to protect blood vessels by stabilizing membrane phospholipids and by increasing production of mucopolysaccharides (484). Grape anthocyanias protect vascular processes in rats. Rat aortas exposed to anthocyanin- enriched blueberry extract in vitro exhibited relaxation caused by endothelium- generated NO (485). Delphinidin induced a maximal relaxation of 89% in rats aortas comparable to wine polyphenols (378). Therefore, fruits containing this phytochemical may provide protection against heart disease (364). Lastly, garlic have also demonstrated positive protective effects vascular resistance (475). Alteration of Cholesterol Metabolism As described earlier the type of lipoproteins that transport fat in the blood influences the plaque-forming tendency of cholesterol. The LDLs are clearly atherogenic, but the HDLs appear to prevent accumulation of cholesterol in the tissues (221). The blood levels of these lipoproteins are partially governed by dietary factors, especially the type of animal fat, and vegetable lipids (phytosterols) eaten (339,486). Controlling fat intake from animal sources has been demonstrated to be a valuable prevention method for modigyng serum lipoprotein and also suggests that other sources of fats may be better options to modify lipoprotein profiles. Plants, both as medicine and nutrition for such health problems have been investigated yet, the processes involved are complex and not yet clearly understood. 95 Niacin levels, in its nicotinic acid fonii from dietary supplements improves all lipid parameters (487,488), while pantothenic acid reduces cholesterol levels (489-491). An inverse association between serum levels of P-carotene and other carotenoids and CHD has been determined (492). Most circulating carotenoids are associated with lipoproteins in plasma, and people with the highest level of carotenoid levels in their blood plasma have 60% less heart attacks and deaths (493). The largest fraction of total carotenoids is found in LDL, as evidenced by the typically yellow color of this lipoprotein fraction (445). Cell culture, animal, human, and in vivo studies showed that P-carotene inhibits cholesterol synthesis (441). Isoprenoids and lycopene, which down-regulate HMG-CoA reductase (a liver enzyme that is responsible for producing cholesterol), appear to suppress of cholesterol synthesis and lower cholesterol levels (35,441). Furthermore, lycopene and tocotrienols down regulate HMG-COA reductase (494). The many flavonoids in plants have extensive biological properties that promote human health and help reduce the risk of disease. A multicenter, placebo-controlled, randomized trial with participants that presented eleveated serum cholesterol, demonstrated that after six weeks of taking artichoke (with caffeoylquinic acid and other flavonoids) extracts, levels of cholesterol decreased by 18.5% vs. 5.6% in the control group (456). In other studies, artichoke extract demonstrated LDL oxidation capabilities (390) while a detailed chemical analysis demonstrated that its luteolin promoted reduction of triglycerides. Luteolin appears to increase conversion of cholesterol to bile acids and 96 this appears to be pivotal in the hypocholesterolemic effect of artichoke. Terpenoids such as limonene, geaniol, menthol and carvone elicit a significant reduction in total and LDL cholesterol levels (339), thereby reducing the risk of heart disease. Xu and colleagues reported that in a hamster fed a hypercholesterolemic diet for 16 weeks, catechin supplementation was as effective as vitamin, E in inhibiting plaque formation (377). These researchers suggested that this action may be related to catechin ability to absorb dietary fat and cholesterol rather than any cholesterol inhibitory effects. In a group of Japanese women, quercetin was inversely related to plasma total cholesterol and LDL cholesterol (356). The phenolic components of red wine, rather than the alcohol content, have been shown to reduce the levels of LDL cholesterol and Lp (a) (391). Also, anthocyanins have been demonstrated to inhibit HMG-CoA reductase and inhibit cholesterol synthesis. Soy protein intake was associated with a 9.3% reduction in serum cholesterol, a 12.9% reduction in LDL-C, and a 10.5%) reduction in serum triglycerides (495,496). A dose-response effect with greater hypocholesterolemic effects with larger amounts of isoflavones also has been suggested (495,496). Because of the conclusive evidence of how soy protein decreases serum cholesterol and LDL-C concentrations, on October 20, 1999 the U.S. Food and Drag administration approved a health claim; "Intake of 25 grams of soy protein a day, as part of a diet low in saturated fat and cholesterol, may reduce risk of heart disease"(435). There is not consensus surrounding the benefits of garlic as a hypolidemic agent (419,421). Garlic contains a number of allyl sulfides that are known significantly lower 97 total and LDL cholesterol levels and to decrease the tendency of blood clots to form. Garlic powder was ineffective in lowering blood lipids yet, different garlic preparations have demonstrated favorable effects in women in terms of CHD risk factors (i.e. increases in HDL-c and reductions in total cholesterol) (421). Eilat and colleagues indicated that allicin had a beneficial effect on serum hpid profile in hyperlipidemic rabbits and suggested further clinical tests. Another research group demonstrated a decrease in total cholesterol (11%), triglycerides (34%), LDL (10%), and an increase of HDL cholesterol (19%) with a 1,200 mg mixture of garlic powder and fish oil (497,498), These changes suggest lipid reduction in arterial cells and prevention of intracellular lipid accumulation. Among other properties, lipoprotein reduction activities of ginger have been researched. After its administration (200 mg/kg orally) to rabbits, cholesterol, triglycerides, lipoprotein and phospholipids were significantly reduced (499). Cayenne pepper, curcumin (in mustard and curry powder), and other plants that contain the phenolic compound capsaicin lower blood cholesterol levels, as does the spicc fenugreek (479). The phytochemicals found in FV are very similar to those in whole grains. The phytochemicals in grains include plant sterols, phytases, phytoestrogens, tocotrienols, lignans, ellagic acid, and saponins (500). Diets high in fiber improve lipid profiles (244,428). The active phytochemicals are concentrated in the bran and the germ, so that the health benefits of grains are maximized when the whole grain product is consumed (345). Refining wheat, for example, causes about a 200 to 300-fold loss in the 98 phytochemicai content (501). The soluble fiber in FV may help to control high serum cholesterol. Many fibers can prevent the efficient absorption of lipid micelles in the digestive tract, resulting in bile acids deficiency, then the rate-limiting enzyme for conversion of cholesterol to bile acids is triggered (346,353). This in turn drains the hepatic cholesterol pool, induces increased hepatic expression of LDL receptors, and lowers serum LDL (346,353). Blood Pressure Reduction Hypertension or high blood pressure (HBP) is one of the main risks for CVD therefore, it is important to consider it separately and describe how different FV phytochemicals have been researched and their properties related to decreasing blood pressure. Even though the main focus of this scction is on phytochemicals, combinations of potassium, calcium, and magnesium are also important componenis of dark green vegetables and are considered important in keeping normal heart rhythm. As mentioned earlier, the results from the Dietary Approaches to Stop Hypertension (DASH) study suggest that a diet rich in fhiits, vegetables, and low-fat dairy product significantly lowered blood pressure (502). These foods are excellent sources of many phytochemicals. Potassium, magnesium, and calcium account for the success of diet to reduce systolic and diastolic blood pressure and make diet comparable in effectiveness to first generation antihj^jertensives. Increased potassium intake hyperpolarizes the vascular endothelium, boosting endothelial NO, and suppressing formation of superoxide (503). Similar results on blood pressure were also reported in a three-armed clinical trial (arm-1-behavioral intervention including weight loss, sodium 99 reduction, increased physical activity, and limited alcohol intake; arm-2, same as 1 plus DASH FV diet; and ami-3, advice only group) (504). In another study of female nurses by Ascheiro and colleagues, a diet high in FV was associated with lower blood pressure. In this study, dietary fiber and magnesium, not calcium and potassium, were inversely associated with systolic and diastolic blood pressures (505). Bobak and colleagues found that serum levels of different carotenoids; a- and )3-carotene, and lycopene were 1.9, 1.7, and 2.7 fold higher, respectively, in Israeli men compared to Czech men. Mortality rates, blood pressure, and CHD rates in the subjects were significantly high in Czech men and lowest in Israeli men who demonstrated high plasma carotenoid values (230). In hypertensive rats, the antioxidant properties of green tea polyphenols attenuated blood pressure increases (506). Garlic and onion and other members of the Allium family are rich in sulfides and other protective substances. Members of the Allium family have international reputations as remedies for lowering blood pressure and generally improving the health of the cardiovascular system. Hypotensive qualities have been identified with daily 600-900 mg garlic powder and aged garlic extract (415- 417), and 0.5-1.0 kg of guava fruit (507). Some of ginger's {Zingiber officinale) chemicals have the ability to act as a calcium antagonist, vasodilators, and diuretics (508). Some members of the carrot family have been studied; primarily Angelica {Angelica archangelica), which contains as many as 15 compounds that may act as calcium channel blockers (509). Derived Irom pineapple {Ananas comusus), bromelain, is frequently used as an anti-inflammatory, to reduce 100 fibrinogen, lessen the risk of blood clots, and as a hypotensive agent, paiticulariy in smokers (307,510). Summary There is a strong relationship between increased FV intakes, their constitutive micronutrients and ph3rtochemicals and decreased CVD risk. In many studies where well-fed people received supplemented amounts of ph>1:ochemicals, concentrations of phytochemicals significantly increased in semm whereas a significant health protective effect was not necessarily seen. Modest phytochemical supplementation of people with diets low in FV may be more successful than the clinical trials that fed large amount of phytochemicals to people with varied diets. Even though there is evidence that clearly supports the detrimental effect of certain antioxidants, such as P-carotene on the incidence of CVD in highly susceptible populations such as smokers, the findings raise questions as to whether there are other substances in FV that provide protection or as to whether supplementation can counteract a person who may be "primed" for a cardiac event. Is it possible that the interaction among several of the protective and antiatherogenic and antithrombotic components in FV can produce a synergistic effect not observed in studies involving antioxidants alone? (332). These results may indicate that there are some other properties in food, besides antioxidant vitamins, which provide the protective effect seen in observational studies. In vitro effects on the mechanisms for heart protection are more pronounced than the in vivo effects in humans. Yet, it remains to be determined whether these effects are of clinical importance and can translate into reduced risk Irom thrombi formation and 101 risk of coronary event. The biological mechanisms whereby FV exert their effect are not entirely clear and are likely to be multiple. Many nutrients and phytochemicals (i.e. carotenoids, flavonoids, and sulfides) may independently or synergistically reduce CVD risk. Diabetes and its Pathogenesis Diabetes pathogenesis is suggested to start with impaired carbohydrate metabolism and hyperglycemia. Glucose homeostasis protects the body against low levels of sugar when periods of fasting and excessive high levels following consumption of high carbohydrate diets. Honnonal regulation of liver glucose production and uptake by skeletal muscle, heart muscle, and fat maintains glucose balance. Impairment in glucose metabolism, leads to physiological imbalances that need to be managed. Oncc glucose enters the body several pathways are engaged in the homeostasis process. First, p-cells of the pancreas are stimulated, insulin is secreted and intracellular inositol 1,4,5-triphospahte (IP-3) sensitive Ca"^ mobilizes its stored calcium (511). The major task of insulin is to enhance glucose disposal. Insulin action is facilitated by the insulin-sensitive glucose transporter (GLUT-4), expressed in skeletal and heart muscles as well as in adipose tissues. The homeostatic relationship between GLUT-4 and insulin may be disturbed when glucose remains at supraphysiologcial levels (281). Elevated amoimts of glucose affect |3-cell release of insulin, change key constituents of insulin gene expression and insulin synthesis starts to occur. In addition, potentially harmful mechanisms, such as overt generation of reactive oxygen species (ROS), begin (512,513). Low expressions of antioxidant enzymes have been reported in the 102 pancreatic islets and this may make them susceptible to ROS (514). Chronic exposure to hyperglycemia has been demonstrated to result in non-enzymatic glycated proteins or advanced glycation products (AGE) thus leading to generation of ROS (515-517). Some proposed mechanisms by which elevated levels of blood glucose perturb cellular properties and aggravate endothelial ROS generation are via the suppression of intracellular mitochondrial function and ROS overproduction by use of low-molecular weight inhibitors. Glycated proteins can also favor lipid peroxidation. Also, glucose and fructose lysine, the first Amadori rearrangement products, generate ROS in the presence of trace amounts of iron or copper which act as catalysts. What is more, signal transduction by the AGE receptor appears to involve generation of free radicals (515- 517). Continuous exposure to hyperglycemia have been shown to not only increase the amount of AGE (518-520), but to also activate several cell systems such as protein kinase-C (PKC) iso forms (517), and to increase glucose flux through aldose reductase pathways all of which result in tissue/organ damage. Antioxidants prevent glucose induced activation of PKC, sorbitol accumulation, and activation of cytokines (521). ROS also increases the generation of tumor necrosis factor (TNF-a), a plciotropic cytokine involved in many metabolic responses in both normal and pathological states that can act as a putative inhibitor of tyrosine phosphorilation of insulin receptors, and aggravates oxidative stress (522-524). TNF-a has been shown to decrease GLUT-4 transporter in muscle cells (525), increase circulating fatty acids (526,527). alter P-cells function (525), and to increase triglycerides and decrease HDL (528). Antioxidants and 103 phenolic compoimds scavenge free radicals, reduce oxidative stress, and decrease the expression of TNF-a (388,529,530). Modulation of Key Diabetes Biological Mechanisms via Plant Constituents The effect of food and plant chemicals in ameliorating diabetes has been investigated by several approaches. Retardation of glucose uptake in the small intestine has been examined via the a) inhibition of digestive enzymes, b) inhibiting the active transport of glucose across the intestinal brush border, and c) by delaying the gastric emptying rate of gastrointestinal content. Plant chemicals have also been studied regarding P-cell regeneration and insulin releasing activity, aldose reductase pathway inhibitors, and antioxidant defense mechanisms (531). This section will focus on food constituents and their actions which stimulate these mechanisms mentioned above. Insulin resistance is when the body lacks the capacity to respond normally to insulin and impaired ability to lower blood glucose is seen. Insulin resistance leads to hyperinsuiinemia. Both insulin resistance and hyperinsulinemia may precede the onset oflGT (532-534). Reducing Cholesterol, Glucose, and Aldose Reductase FV are naturally low calorie, high carbohydrate foods which when consumed in their natural state are also fiber rich. The fiber in FV may also help in the management of diabetes. The dietary fiber recommendation for individuals with or without diabetes is 25g to 35g per day from a wide variety of food sources (535,536). This recommendation is the suggested amount of fiber necessary to successfully blunt the blood glucose and lipid responses associated with diabetes (535,536). It is known that 104 selected soluble fibers can delay blood glucose absorption from the small intestine (321,325,352,537). High fiber diets are uniformiy recommended for diabetics. Particularly important for diabetics is soluble fiber found in many fruits, vegetables, and some seeds, including pectin, gums, and mucilages. Soluble fibers act to increase the viscosity of food in the intestine, thus slowing and reducing the absorption of glucose (321). Foods with high levels of pectin and mucilage have been used effectively for glucose absorption and there is evidence that most of these botanicals provide additional synergistic benefits (531,538). Insoluble fiber is more characteristic of brans and husks of whole grains, nuts and seeds. However, while effective in the short term the long- term effect of insoluble dietary fiber on blood glucose control in individuals with diabetes is probably not as significant as soluble fiber. The data are more convincing for a protective effect of soluble fiber on the serum total and LDL-cholesterol levels in individuals with diabetes, particularly type 2 (352). Lowering total cholesterol and triglycerides while increasing HDL cholesterol are some of the suggested benefits of increasing consumption of certain t3^es of phytochemicals for diabetics (531). Moreover, as with CVD, botanical antioxidants can play a role in diabetes, by helping to maintain the integrity of the cell membranes by preventing PUFA peroxidation. Oxidative stress and resultant tissue damage are hallmarks of chronic disease and cell death, and diabetes is no exception. Researchers have examined the relationship between oxidative stress, and diabetes, and the timing of complications. Oxidative stress plays an important role in predicting diabetic complications (539). The increase 105 in giycoxidation and lipoxidation of tissue proteins in diabetes may therefore suggest antioxidant supplementation which may decrease ceil and tissue damage. The potential of plants to inhibit carbohydrate hydrolyzing enz3Tiies including a- amylase (389) and a-glucosidase (540) and manipulate of glucose transporters (296,541) has been studied. In addition to the previously described antioxidant activity, tea polyphenoiics inhibit a-amylase and sucrase. They are the main substances suppressing postpandrial hyperglycemia and sodium glucose co-transporter-1 (S- GLUT-1) transport across the intestine (541). Flavonoids interfere with starch enzymes and affect postpandrial glucose levels while helping glucose to be released gradually. Plasma glucose levels were reduced by 26% in streptozotocin-induccd diabetic rats with bilberry anthocyanins extracts (542). Aldose reductase converts glucose to sorbitol. This conversion is associated with many of the adverse outcomes associated with diabetes (mainly cataract complications). It has been suggested that ascorbic acid together with other antioxidants may have contributed to this inhibition (373). Varma suggested that flavonoids inhibit aldose reductase (373) and Lim and colleagues suggested that butein was the most promising antioxidant and aldose reductase inhibitor (543). In vitro and in vivo studies have documented the efficacy of several traditional plants in controlling sugar blood levels, yet few clinical studies have been reported. As Tiwari and Rao indicated in their review article that several phytochemicals potently decrease glucose and inhibit S-GLUT-1 activity (531). Phytochemicals mentioned are catechins, isoflavones from soy beans, poiyphenolic compound, tannic acid, chlorgenic 106 acid, crude saponin fractions from Gymnema sylvestre, a herb whose use originated in India, and other saponins from plant extracts Gymnema sylvestre (common name gurmar) stimulated insulin secretion and lowered cholesterol and triglycerides levels in 22 type 2 diabetics participating in a 20 month study (544-546). Momordica charantia L. (common mane bitter goui'd finit (BF)) has been shown to possess hypoglycemic activity (6,547-550). BF is a green, cucumber-shaped tropical fruit with gourd-like bumps and is commonly use in Asia. Many mechanism of action have been suggested. Hence in vitro and in vivo experiments were carried out to study the role of BF juice on diabetic status (531). Alloxan and streptozotocin are chemicals used to produce diabetes and hyperglycemia in experimental animals. The activity of BF juice was tested on streptozotocin treated insulinoma (RIN) cells and isolated islets in vitro. Feeding mice BF juice caused a reduction in streptozotocin-induced hyperglycemia. BF markedly reduced the streptozotocin-induced lipid peroxidation in the pancreas, RIN cells and islets. This suggest a mode of protection of BF juice on RIN cells, islets, and pancreatic |3-cells (549). This research also suggested that a mixture of steroids in this plant may have a potent hypoglycemic effect and that isolated polypeptide-p could mimic insulin activity (551). Momordica charantia, Mucuna pruriens, Pterocarpus marsupium are traditionally used in India as a diabetic remedies. Aqueous extract of these plants have been used to assess their action on glycogen levels of insulin dependent (in skeletal muscle and liver), on insulin-independent tissues (in kidneys and brain), and on enzymes such as 107 glucokinase, hexokinase, and phosphofmctokinase. Administrations of these extracts led to decreases in blood glucose levels ranging from 38% - 60% (549,552) Onions and garlic both contain di-sulfide-bonded thiosulfmates and diallyldisuMdes. These compounds appear to lower fasting blood glucose and improve glucose tolerance (551). Insulin has a similar disulfide bond, so Allium disulfide chemicals are thought to compete with insulin for endogenous insulin-inactivating (551). The effect of feeding either a diet of 15 mg capsaicin or 3% freeze dried onion powder to diabetic rats for eight weeks resulted in less excretion of albumin, urea, creatinine, and inorganic phosphorus (553), which may indicate a kidney protection potential of onions. Onion also appears to produce a significant reduction in the hyperglycemic status of diabetic animals and also exhibited a lowering of lipid peroxides in circulation and in urine. Blood cholesterol (from LDL-VLDL fraction), phospholipids, and triglycerides were lowered significantly by the dried onion powder while dietary capsaicin did not have significant influence on these last parameters tested in diabetic rats. The study concluded that onion feeding improves the metabolic status in diabetic condition, probably becausc of its hypoglycemic as well as liypocholesterolemic effect (553). Capsaicin is also found in chilies and may provide a particular protective effect on those ethnic groups that Jrequently use these types of foods. Preventing Pancreas Damage and Promoting Insulin Action The ability of antioxidants to maintain transcription factors that potentially could harm the pancreas is paramount in the prevention of p-cell death. An in vivo study in 108 mice found that supplementation with vitamin C and E preserved pancreatic P-cell function (554). A group of 1,122 individuals had an oral glucose tolerance test and completed a food-frequency questionnaire. Vegetable consumption demonstrated an inverse association with the risk of nondiagnosed type 2 diabetes (328), while fruit had no effect. Insulin action has been positively correlated with skeletal muscle capillary density. Phytochemicals that improve skeletal muscle capillary fiinction have the potential to directly improve insulin action. Gurmar extracts appear to enhance insulin availability, improve blood glucose homeostasis, and increase P-cell function (548-550). In insulin dependent diabetics, prolonged administration of a water-soluble extract of Gurmar leaves produced a reduction of insulin dosage requirement, improved blood glucose homeostasis, controlled hyperlipidemia, reduccd serum amylase activity, and increased (3-cell function (535). The prevention of pancreas damage and the maintenance of low insulin levels could also protect the heart. Protecting the Heart The capillary walls of people diagnosed with diabetes thicken due to collagen and glycoprotein deposits, thus flexibility is decreased thereby the walls are more susceptible to blockage and atherosclerosis (342). Many mechanisms of heart protection via phytochemicals were presented in the above section yet, additional studies have addressed and related heart disease, diabetes and plant protective agents. The effects of anthocyanins from Vaccinium myrtillus (bilberry) have been studied in diabetic rat aortas. Boniface demonstrated that collagen content of cells was reduced 109 in rat muscle cells cultured with bilberry anthocyanins and that a daily supplement of 600 mg anthocyanosides for two months in adult diabetics helped to prevent injuries caused by malfunction of synthesis-activities (342,343). In an in vitro study with diabetic rats, serum thromboxane B(2) formation level, platelet aggregation, and arachidonic acid were measured. Onion showed a significant inhibitory effect on collagen or amino acid induced thromboxane B(2) formation with greater potency in diabetic platelets than in normal ones (555). Hypoglycemic Agents in Plants and Spices Botanicals demonstrating in vivo h3/poglycemic activity in animals include juniper berries, izui, Siberian ginseng, ganoderma mushroom, cumin, cucumber, and bottle gourd. Many botanical seasonings serve as antioxidants i.e. cloves, cumin, cinnamon. curcumin, rosemary, mint plants, and various bioflavonoid preparations are powerful alone as well as in synergy with antioxidant vitamins supplemented. In addition these antioxidants may directly influence the PUFA desaturase system and arachidonic acid metabolism (501,556). According to Maries and Famsworth, 1,123 plants have been used to treat diabetes. Of 295 traditionally used plants, 81% displayed antidiabetic properties in vitro. Yet, these authors cautioned that 1/3 to 2/3 of these plants may be dangerous, and many have hypoglycemic activity due to metabolic or hepatic toxicity. Conversely, there are safe and effective hypoglycemic plants. Several spices have insulin-potentiating action in vitro: cinnamon, cloves, and bay leaves. Cinnamon, in an epididymal fat cell assay, 110 appears to have the greatest action and contains procyanidin dimmers and oligomers thought to improve capillary function (501,556). Sixteen postmenopausal type 2 diabetics treated with diet or oral hypoglycemic therapy completed a randomized double-blind crossover trial of dietary supplementation with isoflavones from red clover (approximately 50 mg/day) for four weeks. Compared to placebo, mean daytime systolic and diastolic blood pressures were significantly lower during isoflavone therapy compared to placebo. The authors concluded that isoflavone supplementation from red clover may favorably influence blood pressure and endothelial function in postmenopausal type 2 diabetic women (557). Plants such as the Indian cluster bean {Cyamopsis tetragonoloba) and the elephant- foot yam Amorphophallus konjac are known to be usefril in reducing postprandial hyperglycemia. Their fibers (guar gum and konjac mannan respectively) are the main constituents of commercially sold weight-loss tablets (548,558). Plants, such as Aloe and Opuntia which grow in arid regions, have yielded antidiabetic polysaccharides. In Mexico the sap and the leaves of the cactus Opuntia-nop^l (prickly pear cactus) are used as a traditional treatment for diabetes and can be purchased in tablet form to treat obesity (548,558). Common traditional herbal products used to treat diabetes include, fenugreek and karela (bitter melon), gurmar described previously as well as ginseng, tronadora, chromium, and alpha-lipoic acid. For a select number of products, studies have revealed single or multiple mechanisms of action, yet for others their high soluble fiber content is the key factor for a h3q30glycemic effect (261). Korean ginseng was found to decrease fasting blood glucose, glycosilated hemoglobin, and body weight Ill when compared to placebo (559-562). A double-blind placebo-controlled study with 36 participants with type 2 diabetes treated participants for eight weeks with ginseng (100 or 200 nig). Ginseng therapy reduced fasting blood glucose and body weight, and improved glycated hemoglobin compared to the placebo group (559). More than 1000 plants have been documented as being of benefit for the treatment of diabetes, but the majority of these plants have not received adequate scientific scrutiny and many reports of efficacy are little more than anecdotal (130,332). Siimmary The differences between the in vivo and in vitro studies for CVD and diabetes indicate that more research is needed in this area. These differences may simply reflect low rates of absorption of active compounds, differences in the methodologies employed, antioxidant status of subjects, or other factors. It is also important to point out that foods are a complex mixture of phytochemicals with many biological activities that may potentially modify certain risk factors associated with chronic diseases. Clearly, a diet in which herbs are generously used to flavor the food will provide a variety of active phytochemicals that promote health and protect against chronic diseases. Most scientists agree that it is likely the synergistic effects of phytochemicals as they coexist naturally with other phytochemicals and nutrients is what gives them their unique properties. The more bland and processed the diet, the greater the loss of phytochemical presence yet, specific biological and pharmacological effects of phytochemicals require detailed studies. 112 Future studies need to emphasize isolation of specific protective substances and examination of the effectiveness of combinations of these isolated substances as protection against arteriosclerosis and diabetes. Carefully controlled experimental animal studies should be conducted to investigate dose-dependent relationships between combined antioxidants before initiating any extensive human intervention trials. Physicians need to be careful when advising use of antioxidants, especially in combination with lipid-lowering drugs or glucose control medications. Ongoing clinical trials are needed to clarify the role of antioxidants in CVD and diabetes and to suggest which foods and how much are protective and provide advantageous health benefits. Information on optimal levels of dietary phytochemicals could facilitate appropriate development of novel and functional foods that may provide further health benefits. Food synergy is defined as additive or more than additive influences of foods and food constituents on health (332), foods cannot be seen as a sole containing one protective property instead there are many factors that play a role in balance and homeostasis. The precise mechanisms of the way phytochemicals may regulate biological functions are poorly understood. The long tem-safety aspects of individually supplementing with one food chemical versus another are also unclear yet, the overall protective effect of FV cannot be denied. There is overwhelming agreement that the best way to obtain potential benefits of phytochemicals is by eating a wide variety of plant foods. The AZ WISEWOMAN study will provide invaluable information as to the predictors that influence FV consumption among an older, uninsured, low SES, 113 mostly Hispanic population. Additional studies, like the one presented here are necessary to elucidate dietary profiles among at risk populations, their FV pattern consumption, and the factors affecting intake in order to determine and propose dietary interventions that may best decrease risk, improve amount of protective phytochemicals in the body, and eventually be of assistance in diminishing disparities. 114 Explanation of Dissertation Format The Graduate Interdisciplinary Program at the University of Arizona allows published and publishable papers to constitute a substantial portion of the dissertation. Three such papers compose this dissertation; the following paragraph describes my contribution to the research. Economically disadvantaged, underinsiired, and medically underserved women were enrolled into the Well Woman Health Check Program (WWHP), a national breast and cervical cancer screening program. The U.S. Congress mandated the Centers for Disease Control and Prevention (CDC) to develop and evaluate cardiovascular disease (CVD) screening and prevention services for women served by the WWHP (141). The AZ WISEWOMAN demonstration/research project grew out of recognition of the unique opportunity to reduce CVD risk among women attending WWHP screening sites. In Arizona, WISEWOMAN was a collaborative effort administered by the Arizona Department of Health Services, Office of Chronic Disease Prevention from 1995-2000 (contract 853032). The project was accomplished through an Inter-Agency Service Agreement with the University of Arizona and Inter-Govemmental Agreements with the Maricopa County Health Department and Pima County Health Departments and was divided in two phases: Phase I-Phoenix, AZ and Phase II-Tucson, AZ. The AZ WISEWOMAN project (Phase II) started in 1998. Arizona's project included a large population of Hispanic women and because little data are available for this group the significance of this project was noted. The AZ WISEWOMAN study had two main goals; to improve physical activity and to promote an increase in the consumption of FV 115 to 5 or more servings per day. This project tested three levels of intervention based on the combination of communication relationships and two health behavior theories. The present work utilized information from the Phase II. Figure 3 presents a scheme of the WISEWOMAN study and the measurements utilized for this dissertation study. I became involved with the AZ WISEWOMAN study in 1999, as a graduate assistant and coordinator of Community Health Worker (Promotoras) activities. I was responsible for multiple aspects of the study, from interviews, to data gathering, data cleanup, and data quality assurance. As graduate assistant, I realized that several interesting questions could be addressed while investigating the main effect of the study intervention. Primary support for my study came from funding awarded from the AZ WISEWOMAN funds. I completed all analyses, smmnarized results, and drafted papers for journal submission. Dr. James Ranger-Moore, provided me statistical consultation and Dr. Lisa K. Statcn edited manuscripts drafts, assisted in interpretation of results, and suggested additional analyses. Other committee members and co-authors provided significant amounts of edits and suggestions as well. Figure 3. Arizona WISEWOMAN Study Scheme Low income older Mexican American (n=260) and Non-Hispanic Whites (n=88) living in Arizona Baseline 24-hour recalls* N=348 n=62 -one -24-our recall n=82 -two -24 hour recalls 6 months 24-hour recalls* n=204 -three -24 hour recalls N=I95 n=37 -one -24-our recall n=33 -two -24 hour recalls n=125 -three -24 hour recalls 12 months 24-hour recalls* n=29 -one -24-our recall n" 40 -two -24 hour recalls n=143 -three -24 hour recalls Main outcome Dependant variable Fruit and Vegetable servings a Day **Psychological variables Stage of Change ** Sociodemographic Self-efficacy **Health status variables variables Weight control Encouragement / Social Support Smoking status Income Education Ethnicity 'First recall was usually done face-to-face while other two recalls were done via phone Household members "Proposed to be associated with fruit and vegetable intake Acculturation "Acculturation also is modified and alTected by several of the demographic factors presented here. 117 PRESENT STUDY Introduction The methods, results, and conclusions of this study are presented in the papers and manuscripts included in this dissertation in Appendices A-C. The following is a brief account of the study population, analytic methods, particularly for sections not implicitly detailed in the papers, and a summary of the primary findings of each paper. Methods AZ WISEWOMAN Study Population The population targeted in these analyses included women aged 50+ who were primarily Hispanic, had incomes under 200% of the federal poverty level, and were not eligible for the Arizona Health Care Cost Containment System (Medicaid). The project was awarded to the Arizona Department of Health Services (ADHS) by the Center for Disease Control and Prevention. It was accomplished through an Intcr-Agency Service Agreement with the University of Arizona and Inter-Governmental Agreements with the Maricopa County Health Department and Pima County Health Departments. This dissertation focuses of data from Phase II and will be referred to as AZ WISEWOMAN. Well WW HP participants were rccruited from two sites in Pima County; St. Elizabeth's of Hungary Health Center and Planned Parenthood Southwest. The AZ WISEWOMAN study had two main goals: to increase moderate physical activity to 30 minutes or more for five or more days a week as recommended by the 1996 Surgeon General's report (563) and to promote an increase in the consumption of FV to 5 or more servings per day as recommended by the National Cancer Institute 118 (123). This project tested three levels of intervention using: Patient Provider Communication (564,565), Social Cognitive Theory (187), and Social Support Theory (566,567), All women participating in the AZ WISE WOMAN project had to be deemed medically eligible by a medical practitioner. Subject recruitment started in July 1, 1998 and the study was completed August 2000. Recruitment AZ WISEWOMAN personnel, mostly Promotoras (Community Health Workers), were also employed half time by another ADHS subcontractor, the YWCA. The YWCA was responsible for recruiting women to the WWHP. Promotoras are local women who are trained to provide education and other assistance. These women arc respected residents of their communities and have demonstrated abilities to gain the trust and confidence of participants. Promotoras are employed often in Arizona to increase screening rates and to deliver health education. They play an important role for Hispanic families (568,569). Recruitment occurred in one of three ways. First, a clinic specific list of WWHP participants due for their annual visit within three month was developed by ADHS. Most of these numbers were out of service and/or women no longer lived at the provided address. When contact was made, these women were reminded that they were due for a WWHP appointment and were recruited via telephone calls by a University of Arizona (UofA)/WWHP interviewer. The program, was explained. If a woman was interested, the interviewer arranged for them to meet at her WWHP annual visit. If the 119 provider approved her participation, she v/as asked to review and sign the study consent form. The interviewer then proceeded with the baseline interview either at the clinic or at another scheduled time and place. Second, a list was generated of women who received their annual visit within three months before study recruitment began at the clinics. These women were contacted by telephone and an interviewer explained the study. If a woman was interested, she was asked to make a brief visit to the clinic, see the provider for assessment of medical ehgibility and, if eligible, review and sign the study consent form, complete study questionnaires, and receive clinical assessment measures. Last, each week, UofA/WWHP staff was at each clinic and W WHP participants deemed eligible by providers were referred to the AZ WISE WOMAN study staff. Intervention Description This project tested three levels of intervention based on the combination of communication relationships and two health behavior theories: Patient Provider Communication , Social Cognitive Theory, and Social Support. The three levels of intervention included a provider visit in which the following were provided: health education brochures, discussion with the provider of the benefits and barriers to physical activity (PA) and eating more FV, and a written prescription regarding the recommended behavior changes. These above mentioned requirements constituted Intervention Level 1. In Intervention Level 2, in addition to receiving all aspects of Level 1, each woman received a refeiral to two health education classes (one nutrition, one PA) and monthly health newsletters. Participants in Intervention Level 3, received 120 all aspects of Level 2 and worked on a regular basis with a Promotoras who provided them information and support. Provider visits and infomiation was reiterated at six months and one year. Details of AZ WISEWOMAN has been described elsewhere, please refer to Table 3 (568). Table 3. Intervention components for provider counseling, health education, and community health worker groups (568). PC+HE Intervention component PC" PC+HE^ +CHW' Provider Counseling * Prescription: Increase finit/vegetable consumption Prescription: Increase physical activity Hi Referral to education classes Education class: Come eat the rainbow (mifrition) Education class: Let's get moving (physical activity) Monthly newsletter Community health worker support Provider counseling Provider counseling + health education Provider counseling + health education +community health worker Fruit and Vegetable Intervention FV were determined as promotable using the definitions from 5 a Day which are derived from the Food Guide Pyramid (125). A serving of vegetable was explained as Vz cup raw vegetable, y4 cup vegetables or six ounces and raw leafy greens have a serving of 1 cup while for fruits a serving was defmed as Vi cup, fresh, frozen or canned 121 or 1 medium-size fruit. Also a 1/2 cup peas or beans — cooked dry, frozen, or canned, were included in our messages (570). Easy to understand descriptions about serving size were used, i.e. size of a tennis ball among others. Educational tools using an "Eat the Rainbow" message were incorporated in the educational nutritional classes. These messages encouraged consumption of variety of FV (various colors of FV) into the diet, explained the benefits of eating more FV, and explicated what phytochemicals were and mentioned the most common ones. Also, portion sizes were described and easy to make, culturally appropriate, and inexpensive recipes which, incorporated various FV, were provided for taste testing. Messages from the 5 a Day website were incorporated into the newsletters and promoted by the Promotoras (570). Assessment Measures Data collection Participants completed a series of extensive questionnaires at baseline, six-month (±3 months), and twelve-months (±3 months). Participants recruited after Nov 30, 1999 were not eligible for a 12-month assessment. Information collected included age, gender, ethnic origin, marital status, educational level completed, income level, occupation, and medical history forms. Other personal characteristics compiled were health practices, attitudes, and behaviors including: weight control, weight loss, eating habits, professional advice for weight control, mental and physical health, vision, and smoking status. Participants also received standard blood pressure, height, weight, and 122 waist and Mp circumfereBce measurements. In addition, women had blood drawn to measure seram cholesterol, HDL cholesterol, glucose, and other clinical chemistries. ADHS Wellwoman Healthcheck Questionnaire and AZ WISEWOMAN Health Assessment ADHS questionnaires routinely administered to WWHP participants included diabetes and medical history forms, standard breast and cervical cancer screenings. AZ WISEWOMAN utilized various questionnaires in order to address several research questions: Health and Lifestyle Questionnaire (HLQ), Pima Questiomiaire, Arizona Activity Frequency Questionnaire (AAFQ), and 24-hour recalls. AZ WISEWOMAN Health assessment questions addressed participants' blood pressure, height, weight, and waist and hip circumferences measured. Project Questionnaires The HLQ was developed using a selection of Behavioral Risk Factor Surveillance System (BRFSS) questions, including sociodemographics, health practices, and attitudes, and behaviors. In addition women where asked about several psychological factors that may influence their FV intake. Psychosocial Factors in AZ WISEWOMAN Questionnaires Several psychological factors were hypothesized to be mediating variables, that is, to be predictive of FV intake (26): self-efficacy for change, perceived benefits of eating more FV, social support, and weight control. Belief in the association of FV consumption with health (perceived benefits), social support, and weight control were 123 assessed as affirmative or negative questions, (see Tables 4 and 5 for item wording and response options). Measurements of Acculturation, Stages of Change, and Self-Efficacy Accultuiation and several psychological factors were hypothesized to be mediating variables, that is, to be predictive of FV intake (26). A modified acculturation scale was used and self-efficacy for change, perceived benefits of eating more FV, social support for increased consumption, and motivation for weight control were measured. Acculturation We used a modified version of Cuellai*, Harris and Jasso's (1980) Acculturation Rating Scale for MA (ARSMA) (54). The scale is composed of two items that assess language preference, one item that assesses self-consideration of culture, one that assesses traditions, and one that assesses heritage pride. The language and self- consideration items were rated on a 5-point Likert-type scale ranging from 1 (only Spanish) to 5 (only English), while culture consideration was rated on a 5-poinl scale ranging from 1 {very Mexican) to 5 (very Anglo). Assessment of traditions was done using a 5-point Likert-type scale ranging from 1 (always follow Mexican customs) to 5 (always follow American customs). Assessment of heritage pride was done using a 5- point Likert-type scale ranging from 1 (very proud) to 5 (no pride). The items were averaged to obtain an overall measure of acculturation with a range of values fi-om 1 to 5. We created two categories of acculturation: less acculturated (<3) and more acculturated (> 3), as suggested in previous reports (105,571). 124 Stage of Change We measured psychosocial factors related to FV choices using various tools. Although interventions were not matched according to the self-identified stage, we wanted to measure the capacity of WISEWOMAN participants to correctly stage their FV consumption and determine how this staging predicted future behavior modification. Participants were first asked a single question to estimate the total number of FV servings they consumed each day: "How many servings of fruits and vegetables do you think you eat cach day?" Participants then were asked which statements best described whether they ate five or more servings of FV each day for certain time periods: "I currently don't and do not intend to start in the next six months" (pre- contemplation), "I don't, but am I thinking about starting to do so in the next six months" (contemplation), "I currently do, but not regularly" (preparation), "I regularly do, but have only just begun in the past 6 months" (action), and "I regularly do eat five or more servings and have done so for longer than 6 months" (maintenance), then they were categorized as being in one of the following stages based on the Transtheoretical Model (see Table 4). For conceptual and practical reasons, and because at baseline only four participants were in precontemplation and zero in action stages, we combined the precontemplation and the contemplation (PC/C) and the action and maintenance (A/M) stages into two categories for data analysis, similar scales and practical procedures have been used before (183,572-574). 125 Table 4. Stages of Dietary Change Questions for Fruit and Vegetable Consumption Concept Item Response Options Self-rated intake of fruits and vegetables How many servings of fruits and vegetables do you think you eat each day? Stage Definition Item Which of the following statements best describe whether you eat five or more servings of fruits and vegetables each day? Precontemplation J currently don't and do not Self-rated diet intend to start in the next six months Contemplation 1 don't but, I am thinking Self-rated diet about staring to do so in the next six months Preparation I currently do but, not Self-rated diet regularly Action Currently 1 do but. just Self-rated diet started in the past 6 months Maintenance Currently I do and I have Self-rated diet done it longer than 6 months Sclf-Efficacy Participants were asked how sure they were that they could eat five FV per day; the responses were measured using a three-item questionnaire on a five point Likert scale. "How confident are you that you could eat more fruits and vegetables than you now eat?" (5=extremcly confident to l=no confident), "How confident are you that you could eat more fniits and vegetables without it interfering with the things you like to do?" and "Compared to other women, how certain are you that you could eat more fruits and vegetables?" (5=1 am sure 1 could to 1=1 can't). Responses were grouped into two self-efficacy categories: low (0-1.49-no confident) and high (>1.5-very confident). Internal consistency of this scale was 0.87. Self-efficacy, social support, and motivation 126 aspects have been incorporated in scales before (143,192,194,575) and studies have demonstrated that these significantly affect FV intake. Details of the format of these questions are presented in Table 5. Table 5. Items to measure psychological factors: self-efficacy, social support, and weight control motivation. Concept Item Response Options Self-rated health 1 to 5 How would you say your health compares l-~Much better 5-Much worse to others? Self-efficacy for change How confident are you that you could eat 1 to 5 more fruits and vegetables than you now l=extremely confident 5=not confident cat? How confident are you that you could eat 1 to 5 more iruits and vegetables without it 1=1 am sure I could 5=1 can't interfering with the things you like to so? Compared to other women, how certain 1 to 5 are you that you could eat more Suits and 1=1 am sure I could 5=1 can't vegetables? Perceived Benefits Are you confident that eating more fruits Yes, No, Don't Know and vegetables would be good for you? Are you confident that eating more fruits and vegetables would make you feel Yes, No, Don't Know better? Social Support Do you have family or friends who Yes, No, Don't Know encourage you to make healthy changes in your life? If you decided to make healthy changes to your diet or increase your activity, do you Yes, No, Don't Know have people around who would support these changes? Weight Control Yes, No, Don't Know Are you trying to lose weight? Are you trying to maintain weight? Yes, No, Don't Know 127 Dietary Data: 24-hour recalls Three 24-hour recalls were attempted at baseline, six-months, and at one-year of follow-up on each eligible AZ WISEWOMAN participant, with the goal of obtaining recalls from one weekend day and two weekdays over a period of three months. Bilingual AZ WISEWOMAN staff conducted the initial 24-hour recall face-to-face, requesting food eaten Jxom midnight to midnight on the previous day. The Behavioral Measurement Shared Service Core of the Arizona Cancer Center conducted the remaining two 24-hour recalls over the telephone. Participants were not given prior notification. At baseline 59% of participants had three 24-hour recalls. Reasons for completing fewer than three 24-hour recalls per visit included: a highly mobile population, phone inaccessibility, conflicting schedules, and inability to contact the participant. During the 6-month follow-up visit, 195 participants returned and 64% of them completed three 24-hour recalls, and 212 returned for their 12-month follow-up and 68% completed three 24-hour recalls. Probing methodologies for food preparations, brand names, and ingredients were used. Diet recall data were entered and nutrients were calculated in the Nutrient Data System for Research (NDS-R) software version 4.05 33 (Nutrition Coordinating Center (NCC), University of Minnesota. Minneapolis, MN, July 2002). Individual 24-hr recalls that were considered to be implausible for energy intake (<500 or > 5,000 kcals/day) were deleted from the final analysis (n= 75 individual recalls). 128 Estimation of Fruit and Vegetable Intake Total sei"vings of FV, servings of vegetables, servings of finit including juices, servings of fmit juice, and servings of firuit without juice were tallied using a counting method based on definitions and portions sizes from the NCI 5 a-Day program which are derived from the Dietary Guidelines for Americans. The NCC Food Servings Count System separated fruit into citrus and non-citrus classifications. Fruit servings were based on the 2000 Dietary Guidelines for Americans which defines a serving of a whole fruit such as one medium apple, banana, orange or pear; Vi cup of chopped, cooked, or canned fruit; % cup dried fruit or cup of fruit juice. Fruit servings include fruit and juice consumed separately (plain) and in fmit salad. Fruit in baked goods were generally excluded from the fruit servings count. Fruit subgroups included, citrus juice: 100% citrus juice, from fresh or frozen concentrate; included sweetened or unsweetened orange, grapefruit, tangerine, etc; fruit juice excluding citrus: 100% juice, from fresh or frozen concentrate; included apple, grape, nectarine, and similar fruits; citrus fruit: Included fresh, canned; e.g., orange, grapefruit, lemon, tangerine, etc; fruit excluding citrus fruit: Included fresh, frozen, cooked, canned and dried; apple, grapes, banana, raisins, etc. jam, jelly and marmalade; fruit in cereal (except raisins in raisin bran); fruit leather, fruit in candy, ice cream, granola bars, pie, cake and other baked goods; avocado and coconut were excluded from these estimates. For vegetables, the NCC Food Servings Count System separated vegetables into subgroups to permit analysis based on sources of vitamin A (tomato, dark-green vegetables, and decp-yeJlow vegetables). Vegetable servings were generally based on 129 the Dietary Guidelines for Americans 2000, which defines a serving as 1 cup of raw- leafy vegetables, ^2 cup of other vegetables, cooked or raw or % cup of vegetable juice. When multiple forms of a food were available for a given food, the most common form was selected to represent the serving weight for the food. E.g., chopped, sliced, grated. Vegetable servings include vegetables and vegetable juice consumed separately (plain) and in recipes containing vegetables, e.g., stew, soup, lasagna, pizza, salad, casseroles, and commercial entrees. Vegetable subgroups included, dark-green vegetables: included raw, cooked, frozen or canned spinach, broccoli, romaine, collards and similar; deep-yellow vegetables: included raw, cooked, frozen or canned winter squash, carrots, sweet potatoes, and pumpkin; tomato: included raw, cooked and canned tomato, salsa, tomato sauce, tomato-based spaghetti sauce, tomato puree, and tomato paste and excluded catsup, steak sauce, cocktail sauce; other vegetables: included raw, cooked, frozen or canned cabbage, beets, peas, turnip, corn, etc. and excluded olives, pickles and pickled vegetables; vegetable juice: 100% juice, included V-8, tomato, carrot and excluded clamato; fried vegetables: included breaded and fried broccoli, mushrooms, onion rings and similar products; legumes: included cooked dried beans, mature lima beans, refried beans, baked beans, pork and beans, tofu, tempeh and excluded soy-based desserts (Toffutti), textured vegetable protein (TVP), veggie burgers, and soy nuts. Select foods were not incorporated as FV, as they do not meet the criteria of the 5 a-Day program promotable foods, including french fries, fried potatoes, pickled vegetables, olives, coconuts and avocados and vegetable-based snack foods. Because 130 FV servings a day were skewed toward low values, we used a logarithmic transformation scale. Data from National Health and Nutrition Examination Survey III (1988-1994) Introduction The objective of NHANES III was to obtain nationally representative information on the health and nutritional status of the population of the United States tlirough interviews and direct physical examinations. The design of NHANES III has been described elsewhere (576). NHANES III Study Population NHANES III, conducted from 1988 to 1994, included a representative sample of the U.S. population based on a multistage over sampling of African Americans and MA (576). Information on age, insurance, household size, and income level was used to identify a sub-sample of NMANES III participants (n=266) to be used as the comparison group for these analyses. NHANES III data were limited to women aged 50+ years who answered the adult questionnaire, and had dietary data labeled as reliable. Two criteria were used to select a comparable sample of women from NHANES III; female participants who had incomes less than 200% of the federal poverty level in the 2000 or participants that reported no coverage of any type of health insurance (206). Due to limitations in NHANES III sample sizes, nutrient intake was compared between southwestern MA and those from other parts of the U.S.. No significant differences were found. Therefore all participants meeting the original criteria were maintained. 131 Ethnicity Determination NHANES ethnic determination was based on participant self report of race/ethnicity. Dietary Intake and Fruit and Vegetable Determination NHANES utilized a single face-to-face 24-lir recall to assess dietary intake (576). The Dietary Data Collection prototype database was used. The database was adapted specifically for use by National Center for Health Statistics and Food and Drug Administration and mapped to the USDA's Survey Nutrient Data Base. At the time the NHANES III nutritional data were collectcd folate fortification regulations were not in place. Therefore, to make the AZ WISE WOMAN and NHANES databases comparable, vitamin supplementation and fortification data were removed fi^om the AZ WISEWOMAN data for comparisons of the two samples. NHANES III calculations of FV servings were determined using an assigned code system which incorporated the CSFII Pyramid Servings Database (PSDB) food codes, the USDA Nutrient Database for Standard Reference, cookbooks, and the University of Minnesota's Nutrition Data System codes according to the website of the Risk Factor Monitoring and Methods Branch, NCI. Data Management and Analyses AZ WISEWOMAN Data Management In the AZ WISEWOMAN study, the Study Coordinator and other staff developed and maintained an ACCESS data file which included all demographics, and questionnaire data. 132 Dietary data management procedures and questionnaires were based on previous studies from the Cancer Prevention and Control Program and the Behavioral Measurement Shared Service Core of the Arizona Cancer Center. AZ WISE WOMAN data entry personnel and the Behavioral Core at the Arizona Cancer Center conducted data entry. Twenty percent of all forms were entered in duplicate and compared to the original entries Statistical analyses All questionnaire files were recorded in ACCESS (except 24-liour recall data and HLQ) and transferred to STATA and SAS for statistical analysis. Data were cleaned and analyzed to determine its distribution. Descriptive statistics are presented using frequency distribution tables, means, standard deviations and graphs as needed. This information assisted in identification of outliers, out of range data, illogical values, and other miscoded data. Descriptive statistics for the study participants include demographics, medical history, health behaviors, nutritional profile, and relevant health and dietary risks of the AZ WISEWOMANpopulation by ethnicity. Hypothesis 1: The dietary intake and health profile of low income uninsured Arizona Hispanic women, age 50+ years will be comparable to a national sample of Hispanic women age 50+ years participating in National Health and Nutrition Examination Survey III (1988-1994). In an earlier report we showed that an intervention effect was not seen for most nutrients or for increased FV consumption (the main dietary outcome) (568). Before 133 combining 24-hour recall data an initial analysis demonstrated no significant differences across main macronutrients and different time points, see Table 6 and Table 7. Also, a separate analysis compared individuals with one, two or three recalls at each time point and did not find significant differences, refer to Tables 8. Therefore whenever more than one dietary recall was available for an individual, the mean of all recalls collected over a 1 year period was used as a more precise estimate of nutrient intake. Ethnic- specific means and standard errors were calculated for all diet variables selected. Sociodemographics and nutrient consumption were estimated for AZ WISE WOMAN participants while adjustments for unequal probabilities of selection sampling weights were considered for NHANES III data analyses (576). Averages, standard errors, and confidence intervals of macronutricnt, micronutricnt, and mineral intakes of AZ WISEWOMAN and NHANES III participants were calculated by ethnic group and compared between and within groups, using two-sided t-tests, chi square, or non- parametric tests as appropriate when data were not normally distributed. The equivalent test was done using the survey test adjusting methodologies for NHANES III data. Confidence intervals were used to compare intake similarities in both study groups. These intervals assumed a two-sided alternative. Analyses were conducted using intercooled Stata version 7.0 (Stata Corporation, College Station, TX, 2001). 134 Table 6= Analysis of variance of macronutrients and their mean values before collapsing 24-hour recalls by participants and their visits. Baseline 6-montlis 12-months N=838 N=478 N=538 Mean SB Mean SB Mean SD p value* Energy 1294.8 521.2 1244.0 461.4 1303.7 520.0 0.124 Total Fat 45.7 27.5 43.6 25.2 44.7 26.2 0.371 Total 172.8 78.0 165.6 68.5 176.7 76.0 0.058 Carbohydrate Total Protein 54.1 26.5 52.9 23.9 55.4 26.4 0.307 Total Fiber 15.6 9.8 15.2 8.3 16.5 10.2 0.079 Fruits & 3.9 2.9 3.6 2.3 3.8 2.2 0.090 Vegetables N=Total of individual 24-hour recalls collected at each time point *ANOVA of the mean values across visits. Table 7. Analysis of variance of macronutrients and their mean values after collapsing 24-hour recalls by participants. Baseline 6-nionths 12-nionths Total N=348 N=195 N=212 755 P Mean SD Mean SD Mean SD Mean SD value* Energy- 1328.8 422.1 1276.2 387.2 1331.5 492.3 1316.0 434.7 0.333 Total Fat 47.3 20.8 45.5 21.9 46.1 24.2 46.5 22.1 0.618 Total 176.9 65.5 168.6 54.8 179.4 66.3 175.5 63.2 0.188 Carbohydrate Total Protein 55.2 20.8 53.8 18.6 56.2 24.9 55.1 21.5 0.507 Total Fiber 16.0 7.8 15.3 6.6 16.6 8.2 16.0 7.6 0.232 Fruits & 3.9 2.9 3.6 2.4 3.8 2.2 3.8 2.6 0.242 Vegetables N=Total of individuals at each time point *ANOVA of the mean values across visits. **Collapsed 24-hour recalls by participants and visits provided nutrient values that were slightly higher than the ones presented in Table 6, yet no significant differences were seen across time. 135 Table 8. Analysis of variance of macronutrients, their mean values, and comparison between amounts of 24-hoiir recalls before collapsing 24-hour recalls by participants and their visits. Baseline 6 months 12-nioiitlis Mean SD Mean SD Mean SD p value* Energy 1-24-hour recall 1306.6 468.3 1248.1 499.1 1182.9 481.4 0.50 2-24-hour recall 1258.6 562.8 1297.9 445.5 1339.8 812.8 0.61 3-24-hour recall 1299.1 512.9 1233.1 458.8 1315.2 488.4 0.05 Total Fat 1-24-hour recall 45.3 24.4 49.1 31.3 40.9 28.7 0.48 2-24-houT recall 43.6 28.2 43.9 25.4 47.6 39,5 0.61 3-24-hour recall 46.1 27.5 43.1 24.4 44.8 24.5 0.22 Total Carbohydrate 1-24-hoiir recall 177.2 68.0 152.9 56.1 160.9 68.7 0.18 2-24-liour recall 169.4 82.9 175.8 64.1 172.3 99,2 0.87 3-24-hour recall 173.0 77.7 164.6 69.5 179.7 73.7 0.02 Total Protein 1-24-hour recall 55.1 26.9 53.4 23.3 49.7 24.1 0.63 2-24-hour recall 53.1 26.9 54.0 24.4 61.1 41.8 0.14 3-24-hour recall 54.1 26.2 52.6 23.9 55.2 24.8 0.35 Total Fiber 1-24-hour recall 15.6 6.9 13.0 4.9 15.1 8.8 0.17 2-24-hour recall 16.2 10.0 15.6 8.5 15.6 11.1 0.88 3-24-hour recall 15.5 10.0 15.2 8.3 16.8 10.2 0.03 Fruits and Vegetables 1-24-hour recall 4.0 3.3 3.0 2.4 3.9 2.8** 0.26 2-24-hour recall 4.1 2.8 3.6 2.8 3.1 1.6 0.02 3-24-hour recall 3.9 2.8 3.7 2.2 3.9 2.2 0.34 *ANOVA of the mean values across visits **ANOVA of the mean values across number of recalls p<0.05 **Collapsed 24-hour recalls by participants and visits provided nutrient values that were slightly higher than the ones presented here, yet no significant differences were seen across time and amounts of 24- hour recalls. Hypothesis 2: Acculturation is negatively associated with total FV consumption in low-income older Hispanic uninsured women. Various methods were utilized to test how acculturation affects the consumption of FV among MA participants compared with NHW participants. Internal consistency reliabilities for the acculturation scale were measured by means of a coefficient alpha. Baseline similarities of FV consumption were assessed and compared by demographic 136 characteristics; acculturation (less acciilturated or more acculturated), age (50-59 or 60+ years), education (0-3, 4-11, or >12 years), income (<$4,999, $5,000-9,999, or >$10,000/year), marital status (Married / Cohabitating, Single / Divorced / Separated, or Widowed), employment status, smoking status, and BMI status. Prevalence of FV consumption at baseline and by acculturation was related to and characterized according to the sociodemograpMc factors mentioned above. Significance testing was done using chi-square and appropriate non-parametric tests. To evaluate associations at baseline between FV consumption and the socio- demographic characteristics and risk factors, linear regressions were conducted on one half of the data, randomly chosen. The results from these models were then validated, and the associations were confirmed with the other half of the data. Since the validation test demonstrated different results for all significant variables except for acculturation, bivariate analyses were performed. Significant factors fi^om the bivariate analyses were retained in subsequent multivariate analyses (p < 0.05). Appropriate assessments of regression assumptions were done. The dependent variable, servings of fruit and vegetables, was log-transformed to improve normality, but data on FV prevalence consumption are presented in the original units while data in the regression tables are presented as transformed values. To determine if retained factors were related to changes in the consumption of FV at 6 months and 12 months and to account for the statistical non-independence of repeated measures, mixed models with various covariance structures for repeated measures were used (577). The autoregressive covariance structure was selected as best 137 fitting and a computation of the appropriate approximate degrees of freedom for each of the estimated standard errors was done controlling for baseline consumption of FV as a main effect and an interaction between visit and acculturation. Because the intervention effect was not significant, it was removed from the model. Descriptive statistics, group comparisons and multivariate baseline linear regressions were done using intercooled Stata version 7 (Stata Corporation, College Station, TX, 2001) while Generalized Linear Mixed model analyses were done using PROC MIXED in The SAS System for Windows (Release 8.2. SAS Institute Inc. Cary, NC.). Hypothesis 3: Stages of change is a suitable theory to target FV consumption behavior change in Hispanic uninsured older women with low income. Baseline comparisons of similarities of FV consumption by demographic characteristics; age (50-59, and 60+), education (0-3, 4-11, or 12+), income (<4,999, 5,000-9,999, or 10,000+), marital status (Married / Cohabitating, Single / divorced / Separated, or Widowed), number of household members (1, 2-4, or 5+), employment status, smoking status, BMI status, ethnicity (MA and NHW), family support, encouragement, perception of FV being good and making participants feel better, weight control, and SOC were done. Descriptive statistics were used to describe sample characteristics and FV consumption. Chi-square, ANOVA, and non-parametric tests were used. Internal consistency reliabilities for the self-efficacy scale were measured, by means of a coefficient alpha. Although the AZ WISEWOMAN intervention did not demonstrate a significant effect (568) the message of increased FV consumption to more than five was kept throughout our analyses. Objective measures of FV consumption from 24-hour recalls were correlated to perceived reported amounts at baseline. To evaluate associations at baseline between FV consumption and most of the selected sociodemograpMc characteristics and risk factors, linear regressions were done on one half of the data, randomly chosen. These models were used to then validate the other half of the data. Validation was feasible for all significant variables and was confirmed with bivariate analyses and significant factors were retained in subsequent multivariate analyses to test for significance (p < 0.05). Appropriate assessments for the fulfillment of linear regression assumptions, including normality, linearity, outliers, and variance of dependant variable does not depend on level on the independent variable were also completed. Independent variables that were statistically significant in the bivariate and multivariate models were accepted as significantly associated with FV consumption. Assessments of confounding variables to this association were also addressed and adjusted accordingly. The dependent variable, servings of fruit and vegetables, was log-transformed to improve normality, but data on FV prevalence consimiption are presented in the original units while data in the regression tables are presented transformed values. To determine if retained factors were related to change in FV consumption at 6 months and 12 months and to account for the statistical non-independence of repeated measures, a mixed model PROC MIXED which verified several parametric structures on covariance structure of the repeated measures (compound symmetric, autoregressive order one and "unstructured") was used (577). Also dietary change as a function of 139 movement through stage was measured using the same modeling. The compound symmetric covariance structure was selected for these analyses while a computation of the appropriate approximate degrees of freedom for each of the estimated standard errors was done controlling for baseline consumption of FV main effect and interactions between visit, perceived movement through SOC and with the actual SOC. Perceived movement through stages categorization was done based on participant determination of their location in the staging scale. Those participants categorized as moving backward, regressed from Action/Maintenance (A/M) to Preparation or Precontemplation/Contemplation (PC/C) at subsequent visits while those in the Preparation stage at earlier visits changed to P/C. Participants classified as not moving kept their same staging perception at follow-up visits while those that perceived forward movement changed their staging from PC/C at baseline to Preparation or A/M or from Preparation to A/M at subsequent visits. A re-categorization by SOC based on original staging perception and 24-hour recall measured intake was done in order to compare perceived staging versus a dietary intake objective measure. In the re-categorization analyses on'ginal perceived stage was maintained as long as 24-hour recall intake reflected staging. Baseline SOC values were modified according to participants' baseline intake while comparing intake results in their follow-up visits. Participants that perceived themselves as being in the PC/C and were eating more than five FV were categorized at the Preparation stage. Those classified at the A/M stage while eating less than five FV but averaging increase consumption at foilow-up visits of 1.5 servings were re-categorized in the Preparation 140 stage. Those participants that perceived themselves in A/M that were not changing from their low consumption of FV, or their change did not average more than 1.5 servings a day in follow-up visits were also kept in Preparation stage. Analyses addressing this hypothesis were done using participants' perceived FV intake staging and compared to actual FV intake Jxom 24-ho"ur recalls. The re-categorization staging measures were used for comparisons in the discussion section of the manuscript in Appendix C. Re-categorized staging results were used to compare participants self- staging to a re-categorized staging based on 24-hour recall data. All descriptive data analyses were done using intercooled Stata version 7 (Stata Corporation, College Station, TX, 2001) while Generalized Linear Mixed model analyses were done using The SAS System for Windows (Release 8.2. SAS Institute Inc. Cary, NC.). 141 RESULTS AND DISCUSSION This section provides a brief overview of three manuscripts prepared as part of this dissertation. For further details see Appendices A-C. PAPER 1: DIETARY PROFILES OF ARIZONA AZ WISEWOMAN PARTICIPANTS INDICATE NUTRIENT INADEQUACIES. Introduction By the year 2030, the population of U.S. adults over the age of fifty is expected to encompass 25% of the entire population. Coupled with the increased growth rates of the Hispanic population in the U.S., particularly MA, this trend raises concerns about current dietary practices. Practices that influence risk of chronic diseases may also affect the disparities in diseases among older women. Dietary Reference Intake for older age groups have been revised (97,99) coupled with the dietary guideline recommendations (18,104). Despite this attention, many older people are not consuming diets that meet their nutritional needs. Diet reports of older Hispanic women have been limited in the number of recalls collected and the lack of representation by Hispanics. Information from a group of mostly MA (72%) women aged between 50-76 years will enhance nutritional information for older adults and aid in the determination of nutritional deficiencies or excesses. Synopsis of methods Three hundred forty eight participants of the AZ WISEWOMAN study were included in these analyses. Dietary intake was assessed using multiple 24-hour recall data. Initial analyses compared intake of macro and micronutrients, and FV and legume 142 intake, by ethnicity, to that of NHANES III participants by using confidence intervals and survey analyses methodologies. Due to the vast amount of infoiTnation describing the AZ WISEWOMAN diet and comparing them to the NHANES III sample and dietary guidelines, only AZ WISEWOMAN data was reported in the manuscript in Appendix A. ANOVA, t-tests, chi-square, and non-parametric measures were used to evaluate nutrient concentration difference between ethnic groups. Nutrient intake was compared to dietary guidelines and to dietary reference intakes when available. Primary Findings The primary findings from the nutrient comparison based on 24 hour recalls, between AZ WISEWOMAN and NHANES III indicate that nutrient intake was highly comparable between the two groups and that overall; deficiencies were seen in both study groups. The complete manuscript is appended to this dissertation in Appendix A. Supplemental tables comparing AZ WISEWOMAN and NHANES III participants are found in Appendix D. Energy, total carbohydrate, fiber, and FV intakes were lower than recommended guidelines for all groups, while protein intake was higher. Participants met the dietary- guidelines for cholesterol, and total saturated fatty acids. These results mirror previously documented sccular trends in fat and protein intake in Hispanics and NHW (111,162). While older women in these studies were closer to the current recommended dietary allowances (97 ), they did not meet some dietary reference intakes (DRI) (99- 101,103). The majority of the participants had sufficient amounts of ascorbic acid, thiamine, riboflavin, retinol and cobalamin from their diets, while intakes of folate. 143 cholecalciferol, calcium, zinc, and magnesium were low as compared to the dietary recommendations. FV intake of study participants was below the recommended levels. The nutrient intake comparison of confidence intervals, between NHANES III and AZ WISEWOMAN ethnic groups indicate that NHANES III participants with similar sociodemographic characteristics reported a highly similar nutrient profile. The MA women from NHANES III were eating less total amounts of macro and micronutrients when compared to their NHW counterparts yet their intake of carbohydrates, protein, and legumes was higher than that of the NHW women. The results show that the diets of many older women, who do not have health insurance, have low SES and are predominantly MA fail to meet current recommendations. Considering all the beneficial factors and their protective cffccts contained within FV (please refer to section of phytochemicals and mechanisms of action) this population is at increased risks for cardiovascular and diabetes which may result in an increased burden to the U.S. medical system particularly among those younger than 65 years of age which have not received Medicare benefits. 144 PAPER 2: ACCULTURATION ANB FRUIT AND VEGETABLE CONSUMPTION OF OLDER MEXICAN AMERICAN WOMEN. Introduction U.S. dietary patterns tend to be high in fat and low in FV which increase the risk of chronic diseases. When MA immigrants start to change their traditional eating habits to those of the general U.S. population, they may increase their risks for chronic diseases. Still, it is not clear how dietary changes occur within a larger process of sociocultural acculturation. Given that minority women arc disproportionately poor and have an increased risk for CVD compared with white women, understanding the relationship between SES acculturation and diet is crucial (23,158). Older populations are at increased risks of dietary inadequacies, therefore it is critical to create and implement more effective dietary interventions based on the needs of the population. The effect of acculturation on FV consumption in older women has been studied less frequently. Findings from the AZ WISEWOMAN study will provide insights on how acculturation and other SES factors affect FV consumption through time. Synopsis of methods A modified version of Cuellar, Harris and Jasso's (1980) Acculturation Rating Scale for MA (ARSM A) (54) was used. Descriptive analyses were done using ANOVA, t-test, and non-parametric measures. To examine associations at baseline between FV consumption and the socio-demographic characteristics and risk factors, linear regressions were done to determine if retained factors were related changes in the consumption of FV at 6 months and 12 months. PROG MIXED repeated measures 145 were done to determine how movement across SOC and actual SOC predicted FV intake changes. Primary Findings The following paragraph summarizes the primary findings in the examination of FV consumption, acculturation, and other sociodemographic factors. The complete manuscript is provided in Appendix B. Evidence of FV consumption and acculturation in older populations is not well described. This study compared several socio-demographic factors related to dietary behavior and determined that acculturation had a strong association with FV consumption. More acculturated participants demonstrated a significantly lower amount of FV intake at baseline while at the same time they appear to be the most responsive to the time effect (i.e. changing through time). Contrary to other research which indicates that intake of FV of more acculturated individuals is similar to that of NllW, in our study we found that our NHW participants were eating similar amounts of FV servings to the less acculturated participants. More acculturated participants were eating the least amounts of FV servings at baseline. These findings suggest that more acculturated MA may be at higher risk of eating less than 5 a Day while at the same time more likely to benefit from interventions such as the one presented in this study. These findings provide more insights into a culturally sensitive and a varjang cultural component that may hold promise for fiiture research and efforts targeting minority populations. 146 PAPER 3: OLDER WOMEN'S SELF REPORTED CHANGES IN FRUIT AND VEGETABLE CONSUMPTION: ANALYSES FROM A STAGES OF CHANGE APPROACH. Introduction The SOC model is frequently used to address health risk behaviors, particularly smoking. The determination of the cultural appropriateness of the SOC model to address FV intake stage in an older population of predominantly Hispanic women has not been reported. The primary findings of FV consumption and its association to several psychosocial factors are summarized in the following section. The complete manuscript is appended to this dissertation in Appendix C. Determining how people perceive their movement through stages of change and relating it to an objective measure of diet intake behav ior has been the preferred method for interventions targeting SOC staging. Even though the AZ WISEWOMAN intervention was not based on the SOC model, the examination of its ability to accurately predict behavior change was examined and its ability to move people through stage in a 12-month period was measured. Analyses were limited to study participants that completed all three visits. Synopsis of methods Demographic differences between ethnic groups were not seen therefore data for 131 participants were combined. Descriptive statistics were done using: chi-square, ANOVA, and non-parametric tests. Associations between FV consumption and most of the selected sociodemographic characteristics and risk factors at baseline were done 147 using linear regressions on one half of the data and confirmed with bivariate analyses. Change in FV consumption through time was measured using mixed model repeated measures. Dietary change as a function of movement through stage was measured using the same modeling. A re-categorization by SOC based on original staging perception compared to FV consumption from multiple 24-hour recalls was done in order to compare perceived FV staging versus dietary intake estimate from 24-hour recalls. Primary Findings At baseline most participants reported being in the earlier stages of change for FV consumption. Participants appeared to properly stage their FV intake at baseline when compared to other follow up visits. At the end of the intervention participants that identified themselves in the earlier stages of change were eating significantly fewer amounts of FV and even decreasing their intake. Longitudinal movement through stages and FV consumption at one year indicated that 62% were eating less than five at baseline and maintain this eating behavior, yet 64% of these participants indicated that they were moving forward in a SOC. Therefore at baseline respondents were better able to identify their SOC than at 6 or 12-months. Our findings provide unique preliminary findings on the categorizalion of SOC on the general perceived notion of change in FV consumption and actual intake practicc in a female, uninsured, lower educated, with a lower income, predominantly MA population. These findings provide insight into possible methods to move this population through SOC. Personalized feedback based on a dietary estimate coupled 148 with constructs that include participants' thoughts and perceptions may raise awareness and motivate change. Prospective designs that apply the proposed model to a similar population will provide useful information about aiming dietary changes. 149 SUMMARY AND FUTURE DIRECTIONS One of the main dietary messages promoted to decrease the risk of chronic diseases is to raise the amount of FV servings each day to five or more. Based on current knowledge, increased FV intaice will not only reduce the risks for CVD and diabetes, as well as other diseases but, may work as a preventive measure for delaying the risks. Given the health disparities in the U.S. and the poor diet profiles of older aged minority populations, increased FV consumption may have a significant impact on their morbidity and mortality. Despite this knowledge, FV consumption remains low and research indicates that many factors are responsible for the low FV intake. This study was motivated by the need for an examination of the factors that may stimulate older populations to increase FV intake and thereby reducing risk for developing two of the leading causes of death among Hispanic populations, CVD and diabetes. This dissertation examined key sociodemographic factors such as acculturation and other psychological constructs from the SOC model in order to predict baseline FV consumption and changes overtime. The methods presented in this report provide important information related to FV intake and its potential mediators in a group of older, mostly MA, women from Tucson, AZ. Dietary profiles of older low income, mostly Hispanic women, from AZ WiSFiWOMAN and NHANES III indicate a poor dietary risk factor profile. The USD A Food Guide Pyramid recommends 5-9 servings of FV every day, participants in this study were far from that goal. FV consumption monitored over a 12 month period in the AZ WISEWOMAN study indicate that in order to achieve nutritional adequacy 150 and to reduce risk of clironic disease, several factors such as age, smoking, education, acculturation, and readiness to dietary change may need to be considered. Data from this study suggest that more acciilturated MA and those in precontemplation stages had significantly lower daily FV consumption. At baseline more acculturated MA had the lowest intake of FV while at the end of the study this group was the one that more significantly increased their intake. Contrar}' to other studies, FV intake of AZ WISEWOMAN NHW participants was similar to that of less acculturated MA all throughout the study. These results may indicate that NHW in general may have been aware of the increase FV intake message and may had already been making changes in their consumption behavior while more acculturated women became aware of the message and were more responsive to the methodologies used in the AZ WISEWOMAN intervention. Although the SOC model for behavior change was not used to design the AZ WISEWOMAN study, women at baseline appear to more accurately predict their FV intake stage than at follow-up visits. Social desirability and/or inability to properly understand what FV servings meant appeared to play a significant role in the way participants perceived their FV intake. Staging participants in a SOC model would have been more effective if self-perceived reported intake of FV would have been linked to estimates from 24-liour recalls. These results may also indicate that the relatively low intensity of the AZ WISEWOMAN intervention enabled participants to recognize the increase FV message yet, not enough to promote significant behavior changes. 151 The iiico.iporatioii of 5 a Day message was fundamental to the AZ WISEWOMAN study. By applying several health behavioral change metliodoiogies we actively pursued the delivery of the message for increasing FV intake. However, AZ WISE WOM AN study recruited from an already existing group of participants in the WWHP. Recruiting non-behavior seeking participants from an existing program may have limited our ability to improve dietary habits. Since incentives of free blood screenings for CVD and diabetes risk were awarded in connection to all measurement periods, participants may have been more interested in the incentive than in making behavioral changes. Future studies should consider biological markers of FV intake, but above all measures of environmental factors, such as household members, availability of foods, and income among others, should be incorporated in these types of food behavior interventions. Also we can never discard the notion that the older are at a higher risk yet, their food intake habits have been shaped all through out their lifespan, perhaps making behavioral intervention in these age groups more challenging. Clearly more research is needed to elucidate the intake and trends in MA and other Hispanic subgroups. Further efforts to advance disease prevention through healthier diets must give priority to understanding the determinants of eating patterns and behavior change; therefore more studies are necessary to confirm these findings and to provide additional insight into the role of acculturation and SOC in the consumption of FV. This study had several limitations. Some of the limitations of the 24-hour diet recall include error in recall, poor estimation of serving sizes, and cognitive aspects of 152 dietary recall. We had a variable number of completed recalls per participant and although this may have improved our ability to better estimate nutrient intake and strengthen our ability to assess correlations with other variables, it may have also obscure nutrient intake patterns. Our acculturation scale was more extensive than the ones frequently used yet, future research can benefit from more extensive consideration of acculturation and more complete diet assessment, which would likely include more than one method to collect diet intake data (i.e. recalls, diet history and/or food frequency questionnaires). Our small sample size needs additional research. Using a behavioral marker to clarify stage classification may aid in the application of the SOC model for intakes of fruit and vegetable. Also measurement, and correlations of barriers to fruit and vegetable consumption such as cost, taste, availability, and predilection of foods may help in the prediction of our associations and staging capability. However, future research can benefit from more extensive consideration of acculturation and SOC in this population. Findings from this study add information to the generalizable knowledge about acculturation and stages of change. Although these findings are not necessarily generalizable to other Hispanic communities the findings of acculturation and stages of change affecting finit and vegetable consumption is consistent with other researchers and may be generalizable to a similar population of low income, lower education, no health insurance and MA ethnicity. Duplication of this research with a larger sample size is recommended. A baseline assessment of participants' limitations and interests to consume particular foods groups 153 is needed. Such evaluation will provide detailed infonnatioii about willingness and ability to change diet behavior within a personal and individual context. Also incorporation of close social and family systems may aid this population capability of modifying behavior. An intervention using a similar design as the one used by WISEWOMAN may be useful. Nevertheless, a more personalized method to gather dietary information and biomarker availability may aid and support significantly more precise intake estimates. Future studies should include measures of participants' barriers and uncomplicated means to increase FV consumption that potentially will further improve FV intake. Also, small changes in FV intake should be promoted in this population rather than considerable amounts such 5 a Day. The 5 a Day goals are difficult to achieve during short interventions particularly in low income minority groups. Groups of individuals at an older age have similar biological changes, socio- psychological development, and accumulation of life experiences that make it difficult to intervene or change life long behaviors. Nevertheless, studies like this are of increasing importance when considering U.S. demographic shifts towards an older society without a truly dominant racial/ethnic group. 154 WORKS CITED 1. Ness, A. R. & Powles, J. W. 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(1999) Self-efficacy and consumption of fruit and vegetables: validation of a summated scale. American Journal of Health Promotion 13: 290-298. 576. (1994) Plan and Operation of the National Health and Nutrition Examination Survey, 1988- 1994., in Scries 1: programs and collection procedures, pp. 1-407. Vital Health Stat. 577. Littell. R. C.. Milliken, G. A., Stroup, W. W. & Wo1 finger, R. D. (1996) SAS system for mixed models. SAS Institute Inc., Cary, N.C. 206 APPENDICES APPENDIX A: DIETARY PROFILES OF ARIZONA WISEWOMAN PARTICIPANTS INDICATE NUTRIENT INADEQUACIES. Karen Y. Gregory Mercado, MS, MPH,' Lisa K. Staten, PhD," James Ranger-Moore PhD.'"^ Cynthia A. Thomson, PhD, RD FADA,''"^ Anna R. Giuiiano, Ph.D. Julie C. Wili, PhD, Earl S. Ford, MD, MPH,^'James Marshall, PhD' 1 Department of Nutritional Sciences, University of Arizona. 2 Division of Health Promotion Sciences, Mel and Enid Zuckerman Arizona College of Public Health, 'Division of Epidemiology & Biostatistics, Mel and Enid Zuckerman Arizona College of Public Health, ''Arizona Cancer Center, ^Division of Nutrition and Physical Activity, CDC, ^Behavioral Surveillance Branch, Division of Adult Community Health, CDC, Cancer Prevention and Population Sciences, Roswell Park Cancer institute. Send correspondence to Karen Y. Gregory Mercado, MS, MPH, Department of Nutritional Sciences College of Agriculture and Life Sciences, University of Arizona, Tucson. AZ 85721 Phone: (520) 321-7777. Fax: (520)321-7754 (e- mail :[email protected]. edu). Running Title: Diet profile of WISEWOMAN participants Proposed Journal; Journal of the American Dietetic Association 207 Abstract Title: Dietary profiles of the Arizona WISEWOMAN participants indicate nutrient inadequacies. Objectives: This study describes the food intake profile of WISEWOMAN participants, an older, uninsured, mostly Hispanic sample in the Southwestern United States, and compares two ethnic groups: Mexican American (MA) and non-Hispanic White. Methods: Mean nutrient and food group intakes of MA and non-Hispanic White women were estimated and compared based on 24-hr rccalls using t-tests and non- parametric tests as applicable. Results: Differences in macronutrient. micronutrient, and mineral intakes were observed among the two ethnic groups defined in WISEWOMAN. Participants had overall lower intake of most macro and micronutrients when compared to DRI. MA energy, total carbohydrate, total protein, total fat, total monounsaturated fatty acids, vitamin Bs, potassium, copper and selenium intakes were lower than those of non- Hispanic whites. Micronutrient intakes of older women in of both ethnic groups were highly comparable. Diet intakes of WISEWOMAN participants were marginally above the minimal requirements and in some cases below the recommended amounts, particularly for folate, vitamin D, vitamin E, calcium, magnesium, and zinc. Conclusions: MA had overall lower nutrient intake compared to uninsured non- Hispanic White older women. These data indicate that women without health insurance have a poor dietary risk factor profile. Future studies which explore intake of specific food groups, other dietary constituents, ethnic and modern foods, and effects of acculturation are needed. This study provides descriptive data that will allow for targeted nutrient-specific diet interventions. 208 Introduction Ethnic minority women in the United States are more likely than non-Hispanic white women to be poor, have less education, and have less access to health resources (1-4). Mexican American (MA) women in particular fare worse than white women in ternis of health status, and rates of disability (4). As a whole, MAs, the fastest growing minority group in the U.S., comprise 60 percent of the country's 35.3 million Hispanics (1, 5, 6). The smaller proportions of older MAs women in all older age categories when compared to other ethnic groups in the U.S. indicate substantial health disadvantages they face (7). The general prevalences of cardiovascular disease (CVD), diabetes, and h>'pertension among MAs are 15%, 12%, and 20.7 %, respectively (7-11). Even though overall heart disease death rates among Hispanics are lower than for non-Hispanic whites. Hispanic adults arc at increased risk for diabetes and hypertension (7). In general, morbidity from chronic diseases is greater for Hispanic women than for non- Hispanic white women (12-14). Additionally, the age adjusted prevalence of obesity is higher among MA women (39.7%) than among non-Hispanic white women (30.1%) with 69% of MA women classified as overweight (7, 15). Epidemiologic studies have identified an inverse association between diet quality and risks of stroke, coronary heart disease (CHD) (16-20), diabetes (21-23) and other chronic diseases (24). Dietary quantity, quality and diversity vary by age, race/ethnicity, education, inconie, and health insurance status (11, 14, 25, 26). Despite numerous national investigations of diet and chronic disease risk prevention, the diet and nutritional status of uninsured older Hispanic women has been sparsely described. Accurate nutritional profiles from older individuals are needed in order to recognize inadequate or excess intake of specific nutrients and the relationship of intake to chronic disease, to understand nutrition-related disparities, to identify individual characteristics that may affect dietary consumption, and to identify gaps in nutrition education that influence nutritional health. The current study describes and compares nutrient intake data, from repeated 24-hr dietary recalls of older uninsured MA and non-Hispanic white women from the southvvestem U.S. participating in the Arizona (AZ) WISEWOMAN study (27). Methods Data utilized for these analyses are from the AZ WISEWOMAN (Well- Integrated Screening and Evaluation for Women Across the Nation) study conducted in Tucson, AZ from 1998-2000. The study was a Center for Disease Control and Prevention (CDC) demonstration project to reduce CVD risk among women participating in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The objective of the intervention was to test the efficacy of three levels 209 of intervention to increase consumption of fruits and vegetables and physical activity. Details of the WISEWOMAN study have been reported elsewhere (27). WISEWOMAN Study Population The population enrolled in this intervention was women aged >50 years, who were Hispanic (mostly MAs), had incomes less than 200% of the federal poverty level and were not eligible for the Arizona Medicaid program (AHCCCS) or any other health insurance. All women participating in the WISEWOMAN project (n=361) had to be deemed medically eligible by a medical practitioner. Participants completed a series of questionnaires related to diet, acculturation, sociodemographic factors, and physical activity at baseline, six-month, and twelve-months. Ethnicity Determination AZ WISEWOMAN participants self-classified themselves as MA or not. In these analyses we included important sociodcmographic variables: age, ethnicity, number of household members, education, and marital status. Physiologic (systolic and diastolic blood pressure) and anthropometric parameters (body mass index) were also measured. Dietarv' Methods Three 24-hT recalls were attempted at baseline, six-months, and at one-year of follow-up on each WISEWOMAN participant, with the goal of collecting recalls from 1 weekend and 2 weekdays at each time point, for a total of up to nine recalls. Bilingual WISEWOMAN staff conducted the initial 24-hr recall face-to-face, requesting food consumed from midnight to midnight on the previous day. The Behavioral Measurement Shared Servicc Core of the Arizona Cancer Center conducted the remaining two 24-hr recalls over the telephone. Participants were not given prior notification. At baseline 212 (59 %) participants completed three 24-hr recalls. Reasons accounting for fewer than three 24-hr recalls per visit included: change of residence, phone inaccessibility, conflicting schedules, and inability to make a contact with the participant. A total of 199 participants returned to the 6~month clinic visit, and 63 % of these completed three 24-hr recalls. Two hundred sixteen returned for their one year visit and 67 % of these completed three 24-hr recalls. Assessment of whether women who completed three 24-hr recalls consumed different diets than those WISEWOMAN participants who completed only one or two 24-hr recalls at each time point revealed no significant differences across groups. Only 17% of the participants completed all nine 24-hr recalls and 19% completed only six 24-iir recalls. Neutral probing methodologies for complete description of foods, food preparations, portion size estimation, brand names, and ingredients were used. Diet recall data were entered into the Nutrient Data System for Research (NDS-R) software version 4.05 33 210 (Nutrition Coordinating Center (NCC), University of Minnesota, Minneapolis. MN, July 2002). The majority of WISEWOMAN participant nutrient intakes did not vary significantly over time regardless intervention level assigmnent (27). Individual 24-lir recalls which were considered to be implausible for energy intake (<500 or > 5,000 kcals/day) were deleted from the final analysis (n=71 individual 24-hoiir recalls). Total servings of fruits and vegetables, servings of vegetables, servings of fraits including fruit juices, of fruit juice alone, and of fruit alone were tallied using NCI 5 a- Day program definitions and serving sizes derived from the Dietary Guidelines for Americans (28). Statistical Analysis In an earlier report we showed that an intervention effect was not seen for most nutrients or for increased fruit and vegetable consumption (the main dietary outcome) (27). Therefore whenever more than one dietary rccall was available for an individual, the mean of all recalls collecicd over a lyear period was used as a more precise estimate of nutrient intake. Ethnic-specific means and standard errors were calculated for all diet variables selected. Sociodemographics and nutrient consumption were estimated for WISEWOMAN participants. Averages, standard errors, and confidence intervals of macronutrient, micronutrient, and mineral intakes of WISE WOM AN participants were calculated by ethnic group and compared between groups, using two-sided t-tests. chi square, or non-parametric tests as appropriate. Analyses were conducted using intercooled Stat a version 7.0 (Stata Corporation, College Station. TX, 2001). Results The ethnic distribution of the study population was as follows: MA (n=260). and non-Hispanic whites (n - SS). MA women had lower education, were more likely to be married, had larger families, were less likely to smoke, had increased diastolic and systolic blood pressure, BMI, and cholesterol than non-Hispanic whites (Table 1). Dictar>' intake tables (Tables 2-5) illustrate differences in intakes between WISEWOMAN participants. Energy intake differed significantly by ethnic group with non-Hispanic whites consuming significant more than MA. Reported intakes of total fat, total carbohydrate, total protein, alcohol, total monounsaturated and polyunsaturated fatty acids were also significantly lower for MA than for non-Hispanic whites (Table 2). Comparisons of the percent of calories deri ved from macronutrients did not differ significantly between ethnic groups. MA participants reported a significantly lower intake of nearly all macronutrients with the exception of cholesterol, which was lower for non-Hispanic whites (not significantly). 211 Paralleling macroaiitrients, as described in Table 3, intakes of several micronutrients were significantly lower for MA than for non-Hispanic whites: thiamin, riboflavin, niacin, folate, pantothenic acid, vitamin E, calcium, potassium, sodium, magnesium, phosphorus, zinc, copper, and selenium, were alt significantly lower for MA while non-Hispanic whites had significantly lower legume intakes, all these minerals and legumes differences are described in Tables 4 and 5, respectively. Total vitamin A, calcium, and magnesium levels were below the recommended dietary levels while the levels of thiamin, vitamin Be, folate, zinc and copper were marginally meeting the recommendations. Intake of finits and vegetables was below the recommended dietary guidelines. Discussion This study compared nutrient intakes of MA and non-Hispanic whites participating in AZ WISEWOMAN. In general, the group of uninsured older women had inadequate nutrient intake. It is important that MA participants tended to have an increased BMI and higher blood pressure, more were taking vitamin and mineral supplements, and were was less likely to report current smoking habit as compared to non-Hispanic whites. These results are consistent with those reported in previous research (11, 13). Despite selection of subjects with low socioeconomic status, non-Hispanic whites tended to have healthier nutrient intake profiles than their MA counterparts. In general mean reported daily intake of energy was lower than recommended (1,900 kcals for women older than 50 years) (29) particularly for MA (1,306 kcals). Energy and carbohydrate intakes were lower than those reported in other studies of diet intake of older women (25, 30, 31). Conversely, the reported energy intakes are similar to the MA energy intakes reported in the Hispanic Health and Nutrition Examination Survey (HH ANES) (32), an extensive survey of healthy adults living in Arizona (33), findings for non-Hispanic whites from NHANES II (32) and previous reports from NHANES III for MA and non-Hispanic White women aged 60-69 (34). Even though WISEWOMAN intakes were based on as many as nine recalls per person, participants reported lower energy consumption (35). An analysis of dietary estimates using the first WISEWOMAN 24-hour recall indicated significantly higher energy and fat estimates (1399 vs. 1322 k/cal and 52 vs. 47 grams of fat) while other macronutrient estimates were comparable and no significant differences were detected. Thiamin (1.17 vs. 1.24 mg, p=0.02) estimates of one 24-hour recall versus the collapsed estimate values demonstrated significant difference, no other micronutrient and mineral demonstrated this di fference. 212 Given that no standard methodology was used to more accurately estimate total energy expenditure or intake (i.e. direct calorimetry or doubly labeled water) and to calibrate the longitudinally repeated dietary measures, the methods of self-reported dietary assessment utilized in these research study likely underestimated energy intake. Longitudinal dietary estimates have been reported to decrease overtime (36). This phenomenon of imderreporting or low-energy reporting is particularly prevalent among older women and overweight persons (35-38). Given the fact that the mean BMI for the total sample was high, there is a high probability that WISE WOMAN participants under reported intake. On the other hand, these intakes may truly reflect lower consumption due to low-income, increased age. and decreased physical activity commonly shown in older people, particularly among minority women. Also, the potential for impaired memory associated with the aging process may explain low energy diet reporting (35), while age-related reduction in basal metabolic rate, particulariy in sedentary women, may explain the higher BMI (29.5) despite reports of low energy intake (39-43). Although the total percent of energy from fat was slightly above the 30% recommendation (28), saturated fat, and cholesterol (less than 300 mgs a day) were reported to be within the recommended daily amounts (28, 29, 44). Furthermore, contributions to energy from total fat, total carbohydrates, and total proteins were highly similar between the two ethnic groups and not significantly different. Saturated fat intake in MA women appears to be declining over time as comparing to results of HHANES (32), even though their daily average fat intake was higher than 43g, the recommended for a 1,300 kcal diet. Participants' intake of protein and carbohydrate exceeded dietary recommcndations (29). This pattern may indicate that food sources in terms of nutritional content by ethnic group may differ but in terms of proportion of energy from the macronutrients, intake distribution is quite similar. Fiber intake was not significantly different between MA (16.7 g/day) and non- Hispanics (18.1 g/day) it was below was below of the recommended amount of 21 g/day for both groups (45). Fiber intake of 12 g/day has been previously reported for MA women aged 20 to 74 years in HHANES (32) while NHANES III reported 13.7 g/day for MAs and 14.6 for non-Hispanic whites women (34, 46). These intakes are also well below recommended intake to reduce the risk of chronic diseases, yet considering this population low energy and evaluating their intake based on 10 grams/1,000, kcals these two groups were having appropriate intakes of fiber. Thiamin, riboflavin, niacin, vitamin Bg, folate, pantothenic acid, vitamin D, and vitamin E mean intakes were marginally at or below the recommended levels of intake (47-49) in all ethnic groups, similar to a published report of another report of Southwestern women (33). Although not defmite (50), research has suggested that inadequate intake of vitamin B,, and folate can lead to elevated serum homocysteine and 213 subsequent risk of cardiovascular disease(51-55). These factors should be assessed in this population. Vitamin E has been shown to protect against low density lipoprotein oxidation, particularly in non-smoker populations (56), thus the reportedly low vitamin E intakes may increase the health risks in these participants. Similar to other studies, Hispanics populations reported lower intalce of vitamin D and calcium compared to non-Hispanic whites (30, 33, 57) and a level of intake which was also below current recommendations for prevention of osteoporosis (48). Increased calcium intake in adults has been shown to reduce age-related bone loss, bone fractures or both (58, 59). Decreased vitamin D intake may be a concern and may result in decreased bone health status. People residing in the southwest may be afforded some protection due to UV exposure however; darker pigmentation among MA could increase risk and warrant promotion of increased vitamin D intake. In these study groups, low reported intakes of magnesium and calcium could fiirther increase the risk for cardiovascular disease, hypertension, and bone health, while inadequate intake of zinc could suppress immune function (51, 60). Lower intakes of these minerals have also been reported in earlier studies (46). A nutrient intake comparison of confidence intervals, between NHANES III (61) and WISEWOMAN ethnic groups done by this research group indicated that NHANES III participants with similar sociodemographic characteristics reported a highly similar nutrient profile. The MA women from NHANES III were eating fewer overall macro and micronutrients when compared to their non-Hispanic white counterparts yet, their intakes of carbohydrates, protein, and legumes were higher than that of the non-Hispanic white women (data not presented). Also, these data were compared using only the first 24-hour recall estimates from WISE WOMAN and results indicated same macro and micronutrient intake patterns in which WISEWOMAN were reporting less than NHANES III participants. These results may indicate unique patterns of low consumption reporting among WISEWOMAN participants. Overall energy, total carbohydrate, fiber, and fruits and vegetables intakes were lower than recommended by guidelines for all groups, while fat intake was higher. Participants met the dietary guidelines for cholesterol and total saturated fatty acids, while protein consumption was higher than recommended (29, 62). It appears that the diet of this older population was marginally above their absolute minimal requirements set by the Food and Nutrition Board (47-49, 62). While older women in this study were closer to the current recommended dietary allowances (63), they did not meet some dietary reference intakes (DRI) (29, 47-49, 62). The majority of the participants had sufficient intake of ascorbic acid, thiamine, riboflavin, retinol and cobalamin from their diets, while intakes of folate, cholecalciferol, calcium, zinc, and magnesium were low as compared to the dietary recommendations. 214 Although our study had a small sample of non-Hispanic whites, data from this study are concordant with several studies which have used different methods to assess dietary intake ranging from three day food records, to a single 24-hour recall, to food fr-equency questionnaires (25, 30, 33, 34). While the differences in nutrient intakes shown here could reflect true differences in intake between MA and non-Hispanic whites, other factors may have affected our findings. The study groups presented here differed from one another with respect to some socioeconomic characteristics. These factors may have influenced dietary behavior (25, 64, 65). Further analyses of these data are needed to detemine if differences in intakes between ethnic groups are related to food choices, level of acculturation, or socioeconomic characteristics. This study would also be strengthen by the use of biological markers to address long term nutritional exposure (66). No substantiated currently published evidence is available to determine if nutrient requirements differ by ethnic group, but this study indicates that ethnic food choices likely affect the mean intake of certain nutrients. Differences in energy intake and some nutrient findings between WISEWOMAN and previous studies may be due to differences in geographic coverage, sample size, dietary methods, and food composition data. Caution should be used in generalizing these results, bccause of differences in databases, sample design, temporal trends in food intakes, methods in collecting dietary information, region, age and education across studies (64, 67). This study also did not focus on an analysis of vitamin or mineral supplementation data; nevertheless, it provides valuable information that could be used in developing targeted nutritional educational programs that aid low income and uninsured MA elderly in meeting nutritional requirements. The proportion of elderly women (65 years or older) in the U.S. population is increasing, particularly among non-Hispanic whites (17%), about also among MAs. Their participation in federal food and nutrition programs will likely increase as their poverty rates increase with age and as they become either single or widowed (1). Our results show that the diets of many older women, particularly those who do not have health insurance or who have low SES (predominantly MA) fail to meet current recommendations. Thus this potentially unique population increased risk for chronic diseases that could, in turn, result in a subsequent burden to the medical system. Appllcatlons/Conclnslons The older participants in the WISEWOMAN study whether MA or non- Hispanic whites, should be considered vulnerable with respect to the intake of vitamins and minerals. Efforts to increase intake of nutrient dense foods compared by energy intake are needed. Leafy vegetables, yeast, and fruits rich in folate should be recommended as well as dairy products or their acceptable alternatives, in addition to fortified whole grain cereals and grains. These findings parallel the heightened risk of CVD among ethnic minority populations and argue for appropriate primary and 215 secondary prevention programs, modified for the language, cultural, and medical needs of older ethnic minorities. The high prevalence of chronic diseases in MA highlights the critical need for effective primary and secondary preventive efforts to lessen the substantial health disadvantages faced by ethnic minority women and women with low socioeconomic status. Appropriate primary and secondary nutrition-based prevention programs, modified for the language, cultural, and medical needs of older ethnic minorities, may provide means of addressing specific nutrient needs for certain populations. Acknowledgements This research was funded by a grant from the Centers for Disease Control and Prevention. The authors appreciatively acknowledge the contribution of Jose Guillen for NHANES III data set up assistance and the staff of the Behavioral Measurement Shared Service Core of the Arizona Cancer Center, particularly Vem Hartz and Robin Whitacre, and thanks to all our participants for being part of this study. Table 1. Sociodemo graphic and health characteristics of Mexican American and non-Hispanic white WISEWOMAN participants. WISEWOMAN Total** Mexican Americans Non-Hispanic White Characteristic N 361 260 Mean (SE) Mean age( years) 57.5(0.3) 57.6(0.3) 57.3(0.5) Mean Income($) 9,755.3(277.8) 9,806.6(344.4) 9.972.8(467.0) Mean years of education-' 9.3(0.2) 7.8(0.2) 13.2(0.2) Family size (mean no. of persons)^ 2.5(0.1) 2.9 (0.1) 1.5 (0.1) Mean BMI (wt/m^) 29.5(0.3) 29.7(0.3) 29.3(0.8) Mean systolic blood pressure, mm Hg 124.8(0.9) b 125.5(1.1) 122.4(1.7) Mean diastolic blood pressure, mm Kg-' 74.0(0.5) 76.3(0.6) 69.7(0.9) %' Married participants^ 43.2 50.4 27.3 BMI > 25 " 77.3 80.4 68.2 High glucose levels* 15.2 15.8 13.6 High Cholesterol levels*'' 26.3 28.1 19.3 Take vitamins & minerals 48.8 49.4 47.7 Smoke 13.6 12.0 15.9 ^WISEWOMAN ethnic differences (t Test, P<.0001). ''WSEWOMAN test significant "These results are based on WISEWOMAN laboratory values of glucose serum levels higher or equal to 110 mg/dL and cholesterol levels higher equal to 240 mg/dL. "Total number of participants in WISEWOMAN was 361 (13 participants had identified themselves in other ethnic minority groups). Table 2. Mean dietary intake of macronutrients by ethnicity for women participating in WISEWOMAN.*' WISEWOMAN RDA, AP or STI Mexican Americans !\on- Hispanic White N-361 N=260 N=88 Macronutrients AMDR2 Mean (SE) "Energy, k/cal™ 1900 1322(19.3) 1306 (31.9) 1444 (47.3) Total fat, g 60 47 (0.9) 46.9(1.6) 50.9 (2.2) Total carbohydrate, g*** 250 176 (2.9) 171.4(4.2) 192.3 (7.9) Total protein, 50 55.2 (0.9) 55.6(1.6) 60.7 (2.2) Animal protein, g** ~ 36 (0.8) 36.6(1.3) 39.1 (1.9) Vegetable protein, g^ ~ 19 (0.4) 18.7 (0.6) 21.2(1.1) Alcohol, g*** - 0.5 (0.1) 0.3 (0.1) 0.9 (0.3) Cholesterol, mg 300 202.3 (5.5) 210.8(8.2) 183.1 (12.8) Total SFA, g 20 or less 16(0.4) 16.3 (0.7) 16.3 (0.8) Total MUFA, g** - 17.8(0.4) 17.7(0.6) 19.7(0.9) Total PUPA, g''** - 8.9(0.2) 8.7(0.3) 10.7(0.6) Total Dietary Fiber, g 21 16.0(0.3) 16.0(0.5) 16.7(0.8) Soluble Dietary Fiber, g* ~ 5.2(0.1) 5.2(0.2) 5.6(0.3) Insoluble Dietary Fiber, g .. 10.6(0.2) 10.6(0.3) 11.0(0.6) % energy from Fat^ (20-35%) 30.0(0.4) 30.1(0.3) 30.0(0.5) % energy from Carbohydrate* (45-65%) 54.0(0.4) 54.1(0.4) 53.2(0,7) % energy from Protein^' (10-35%) 16.1(0.2) 16.4(0.2) 17.0(0.3) SFA= Satiiratecflatty acids, MUFA=Monounsaturated fatty acids, FUFA=Folyimsatiirate WISEWOMAN Mexican iN on-Hispanic All Americans White N-361 N=260 N=88 Micronutrients" RDA or All Mean (SE) Total vitamin A activity, lU 2330 6509.1 (273.4) 6587.7(378.1) 7174.9(638.4) Thiamin, 1.1 1.2(0.0) 1.1(0.0) 1.3(0.1) Riboflavin, 1.1 1.3(0.0) 1.3(0.0) 1.5(0.1) Niacin, mg"^" 14 15.5(0.3) 15.4(0.5) 18.1(0.8) Vitamin mg 1.5 1.5(0.0) 1.5(0.1) 1.6(0.1) Vitamin meg 2.4 3.3(0.2) 3.4(0.3) 3.5(0.5) Folate, meg# 400 231.8(5.6) 232.4(9.5) 256.9(15.2) Pantothenic acid, mg^* 5* 3.5(0.1) 3.6(0.2) 4.0(0.2) Vitamin C, mg 75 105.4(3.2) 101.8(4.3) 112.0(7.6) Vitamin D, meg'' 15* 3.1(0.1) 3.2(0.2) 3.6(0.3) Total Vitamin E activity, 15 6.0(0.2) 5.8(0.4) 7.5(0.5) 'Adapted Irom DRl reports for women older than 51 years. Recommended Dietary Allowance (RDAs) are in bold type and Adequate intake (AIs) are in ordinary type followed by an asterisk (*) (47, 63) "Averages reported are crudc meaning that these are not adjusted for the different age distribution of these populations. WISEWOMAN ethnic differences *p<0.05, **p<0.01, ""^p^O.OOl using non-parametric ranksum test ''Calciferol "^Total alpha-tocopherol equivalents Table 4. Mean dietary intake of minerals by ethnicity for women participating in WISEWOMAN. WISEWOMAN Mexican Non-Hispanic All Americans White N=36I N=260 N=88 Minerals RDA or All Mean (SE) Calcium, mg^' 1200* 597.7 (13.5) 600.2 (23.7) 668.7 (36.8) Potassium, 2000 2223.4 (37.6) 2185.8 (55.0) 2392.9 (88.7) Sodium, 2400 2262.6 (46.9) 2212.4 (71.7) 2530.5 (108.7) Magnesium, mg^^- 320 228.7 (4.2) 227.1 (6.1) 251.5(11.1) Phosphorus, mg^^ 700 890.7 (15.9) 895.1 (26.3) 979.4 (40.8) Iron, mg 8 11.4 (0.2) 11.3(0.4) 12.7 (0.7) Zinc, mg'" 8 7.8 (0.2) 7.8 (0.3) 8.7 (0.7) Copper, mg'^"" 0.9 1.0 (0.0) 0.9 (0.0) 1.1 (0.1) Selenium, mcg^-^ 55 73.8(1.6) 72.3 (2.4) 87.7 (4.9) 'Adapted from DRl reports for women older than 51 years. Recommended Dietary Allowance (RDAs) are in bold type and Adequate intake (AIs) are in ordinary type followed by an asterisk (*)(48) ''Averages reported arc crude meaning that these are not adjusted for the different age distribution of these populations. WISEWOMAN ethnic differences *p<0.05, '^p^O.Ol, "^p^O.OOl using non-parametric ranksum test •vO Table 5. Mean dietary intake of fruits, vegetables and legumes by ethnicity for women participating in WISE WOMAN.'* WISEWOMAN __ ^ Noi^ Mexiean All . . Hispanic Americans White N-361 N=260 N=88 Fruits, Vegetables & Legumes Dietary Guidelines* Mean (SE) Fruit servings a day 2 servings each day 1.9 {(). 1) 1.8 (0.1) 1.9 (0.1) Vegetable servings a day ^ 3 servings each day 1.7 (0.1) 1.6 (0.1) 2.0 (0.2) Legume servings a day^^#' 0.3 (0.0) 0.3 (0.0) 0.2 (0.1) Fruits, vegetables, & legumes 5 servings each day 3.8 (0.1) 3.8 (0.1) 4.0 (0.3) servings a day " Dietary Guidelines (28) "Averages reported are crude meaning that these are not adjusted for the different age distribution of these populations. WISEWOMAN ethnic differences *p<0.05, **p<0.01, ***p<0,001 using non-parametric ranksum test K3 to O 221 References 1. U.S. Department of Health and Human Services, Health Resources and Services Administration. Maternal and Health Bureau. 2003. Women's Health U.S.A. 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Differences in energy, nutrient, and food intakes in a U.S. sample of Mexican-American women and men: findings from the Third National Health and Nutrition Examination Survey, 1988-1994. Am J Epidemiol 2000;152(6):548-57. 65. Guendelman S, Abrams B. Dietary intake among Mexican-American women: generational differences and a comparison with white non-Hispanic women. Am J Public Health 1995;85(l):20-5. 66. Marshall JR. Methodologic and Statistical Considerations Regarding Use of Biomarkers of Nutritional Exposure in Epidemiology. J. Nutr. 2003; 133(3 ):881S-887. 67. Thompson FE, Bycrs T. Dietary assessment resource manual. J Nutr 1994:124(11 Suppl):2245S-2317S. 226 APPENDIX B: ACCULTURATION AND FRUIT AND VEGETABLE CONSUMPTION OF OLDER MEXICAN AMERICAN WOMEN. 1 Karen Y. Gregory Mercado, MS, MPH, Lisa K. Staten, PhD, James Ranger-Moore, PH3,^'^CyBtMa A. Thomson, PhD, RD FADA, ^ Earl S. Ford, MD, MPH Jose Guillen,^ Anna R. Giuliano, Ph.D, Julie C. Will, PliD, James Marshall, PhD'' 'Department of Nutritional Sciences, University of Arizona, ^Division of Health Promotion Sciences, Mel and Enid Zuckerman Arizona College of Public Health, 'Division of Epidemiology & Biostatistics, Mel and Enid Zuckerman Arizona College of Public Health, Arizona Cancer Center, ^Division of Nutrition and Physical Activity, CDC, ^Behavioral Surveillance Branch, Division of Adult Community Health, CDC, ^ Cancer Prevention and Population Sciences, Roswell Park Cancer Institute. Send correspondence to Karen Y. Gregory Mercado, MS, MPH, Department of Nutritional Sciences College of Agriculture and Life Sciences, University of Arizona, Tucson, AZ 85721 Phone: (520) 321-7777. Fax: (520)321-7754 (e- mail :[email protected]. edu). Running Head: Acculturation and fhiit and vegetable consumption Prepared for submission American Journal of Public Health 227 Abstract Backgroimd: Little is known about the association between ethnicity and accuituration and fniit and vegetable consumption particularly among older Mexican American (MA) with limited access to health care. The environmental and lifestyle changes experienced by immigrants to the United States may markedly affect their diet and their risk for chronic diseases. Objective: Our goal was to examine the cross-sectional and prospective effect of acculturation on fruit and vegetable consumption among indigent MA women, comparing their fhiit and vegetable consumption to that of non-Hispanic whites. Design: We used data from 348 underinsured women aged 50-76 years who participated in the WISE WOMAN study, a I -year lifestyle intervention. Fruit and vegetable intake was measured from up to three 24-hour recalls at baseline, 6-months, and 12-months. Longitudinal change in fruit and vegetable consumption was explored with repeated measures analysis. Results: Approximately 8% of more acculturated MA, 25% ofless acculturated MA women, and 36% of white women consumed >5 fruit and vegetables per day (p=0.039). Intake of fruit and vegetables was significantly associated with education among less- acculturated MA women, employment status among more acculturated MA women, and smoking status and body mass index among non-Hispanic white women. During the 6- month follow-up, non-Hispanic white women increased their intake of fhiit and vegetables (p=0.009) when compared to less and more acculturated MA whereas at the 1-year follow-up, more acculturated women increased their intake of fruit and vegetables intakes (p=0.029) when compared to less acculturated MA. Conclusions: Public health efforts to improve the intake of fruit and vegetables among MA women should be sensitive to their cultural background and accuituration status. 228 Introduction The national average daily consumption of finit and vegetables of 3 Vi servings per day [1], varies by gender, acculturation, age, ethnicity, income, and education [2-4]. Numerous epidemiologic studies have identified an inverse association between fhiit and vegetable consumption and stroke, coronary heart disease (CHD) [5-10], diabetes [11] and other chronic diseases [12-14], Minority women are disproportionately poor and have an increased risk for chronic disease compared with non Hispanic white women. Older MA women and recent immigrants may need targeted health initiatives because they are often linguistically inaccessible, of low socioeconomic status [15, 16], and at increased risk of morbidity caused by their unhealthy hfestyle [17]. MA bom in the United States who speak mostly Spanish, have markedly increased levels of risk factors for chronic disease when compared with their counterparts who speak predominantly English [18]. Behavioral risk factors among Hispanics have been commonly explained by their adoption of attitudes, values, and behaviors of the mainstream culture, a concept known as acculturation [19], In general, U.S. dietary patterns tend to be high in fat and low in fruit and vegetables. Several national programs have promoted increased fruit and vegetable consumption. Adults in these programs increased their consumption of fruit and vegetables ranging from 0.2 to 1.7 servings/day, with fruit consumption increasing more than that of vegetables [15, 20-22]. When immigrants start to change their traditional eating habits to those of their adopted countries, they may increase their risks for chronic diseases. Still, it is not clear how dietary changes occur within a larger process of sociocultural acculturation. Identifying the correlates of people's diet may be critical to understanding the relationship between their socioeconomic acculturation and dietary acculturation (the process by which they adopt mainstream dietary practices) [23, 24]. Therefore, our objectives were: 1) to describe the consumption of fruit and vegetables in relation to the distributions of several soci o-demographic characteristics in a population of older MA and non-Hispanic whites. 2) to explore the relationship between fruit and vegetable consumption and acculturation, 3) to explore the relationship between fruit and vegetables consumption and socio-economic variables and how these associations may be affected by level of acculturation and ethnicity, and 4) to detennine how acculturation may influence changes in the intake of fruit and vegetable during one year of follow-up. 229 Methods The Arizona WISEWOMAN study, conducted from 1998 to 2000, was a controlled intervention trial of diet and physical activity change in older uninsured women. The object of the intervention was to test three different levels of intervention to increase consumption of fruit and vegetables and physical activity. Detaiis of the AZ WISEWOMAN study and project outcomes have been reported elsewhere [25], WISEWOMAN Population Women aged >50 years, who were primarily Hispanic (mostly MAs), who had incomes under 200% of the federal poverty level, and who were not eligible for the Arizona Medicaid program (AHCCCS) were included in this intervention. All women participating in the WISEWOMAN project had to be deemed medically eligible by a medical practitioner. Three levels of intervention were developed. Intervention Level I included a health provider visit in which the following were issued; health education brochures, discussion of the benefits and barriers to physical activity and of eating more fruit and vegetables, and a written prescription regarding recommended activities. In Intervention Level 2, in addition to receiving all aspects of Level 1, each woman was referred to two health education classes (one nutrition, one PA) and scheduled to receive a monthly health newsletter. Participants in Intervention Level 3 received all aspects of Level 2 and worked on a regular basis with a lay health worker or promotora who provided information and support. Provider visits and data collection were repeated at six months and one year. Participants completed a series of extensive questionnaires at baseline, six-month, and twelve-months. A total of 361 subjects had complete dietary information. For our analyses, we used data from 348 participants for whom ethnicity was defined as either as MA or NHW and for whom acculturation scales were available. High body mass index (BMI), calculated from measured height and weight, was defined as >25 kg/m^[26]. Acculturation We used a modified version of Cuellar, Harris and Jasso's (1980) Acculturation Rating Scale for MA (ARSMA) [19]. The ARSMA, a Likert-type scale, assesses the acculturation process by measuring movement of cultural orientation from a Mexican culture at one extreme to a U.S. culture to the other extreme [19] and measures assimilation rather that integration. This scale had been used previously [27]. The scale is composed of two items that assess language preference, one item. that assesses self-consideration of culture, one that assesses traditions, and one that assesses heritage pride. The language and self-consideration items were rated on a 5- point Likert-type scale ranging from 1 (only Spanish) to 5 (only English), while culture consideration was rated on a 5-point scale ranging from 1 (very Mexican) to 5 (very Anglo). Assessment of traditions was done using a 5-point Likert-type scale ranging 230 from 1 (always follow Mexican customs) to 5 (always follow American customs). Assessment of heritage pride was done using a 5-point Likert-tj^e scale ranging from 1 (very proud) to 5 (no pride). The items were averaged to obtain an overall measure of acculturation with a range of values from 1 to 5. We created two categories of acculturation: less acculturated (<3) and more acculturated (> 3), as suggested in previous reports [28, 29], Since this report focuses on the comparison of MA and NHW, participants who reported their race/ethnicity as African American (n=6), Asian (n=l), and other Hispanic (n=7) were excluded from the analysis. Dietary Methods Three 24-hour recalls were attempted at baseline, six-months, and at one-year of follow-up on each WISEWOMAN participant, with the goal of obtaining dietary intake fori weekend and 2 weekdays. Bilingual WISEWOMAN staff conducted the initial 24- hour recall face-to-face, requesting information on food eaten from midnight to midnight on the previous calendar day. The Behavioral Measurement Shared Service Core of the Arizona Cancer Center [30] conducted the remaining two 24-hour recalls over the telephone. Participants were not given prior notification. At baseline, 59% participants completed all three 24-hour recalls. Reasons for completing fewer than three 24-hour recalls per visit included: a highly mobile population, telephone inaccessibility, conflicting schedules, and inability to locate participant. One hundred ninety-five participants returned for the 6-month follow-up visit and and 64% completed three 24-hour recalls, while 212 returned for their 12 month follow-up and 68% completed three 24-hour recalls. Probing methodologies for food preparations, brand names, and ingredients were used according to standard protocols. Diet recall data were entered and nutrients estimated using the Nutrient Data System for Research (NDS-R) software version 4.05 33 (Nutrition Coordinating Center (NCC), University of Minnesota, Minneapolis, MN, July 2002). Participants whose daily energy intake was <500 or > 5,000 kcals/day were considered invalid and excluded (75 individual recalls). Two individuals reported very high intakes of fruit and vegetables at baseline (17.2 and 26.5 servings). They were retained in the initial analysis because they were vegetarians and their intakes were plausible. However, when modeled the possible associations of fruit and vegetable consumption, the two participants were removed from the analyses. Estimation of Fruit and Vegetable Intake Total servings of fhiit and vegetables, servings of vegetables, servings of frait including plus juices, servings of fruit juice, and servings of fruit were tallied using a counting method based on definitions and portions sizes from the NCI 5 a-Day program which are derived from the Dietary Guidelines for Americans. A fruit serving is defined as a whole fruit such as one medium apple or pear; Vi cup of chopped, cooked, or canned fruit; % cup dried fruit or y4 cup of fruit juice. Fruit servings included fruit 231 and juice consumed separately and in fruit salad. Fruits in baked goods were excluded from the fruit servings count. A vegetable serving was 1 cup of raw leafy vegetables, 'A cup of other vegetables, cooked or raw or y4 cup of vegetable juice. We also included and counted legumes, Vz cup serving. When multiple forms of a food were available in the database for a given food, the most common form was selected to represent the serving weight for the food (e.g., chopped, sliced, grated). Vegetable servings include vegetables and vegetable juice consumed separately and recipes containing vegetables, e.g., stew, soup, lasagna, pizza, salad, casseroles, commercial entrees, and similar. Select foods were not incorporated as fruit and vegetables: french fries, fried potatoes, pickled vegetables, olives, coconuts and avocados and vegetable-based snack foods. Because fruit and vegetables servings a day were skewed toward low values, we used a logarithmic transformation scale. Statistical Analysis Internal consistency reliabilities for the acculturation scale were measured by means of coefficient alpha [31]. Baseline similarities of fruit and vegetable consumption were assessed and compared by demographic characteristics; acculturation (less accuiturated or more acculturated), age (50-59 or 60+ years), education (0-3, 4-11, or >12 years), income (<$4,999, $5,000-9,999, or >$ 10.000/year), marital status (Married / Cohabitating, Single / Divorced / Separated, or Widowed), employment, smoking, and BMl. Prevalence of fruit and vegetable consumption at baseline and by acculturation was characterized according to these sociodemographic factors. Significance testing was done using chi-square, ANOVA, or t-tests and when appropriate non-parametric tests were utilized as well. To evaluate associations at baseline between fruit and vegetables consumption and the socio-demographic characteristics and risk factors, linear regressions were conducted on one half of the data, randomly chosen. The results from these models were then validated with the other half of the data. Since validation test demonstrated different results for all significant variables except for acculturation, bivariate analyses were performed and significant factors were retained in subsequent multivariate analyses (p < 0.05). The dependent variable, servings of fruit and vegetables, was log- transformed to improve normality, but data on fruit and vegetable prevalence consumption are presented in the original units while data in the regression tables are presented as transformed values. To determine if factors were related to changcs in the consumption of fruit and vegetables at 6 months and 12 months and to account for the statistical non- independence of repeated measures, mixed models with various co variance structures for repeated measures were used [32]. The autoregressive covariance structure was selected as best-fitting and a computation of the appropriate approximate degrees of freedom for each of the estimated standard errors was done controlling for interaction 232 between visit and acculturation. Because the intervention effect was not significant, we decided to remove it from the model. Variables describing participant fruit and vegetables consumption, sociodemographic characteristics and multivariate baseline linear regressions were done using intercooled Stata version 7 (Stata Corporation, College Station, TX, 2001) while Generalized Linear Mixed model analyses were done using PROC MIXED in The SAS System for Windows (Release 8.2. SAS Institute Inc. Gary, NC ). Results Sociodemographic characteristics of the sample at baseline Sociodemographic characteristics of the study sample are shown in Table 1. Among 348 participants considered in these analyses, the mean age was 57.5 ± 5.0 years (range 50 to 76 years). Only 36% had graduated from high school. Fewer than half (43%) had a family income over $10,000, 48% were married or cohabiting, 32% reported that they were currently employed, and the average household size was 2.5. Mean fruit and vegetables consumption was 3.95 servings a day (median 3.4). Participants who attended all three visits had similar sociodemographic characteristics and fruit and vegetable consumption as those who attended only one or two visits. Diet Related Factors About 25% of WISEWOMAN participants ate >5 fruit and vegetables per day at baseline (Table 1). Intake of fruit and vegetables varied signi ficantly by age. Participants aged >60 years consumed significantly more fruit and vegetables than younger ones. Participants with the highest education levels had significantly greater intake of fruit and vegetable than those with less education (x'=11.9. p=0.003 ). Significant differences in the mean intake of fhiit and vegetables and the proportion of participants eating >5 fruit and vegetables per day by acculturation level existed. More acculturated MA were eating significantly fewer fruit and vegetables than less acculturated MA (p=0.034) and non-Hispanic whites (p=0.016). Acculturation The reliability analysis indicated that the coefficient alpha for the acculturation scale was 0.82. Most of the participants were aged 50-59 years, and the proportions of the two age groups were similar for the three groups of acculturation (Table 2). However, there were significant differences in educational achievement, income, marital status, employment status, and BMI among the three groups. Less acculturated MA (1,284.8 ±419.4 kcal) had a significant lower energy intake than more acculturated MA (1,345.6 ± 415.1 kcal) or NHW (1,440.7 ± 414.7 kcal) (p=0.012) (data not presented). NHWs with at least 3 recalls per follow-up visits, reported more 233 consumption of fruit and vegetables than their MA counterparts (p= 0.002) (data not presented). Dietary acculturation A significant higher proportion (25%) of less acculturated MAs consumed >5 fhiit and vegetables per day than the more acculturated women (8%), but the proportion was significantly lower than that of NHW (37%) (x^'=4.3, p= 0.039). When compared with the other groups, NHW consumed significant higher amounts of dark green vegetables (p=0.032), while less acculturated MA consumed significant higher amounts of legumes (p<0.001) (data not presented). Education was positively associated with mean intake of fruit and vegetables (p=0.008 ) and the proportion eating >5 fruit and vegetables per day (x^=8, p= 0.018). Among participants whose income was >$10,000 per year, no participants who were more acculturated consumed at least 5 fruit and vegetables per day, whereas 29% of less acculturatcd participants and 42% of NHW did so ('£=6.2, p= 0.045). Among NHW participants, the percentage of women who consumed >5 fruit and vegetables per day was higher among women who were single, divorced, or separated (37%), non- employed (42%), or non-smokers (39%) than among their respective counterparts (£=1.6, p= 0.022, x"=9.0. p= 0.011, and y/^=7.8, p= 0.020, respectively). NHW with a high BMl were less likely to consume >5 fruit and vegetables per day than women who had a low BML The opposite pattern was present among less acculturatcd MA. A subanalysis demonstrated that 37% of NHW who had at least 3 recalls reported consuming >5 fruit and vegetables per day compared with19% of less acculturated and 6% of more acculturated participants (x^=9.9, p=0.007) (data not presented). Multivariate Models After adjustment for potential confounders, less acculturated MA women had the highest and more acculturated MA women the lowest intake of fruit and vegetables (Table 3). A positive association between educational status and the intake of fruit and vegetables was present. In addition, women who smoked reported higher intakes of fruit and vegetables than women who did not smoke. Tables 4 and 5 indicate a differential effect of increase fruit and vegetable consumption throughout visits. Acculturation groups indicated significant increased fruit and vegetable consumption and when visits and their interactions with acculturation were considered, significant effects were eminent, particularly in more acculturated MA. When acculturation was adjusted for education and smoking status all significance was lost. 234 Discussion This study was desigiied to estimate the average daily fruit and vegetable consumption among Mexican American women aged >50 years who were uninsured and resided in Arizona, and to compare their intake to that of NHW, and to relate their intake to selected sociodemograpMc factors. The mean intake of fhiit and vegetables and the percentage of study participants who consumed >5 fruit and vegetables per day were comparable with results from other reports [33] and BFRSS Arizona data ixom 1998 and 2002 [34], The estimated intake of fruit and vegetables in this study is one serving short of the goal of eating at least five fhiit and vegetables per day. The modest change in the intake of fruit and vegetables seen in a brief period of one year in our study is similar to the modest changes seen in a period of six years that were reported previously in an adult population [15]. Cuellar's modified -short version- acculturation scale [19] indicated that the majority of MA women had low levels of acculturation as previous studies had found with other Hispanic elder populations [28, 35]. Findings demonstrated that even though the distribution of participants in the mid range of our determined income categories was higher for those more acculturated and for NHW, the actual income mean was higher for more acculturated MA than for the other groups. Despite their slightly higher average income, their fruit and vegetable intake was the lowest, as has been shown in another report [4]. Contrary to the findings for NHW women, more financial resources did not translate to greater fruit and vegetable intake. This may suggest that higher incomes may lead participants to more convenience foods and foods eaten away from home that are of lower nutritional quality. In fact this phenomenon has been suggested in earlier reports [36]. At baseline, the more acculturated MA appeared to have made a transition to eating fewer traditional fruit and vegetable based foods, while the less acculturated and NHW participants shared similar consumption of fruit and vegetables. Our findings are contrary to those of a previous study that found that NHW ate fewer fruit and vegetables than Hispanics [4]. While more acculturated MA had significantly lower fiiiit and vegetable intake at baseline, there was a significant increase in fruit and vegetable consumption over time particularly at their third visit when compared to less acculturated MA or NHW. The participant with less acculturation reported a significant decrease in their fruit and vegetable intake when compared to NHW at their third study visit. Acculturation as noted in other studies appears to be an independent predictor of diet, and in this study acculturation was also a predictor of diet change [4]. Although knowledge alone does not appear sufficient to change behavior, it was the first step in our interventions to increase awareness and may be an excellent tool for promoting fruit and vegetable consumption for those more acculturated people who are ready to make dietary changes or reconsider some of their traditional healthy foods. 235 The Mexican diet includes native foods such as com, chiiies, beans, squash, and a wide variety of fruit and vegetables [37]. Evaluating the degree to which traditional foods were incorporated in the participants' diets was beyond the scope of this study. However, the majority of the participants consumed fewer than the recommended >5 Iruit and vegetables per day. Adherence to message and to change could have been influenced by participant support networks, involving family members, relative, neighbors or friends [21, 24, 38], factors not explored in these analyses. The study of acculturation and its relationship to healthy behaviors is complex. Food patterns, availability, convenience, social structure, health concerns, purchasing power, and food responsibilities must be considered in order to be able to make appropriate inferences in this population. Qualitative data about health beliefs and barriers to consumption of fruit and vegetables may have enhanced our ability to determine effects on lack of goal attainment. Alternatively, the acculturation scale may have been too insensitive to detect differences in diet or might need all its components in order to properly address the relationship with fruit and vegetable intake. The fact that our more acculturated category had only 26 participants also may have obscured our ability to make inferences; still, we saw a signi ficant effect, which only eliminated the possibility of a type II error, in fact when we further created an additional bi- acculturation and included 12 participants to the more acculturated category and the significance effect was lost. This may suggest that particular differences in the more acculturated group may have been diluted, when in fact more acculturated MA where increasing their fruit and vegetable intake through time, yet when adjusting for smoking and for education level our results became non-significant suggesting that our acculturation association was closely related and obscure by the education level. The group of more acculturated MA who had a higher average income and lower intake of fruit and vegetables, also may have had more acquisition power and more food availability and security, which influenced food selection. Additionally, some of the limitations of the 24-hour diet recall include error in recall, poor estimation of serving sizes, and cognitive aspects of dietary recall. While we had a variable number of completed recalls per participant, we were able to assess associations between fruit and vegetable intake and other variables. Future research can benefit from more extensive consideration of acculturation and more complete diet assessment, which would likely include more than one method to collect diet intake data (i.e. recalls, diet history and/or food frequency questionnaires). Maintenance of a nutritious diet have been reported to be difficult in low-income older population who tend to be less educated or solitary [39, 40], In addition, the changing structure of Southwestern families and the increasing diversity of the region's population, intensify nutrition and health issues [41]. In 2000, 39% of Arizona females ate the recommended amount of fruit and vegetables [34, 42], Only 25% of the women in WISEWOMAN ate the recommended amount, continued efforts to explore patterns 236 of food intakes over time are needed. Furthermore, an improved understanding of the dietary beliefs and practices of people along various stages of acculturation continuum is necessary to develop and implement dietary interventions for immigrants. Moreover, it is particularly important to promote diets that include both traditional and modem foods and that focus on adopting or maintaining healthful dietary patterns that will satisfy the biological, emotional, and social needs of the diverse Hispanic groups in the United States. 237 Applications/Conclusions The diets of U.S. Hispanics lack sufficient amountsof fruit and vegetables and this places these populations at long-term health risk. Our findings suggest that the more acculturated MA may be at higher risk of consuming less than 5 a Day intake of fruit and vegetables recommended. At the same time less acculturated participants were more likely to benefit from interventions such as the one presented in this study. These findings provide more insights into a culturally sensitive and variable intensity intervention to increase fruit and vegetable intake, one that may hold promise for future research efforts. In the light of the impact of immigration on food patterns and food consumption it seems appropriate to consider the dynamics of acculturation when counseling MA patients to achicve increased fruit and vegetable intake as well as in programs and policy development. More research is needed to elucidate the intake and trends among MA and other ethnic groups as well as factors that influence fruit and vegetable intake. 238 Table 1. WISEWOMAN social, cultural, aiid health related characteristics and their relationship with fruit and vegetable consumption (>5 servings a Day) at baseline®. % Mean(SD) N Eating 5+ Servings Servings a day Age,years 50-59 226 24,3 3.76(2.74) 60+ 122 30.3 4.29(3,24)" Education, years" 0-3 122 19.7 3,47(2,50) 4-11 97 21.7 3.90(2.69) 12+ 122 37.7 4.54(3.44)" Income, annual <$4,999 67 19.4 3.74(2.73) $5000-9,999 129 26.4 3.86(2.72) $10,000 145 30.3 4.16(3.24) Marital Status Married/cohabitating 155 26.5 3.99(3.16) Single/divorced/separated 123 23.6 3.72(2.53) Widowed 45 31.1 4.43(3.26) Acculturation" MA Less 234 24.8 3.93(2.72) MA More 26 7.7 2.77(1.87)'' non Hispanic white 88 36.4 4.34(3.58)' Employed Yes 109 23.9 4.04(3.57) No 238 27.7 3.91(2.6) Smoking Yes 45 17.8 3.42(2.97) No 301 27.9 4.03(2.93)" High BMI >25 Yes 269 24.9 3.76(2.51)" No 68 32,4 4.69(4.21) Significance values are based on a transformed fruit and vegetables servings a day between category and intake of > 5 a Day p< 0.05 Vtest between acculturation groups (less and more acculturated) - post hoc test -p < 0.05 ''ANOVA fruit and vegetable servings a day different between categories p<0.05 239 Table 2. WISEWOMAN social, cultural, and health related characteristics and their . = A relationship with finit and vegetable consumptioB at baseline by acculturation group. Less More Non-Hispanic Acculturated Acculturated White N Mean(SD) N Mean(SD) N Mean(SD) N=234 N=26 N=88 Age, years 50-59 152 3.79(2.69) 15 2.56(1.83) 59 3.99(3.00) 60+ 82 4.19(2.78) 11 3.05(1.96) 29 5.04(4.52) Education, years 0-3 119 3.47(2.50)' 2 4.47(2.99) 1 1.46(0.00) 4-11'' 72 4.27(2.82) 13 2.54(1.80) 12 3.16(2.19) 12+ 38 4.89(3.03) 10 2.71(1.91) 74 4.6(3.75) Income, annual <$4,999 53 3.55(2.51) 4 3.43(0.60) 10 4.85(4.06) $5,000-9,999 75 4.02(2.84) 13 3.13(2.25) 41 3.79(2.64) $10,000'' 100 4.12(2.79) 9 1.94(1.39) 36 4.81(4.36) Marital Status Married/Cohabitating 119 3.99(2.59) 12 2.52(1.96) 24 4.76(5.36) Single/divorced/separated 72 3.68(2.47) 10 2.55(1,74) 41 4.08(2.75) Widowed 27 4.97(3.87) 2 3.32(0.20) 16 3.65(2.00) Employed Yes'' 59 4.02(2.99) 7 1.78(1.57)' 43 4.43(4.37) No 174 3.91(2.64) 19 3.13(1.87) 45 4.25(2.67) Smoking Yes 28 3.85(3.16) 3 1.33(0.90) 14 3.00(2.70) No" 205 3.95(2.67) 22 2.91(1.92) 74 4.59(3.69f High BMI Yes'' 185 3.95(2.65) 24 2.62(1.75) 60 3.61(2.16) No 41 3.99(3.11) 1 2.35(0.00) 26 5.87(5.43)^' Acculturation score range = 1 to 5. l=Hispanic non-acculturated and 5=U.S. acculturated ^Significance values are based on a transformed fruit and vegetables servings a day "ANOVAtest within categories in an acculturation groups and fruit and vegetable mean values p<0.05. "'ANOVA test between acculturation groups and fruit and vegetable mean values p<0.05 240 Table 3. Relationship of selected sociodemograpMc factors to fruit and vegetable consumption for WISEWOMAN participants from bivariate and multivariate linear regression models at baseline. ^ Bivariate Multivariate ' b SE p b SE p Acculturation MA Less MA More -0.35 0.14 0.01 -0.53 0.15 0.00 NHW 0.04 0.08 0.61 -0.19 0.11 0.08 Age 50-59 60.00 0.09 0.08 0.24 0.11 0.08 0.15 Education 0-3 4-11 0.11 0.09 0.21 0.19 0.10 0.05 12+ 0.24 0.09 0.01 0.37 0.11 0.00 Income <$4,999 $5,000-9,999 0.01 0.10 0.95 -0.01 0.10 0.90 >$10,000 0.08 0.10 0.44 0.04 0.10 0.66 Marital Status M/C S/D -0.05 0.08 0.55 -0.04 0.08 0.66 W 0.07 0.11 0.53 0.08 0.11 0.50 Employed Yes No 0.07 0.08 0.36 0.12 0.08 0.13 Smoking Yes No 0.18 0.11 0.09 0.22 0.11 0.04 High BMI Yes No 0.12 0.09 0.20 0.12 0.09 0.21 *These values are based on log-transformed daily fruit and vegetables servings a day MA^ Mexican American, NHW-non-Hispanic white, M/C =Married/Cohabitating, S/D= Single/Divorced/Separated, W=Widow 'All Models were adjusted for baseline for significant categories at the bivariate model Table 4, WISEWOMAN fruit and vegetable consumption least square means and relationship to visits, and acculturation levels over time using repeat measures. Estimate of Fruit & Effect Vegetable Intake Error p value p value* Type 111 Test Visit 0.019 0.769 Baseline 1.80 0.04 6-month follow-up 1.81 0.05 12-month follow-up 1.97 0.05 Acculturation 0.036 0.414 MA Less Acculturatcd 1.82 0.02 MA More Acculturatcd 1.98 0.07 NHW 1.77 0.04 Acculturation * Visit 0.001 0.701 * Adjusted values for education and smoking status MA=Mexican American NHW- non-His-panic white Table 5. WISEWOMAN fruit and vegetable consumption differences of least squares mean its relationship to visits and acculturation levels* Effect Diff of Least Diff of Least* P P Square Means SE value Square Means SE* value* Time -0.01 0.06 0.885 -0.10 0.12 0,369 differences 2 adjusted for -0.16 0.07 0.023 0.01 0.08 0,852 3 acculturation -0.17 0.06 0.008 0.12 0.11 0,298 Acculturation MA Less vs. More -0.16 0.07 0.025 -0.03 0.09 0,739 differences MA Less vs= NHW adjusted for 0.04 0.05 0.366 -0.02 0,10 0,841 time MA More vs. NHW 0.21 0.08 0.010 -0.05 0.09 0,599 Time MA Less Accultuiated ] 0.04 0.06 0.449 0.03 0,07 0,685 differences 1 0.01 0.06 0.920 0.03 0.08 0,663 adjusted for 3 0.05 0.05 0,365 0.06 0.07 0.353 acculturation MA More Acculturated 1 -0.19 0.16 0.232 -0.20 0.22 0.369 level 2 -0.38 0.17 0.030 -0.08 0.25 0.751 3 -0.56 0.16 0.000 -0.28 0.24 0.246 NHW 1 0.12 0.09 0.209 0.09 0.10 0.403 2 -0.11 0.10 0.282 -0.01 0.11 0.917 3 0.01 0.09 0.927 0.08 0.10 0.468 Acculturation MA Less vs. MA More 1 -0.07 0.13 0.593 -0.11 0.18 0.525 differences 2 -0.49 0.13 0.000 -0.22 0.21 0.280 adjusted for 3 -0.45 " 0.13 0.001 -0.19 0.20 0.337 time level MA Less vs. NHW I 0.15 0.08 0.060 0.08 0.11 0.464 2 0.00 0.09 0.974 0.04 0.11 0.743 3 0.04 0.08 0.614 0.07 0.11 0.532 MA More vs. NHW 1 0.03 0.12 0.809 -0.01 0,17 0.960 2 0.11 0.14 0.447 0.18 0,19 0.339 3 -0.08'' 0.12 0.524 -0.02 0,18 0.907 'Adjusted values for smoking and education 'Baseline vs. 6-month ^6-month vs. 12-month ^Baseline vs. 12-month MA=Mexican American NHW=non-Hispanic white "Less acculturated vs More acculturated estimate significantly lower difference at visit 3 p<0.001 ""More acculturated vs NT-IW estimate significantly higher difference at visit 3 p<0.001 National Cancer Institute. 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Hispanic Journal of Behavioral Sciences 1995, 17(3):275-303. 32, Littell RC, Milliken GA, Stroup WW, Wolfingcr RD; SAS system for mixed models. Cary, N.C.: SAS Institute Inc.; 1996. 33, Subar AF, Heimendinger J, Patterson BH, Krebs-Smith SM, Pivonka E, Kessler R; Fruit and vegetable intake in the United States: the baseline survey of the Five A Day for Better Health Program. Am J Health Promot 1995, 9(5):352- 360. 34, National Center for Chronic Disease Prevention & Health Promotion. Behavioral Risk Factor Surveillance System. U.S. Department of Health and Human Services [http://apps.nccd.cdc.gOv/brfss/1 35. Mark ides KS, Lee DJ, Ray LA: Acculturation and hypertension in Mexican Americans. Ethn Dis 1993, 3(l):70-74. 36. Aldrich L, Variyam JN: Acculturation erodes the diet quality of U.S . Hispanics. Food Review 2000, 23(l):51-58. 37, Romero-Gwynn E, Gwynn D, Grivetti L, McDonald R, Stanford B, Turner B, West E, Williamson E: Dietary acculturation among Latinos of Mexican descent. Nutrition Today 1993, 28:6(7). 38. Krebs-Smith SM, Heimendinger J, Patterson BH, Subar AF, Kessler R, Pivonka E: Psychosocial factors associated with fmit and vegetable consumption. Am J Health Promot 1995, 10(2):98-104. 39. Guthrie J, Lin BH: Older Americans need to make every calorie count. Food Review 2002, 25(2):8-14. 40, Guthrie JF, Lin BH: Overview of the diets of lower- and higher-income elderly and their food assistance options. JNutr Educ Behav 2002, 34 Suppl 1:831-41. 41. Foote JA, Giuliano AR, Harris RB: Older adults need guidance to meet nutritional recommendations. J Am Col! Nuir 2000, 19(5):628-640. 42. Li R, Serdula M, Bland S, Mokdad A, Bowman B, Nelson D: Trends in fruit and vegetable consumption among adults in 16 U.S. states: Behavioral Risk Factor Surveillance System, 1990-1996. Am J Public Health 2000, 90(5):777-781. 246 APPENDIX C: OLDER WOMEN'S SELF REPORTED CHANGES IN FRUIT AND VEGETABLE CONSUMPTION: ANALYSES FROM A STAGES OF CHANGE APPROACH. Karen Y. Gregory Mercado, MS, MPH.' Lisa K. Staten, PhD," James Ranger-Moore, PhD,'"'* Cynthia A. Thomson, PhD, RD FADA,^'^ Stuart J. Cohen, EclD," Jose Guillen,"''^ Anna R. Giuiiano, Ph.D,-'"^ Julie C. Will, PhD'\ Earl S. Ford, MD, MPH,' James Marshall, PhD® 'Department of Nutritional Sciences, University of Arizona, 'Division of Health Promotion Sciences, Mel and Enid Zuckerman Arizona College of Public Health, 'Division of Epidemiology & Biostatistics, Mel and Enid Zuckerman Arizona College of Public Health, "'Arizona Cancer Center, "Biometry, ''Division of Nutrition and Physical Activity, CDC, 'Behavioral Surveillance Branch, Division of Adult Community Health, CDC, ^ Cancer Prevention and Population Sciences, Roswell Park Cancer Institute. Send correspondence to Karen Y. Gregory Mercado, MS, MPH, Department of Nutritional Sciences College of Agriculture and Life Sciences, University of Arizona, Tucson, AZ 85721 Phone: (520) 321-7777 Fax; (520)321-7754 (e- mail:ky g@email .arizona. edu). Running Head: WISEWOMAN Fruit and Vegetable Consumption and stages of change Proposed Journal: American Journal of Health Promotion 247 Abstract Title: Older women's self-reported changes in fruit and vegetable consumption: analyses from a stage of change approach. Objectives: Describe perceived stage of change of fruit and vegetable consumption in an adult uninsured population, to determine fruit and vegetable change as a function of movement through the stages of dietary change, and to study whether fruit and vegetable consumption is positively associated with stage of change and finit and vegetable consumption changes through time. Methods: WISEWOMAN participants that returned to all three follow-up visits were assess for their changes in fruit and vegetable consumption and their stages of change self classification. Using participants' self-reported staging based on one item fruit and vegetable consumption question, we compared their staging to fniit and vegetable intake from 24-hr recalls. Using PROC MIXED model we determined how participants' movement across stages predicted intake change and how time and staging related to final intake of fruit and vegetable through time. Results: The largest of participants (52%) identified themselves at the first stage of change, precontemplation/contemplation stage, while 18% identified themselves at the action/maintenance stage (p = 0.002). Participants' perception of movement in stage indicated that 64% were moving forward in stages of change, yet only 38% actually demonstrated a 24-hour recall estimated increase. At 12-month follow-up participants that identified themselves in the lower stages of change were eating significantly fewer amounts of finits and vegetables. Conclusion: Perceived notion of self-rated change in fruit and vegetable consumption and actual intalce practice in an adult, uninsured, lower educated, with a lower income population differed considerably. Movement through changes was related to minimal changes in fruit and vegetable consumption, particularly in participants moving to earlier stages. Self-rated diet together with dietary intake measure, followed by personalized feedback to help raise awareness and motivate change possibly may be the most helpful tool to move people through the stages of change of fruit and vegetable consumption, particularly in older populations. 248 Introduction Increased consumption of fhiits and vegetables has been inversely associated with risk for several chronic diseases [1-3], While U.S. dietary guidelines emphasize consumption of foods of plant origin, the American diet still includes too few grain, vegetable and fruit products. [4]. Achievement of nutritional goals has been demonstrated consistently to be less than adequate particularly among older individuals [5,6]. Many barriers to increased consumption of fruits and vegetables have been identified including, food habits, availability of food, taste and costs. Because a high percentage of individuals are not meeting the guidelines for fruit and vegetable consumption, researchers have sought to identify the factors most relevant in assisting people to both initiate and maintain healthy eating. Initiation of behavior change and maintenance of change have independent antecedents [7-9], Understanding the behavior change antecedents and knowing at which stage of behavior change a person is at can assist both practitioners and researchers in the implementation of strategies that are appropriate for reaching individuals at the various stages of change, thus enhancing succcss with behavior change. The Stages of Change Model (SOC) for promoting behavior has shown some interesting results in a dietary context [7,10, 11]. Initial measurement of readiness to change has aided in the development of targeted programs, development of specific health education material, and better assessment of program effects [7. 10]. The SOC model has been applied to dietary change efforts [10] focusing on lowering fat intake [12-14], modifying milk consumption, and increasing fruit and vegetable intake [9, 13, 15-17]. Targeting SOC has proven to be effective in several physical activity and smoking interventions, but findings are less consistent in diet intervention studies[18-20]. Several studies have utilized the SOC model and found it effective in predicting dietary behavior change of participants toward a lower consumption of dietary unhealthy foods. [11,21, 22]. Classification of participants using SOC in a dietary context is challenging. Compared to the more straight forward stage classification for a clearly understood behavioral goal such as smoking cessation, a diet outcome involving multiple behavior changes is extremely difficult to assess [8, 23, 24]. One problem of applying the model to dietary habits is lack of awareness of intake, and servings or portion sizes. Use of SOC model requires a clear definition of the target behavior, assessment if the target was met, and for how long the target has been met. If people are optimistically biased in the self- assessment of SOC, this could lead to the perception of being at action or maintenance stages even though the person fails to meet the target behavior [8, 24]. As suggested by Glanz and colleagues, few longitudinal analyses have been reported that allow evaluation of stage constructs as an intermediate marker of progress toward dietary behavior change [25]. 249 This model measures people's thoughts about their behaviors and their interest in changing. In a SOC based situation or intervention the stage of behavior change would be identified and then a well-defined sequence of intervention steps will be deliver to move the person through successive stages. Conceptual and methodological issues have complicated the application of SOC model to different eating patterns. The model requires an awareness of eating patterns and socio-environmental contexts [26]. Nutrition interventions are more likely to have an effect when they are based on an understanding of the factors that influence food choice, and familiarity with established theory and research on changing health related behavior [26, 27]. Although the model has been used in interventions for increasing fruits and vegetable consumption in adults, [17, 21, 28] it has been used less frequently in older [29], low socioeconomic populations and even less in Hispanic female populations. Misidentification of stage may result in inappropriate stage-match intervention. Older people have previously been reported to more likely classify themselves to be in the action phase. The purpose of the present study was to determine whether self-assessed SOC classification was able to accurately prcdict and improve classification over time in a non- SOC based intervention. Initial assessment of appropriateness of this theory to address nutritional behavior stages in an older population is necessary in order to eventually determine if people are moving forward within this framework. The main objectives of this study were as follows: 1) to determine participants initial perceived SOC for fruit and vegetable, 2) to determine fruit and vegetable consumption intake over time as a function of movement through the stages of dietary change, and 3) to study whether fruit and vegetable consumption is positively associated with SOC and changes over time. Methods Design The Arizona WISEWOMAN study, a CDC demonstration project funded to the Arizona Department of Health Services (ADHS), was a diet and physical activity intervention trial among older women conducted from 1998 to 2()()(). The purpose of the intervention was to test three different levels of intervention to increase consumption of fruits and vegetables and physical activity. AZ WISEWOMAN was designed to reach people at all stages of behavior change and did not provide a stage match based intervention. Participants were approached as to improve fruit and vegetable intake through building awareness, follow-up visits, behavior change reminders, and maintenance motivations. This project tested three levels of intervention based on the combination of communication relationships and two health behavior theories: Patient Provider, Social Cognitive Theory, and Social Support. The three levels of intervention included a provider visit in which the following were provided; health education brochures, discussion of the benefits and barriers to physical activity (PA) and increased fruit and vegetable consumption, and a written prescription regarding recommended activities. Details of the AZ WISEWOMAN study have been reported elsewhere [30]. 250 Sample The population included in this intervention was women aged >50 years, who were primarily Hispanic (mostly MAs), had incomes under 200% of the federal poverty level and were not eligible for the Arizona Medicaid program (AHCCCS) or other insurance programs. All women participating in the WISEWOMAN project had to be deemed medically eligible by a medical practitioner. Participants completed a series of extensive questionnaires and anthropometrical measurements at baseline, six-month, and twelve-month. A total of 361 subjects completed dietary information at baseline, however for these analyses we used data from 130 (36%) participants that retumed to all three visits and for whom complete diet and SOC data were available. Measures Demographic Characteristics. Age, ethnicity, education, marital status, household income were assessed. Dietary Methods. Tlirec 24 hr recalls were attempted at baseline, six-months, and at one-year of follow-up on each WISEWOMAN participant, with the goal of collecting dietary intake for 1 weekend and 2 weekdays at each time point. Bilingual WISEWOMAN staff conducted the initial 24 recall face-to-face, and the Behavioral Measurement Shared Service the Arizona Cancer Center conducted the remaining two 24 hr recalls over the telephone. Details of the project dietary protocols can be found elsewhere [30, 31], Diet recall data were entered and nutrients were estimated using the Nutrient Data System for Research (NDS-R) software version 4.05_33 (Nutrition Coordinating Center (NCC), University of Minnesota, Minneapolis, MN, July 2002). Estimation of Fruit and Vegetable Intake Total servings of fruit and vegetables, servings of vegetables, servings of fruit including juices, servings of fruit juice, and servings of fruit were tallied using a counting method based on defimtions and portions sizes from the NCI 5 a-Day program which are derived from the Dietary Guidelines for Americans [32]. We also included and counted legumes, V2 cup serving. Foods that did not meet the criteria of the 5 a-Day program promotable foods were not included [32]. Body Mass Index. The body mass index (BMI) was an indicator of body size based on measured height and weight [weight (kg)/height (m)"]. BMI categories were based on the approach used in the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. High BMI was defined as people with BMI > 25.0 kg/ml 251 Psychosocial Factors Several psychological factors were hypothesized to be mediating variables, that is, to be influenced by SOC and predictive of fhiit and vegetable intake [26]: self-efficacy for change, perceived benefits of eating more fruits and vegetables, social support, and weight control. Belief in the association of finit and vegetable consumption with health (perceived benefits), social support, and weight control were assessed as affirmative or negative questions. Stage of Change. We measured psychosocial factors related to fruit and vegetable choices using various tools. Even though information related to SOC was not used to design the diet intervention, we wanted to measure the capacity of WISEWOMEN participants to correctly stage their fruit and vegetable consumption and determine how this staging predicted future behavior modification. After provider counseling was received and visit to the provider was completed participants were first asked a single question to estimate the total number of fruit and vegetable servings they consumed each day: "How many fruits and vegetables do you think you cat each day?" This question was separate from the one used to calculate fruit and vegetable consumption from the 24-hr recalls. Participants then were asked which of the statements best described whether they ate five or more servings of fruits and vegetables each day for a determined time periods. They were then categorized as being in one of the following stages based on the Transtheoretical Model: "I currently don't and do not intend to start in the next six months" (pre-contemplation), "I currently don't, but I think about starting in the next six months" (contemplation), "Currently 1 do, but not regularly" (preparalion). "I regularly do, but have only just begun in the past 6 months" (action), and "I regularly do eat five or more servings and have done so for longer than 6 months" (maintenance). For conceptual and practical reasons, and because at baseline only 4 participants were in precontemplation and zero in action stages, we combined the precontemplation and the contemplation (PC/C) and the action and maintenance (A/M) stages into two categories for data analysis. Self-Efficacy. Participants were asked how sure they were that they could eat five fruits and/or vegetables per day; the responses were measured using a three-item questionnaire on a five point Likert scale. How confident are you that you could cat more fruits and vegetables you eat? (5=extremely confident to l=no confident), "How confident are you that you could eat more fruits and vegetables without it interfering with the things you like to do?", and "Compared to other women, how certain are you that you could eat more fruits and vegetables?" (5=1 am sure I could to 1=1 can't). Responses were grouped into two self-efficacy categories: low- (0-1.49-no confident) and high (>L5-very confident). Internal consistency of this scale was 0.87. 252 Statistical Analysis Baseline analysis of similarities of fkiit and vegetable consumption by sociodemographic characteristics, age (50-59, and 60+), education (0-3, 4-11, or 12+), income (<4,999, 5,000-9,999, or 10,000+), marital status (married / cohabitating, single / divorced / separated, or widowed), household members (1, 2-4, or 5+), employment status, and ethnicity (Mexican American and non-Hispanic white). Differences in questions related to family support, encouragement, perception of fruit and vegetable being good and making participants feel better, weight control, and SOC, as well as smoking status, BMI status, were done. Descriptive statistics were used to describe sample characteristics and fruit and vegetable consumption; chi-square, ANOVA, and non-parametric tests were used. Internal consistency reliabilities for the self-efficacy scale were measured, by means of a coefficient alpha. Although AZ WISEWOMAN intervention previously demonstrated no significant effect on fruit and vegetable intake [30] the message to increase fruit and vegetable consumption to more than five was kept throughout our analyses. Self reported estimate measures of fhiit and vegetable consumption from 24-hour recalls were correlated to perceived reported intake at baseline. To evaluate associations at baseline between fruit and vegetables consumption and most of the selected socio demographic characteristics and risk factors, linear regressions were done on one half of the data, randomly chosen. These models were used to then validate the other half of the data. Validation was feasible for all significant variables and was confirmed with univariate analyses. Significant factors were retained in subsequent multivariate analyses to test for significance (p < 0.05). Appropriate assessments for the fulfillment of regression assumptions were also completed. Independent variables that were statistically significant in the univariate and multivariate models were accepted as significantly associated with fruit and vegetables consumption. Assessments of confounding variables to this association were also addressed and adjusted accordingly. The dependent variable, servings of fruit and vegetables, was log-transformed to improve normality, but data on fruit and vegetable prevalence consumption are presented in the original units. To determine if retained factors were related to change in fruit and vegetables consumption at 6 months and 12 months and to account for the statistical non- independence of repeated measures, a mixed model PROC MIXED which verified several parametric structures on covariance structure of the repeated measures (compound symmetric, autoregressive order one and "unstructured") was used [33]. Also dietary change as a function of movement through stage was measured using the same modeling. The compound symmetric covariance structure was selected for these analyses while a computation of the appropriate approximate degrees of freedom for each of the estimated standard errors was done controlling for baseline consumption of fruit and vegetable main effect and interactions between visit, perceived movement through SOC and reported SOC. Perceived movement through stages categorization 253 was done based on participant determination of their location in the staging scale. Those participants categorized as moving backward, changed staging from A/M to Preparation or PC/C while those in the Preparation stage changed to P/C. Participants classified as not moving kept their same staging perception at follow-up visits while those that perceived forward movement changed their staging from PC/C to Preparation or A/M or from Preparation to A/M. A re-categorization by SOC based on original staging perception and 24-hour recalls was done in order to compare perceived staging versus a dietary intake estimates. Original perceived stage as reported by participant was maintained as long as the 24-hour recall fruit and vegetable intake reflected staging. Baseline SOC values were modified according to participants' baseline intake wliile comparing intake results in their follow-up visits. Participants that perceived themselves as being in the PC/C and who were eating more than five servings of fruit and vegetable were categorized at the Preparation stage. Those who classified themselves at the A/M stage while eating less than five servings of fruit and vegetable but averaging an increase consumption at follow-up visits of 1.5 servings were re-categorized in the Preparation stage, as well as those that perceived themselves in the A/M that were not changing from their low consumption of fruit and vegetables, or their change did not average more than 1.5 servings a day in follow-up visits. Analyses presented in this study used participants' perceived staging. All descriptive data analyses were done using intercooled Stata version 7 (Stata Corporation, College Station, TX, 2001) while Generalized Linear Mixed model analyses were done using The SAS System for Windows (Release 8.2. S AS Institute Inc. Cary, NC.). Results A comparison of sociodemographic characteristics between those participants that returned to all three visits and those that only came to one or two visits indicated no significant differences among groups, yet participants that did not returned were more likely to have more than 5 family members at home (X^=5.4, P = 0.066). Also we determined no significant difference in sociodemographic characteristics between those self-classified in the PC/C stages or the A/M stages therefore these stages were collapsed to PC/C and A/M and a third group Preparation. As summarized in Table 1 overall study population demographics reflected an older, low income and lower educated population as designed. Mexican American women were less educated (7.5 years) and had higher household size average (2.6) as compared to non-Hispanic whites (12.9 years and 1.6 members). Also 81 % of Mexican American women had a high BMI (higher that 25) compared to 66% of non-Hispanic whites. Table 2 shows the differences between categorical variables and the prevalence of more than five fruits and vegetables a day at baseline. Also Mexican American women self-perceived consumption of fruit and vegetable was significantly lower than that perceived by non- Hispanic whites. Baseline fruit and vegetable consumption from 24-hour recalls and 254 perceived reported amounts, were significantly correlated, correlation value 0.53 (P=0.000). An analysis that included interventions in the repeated measures model ruled out the potential for individual components of WISEWOMAN intervention as estimates of behavior changes and stage changes. Fruit and Vegetables and associations among variable distributions Older (60+) participants were more likely to consume fruit and vegetables. Smokers, those with higher weight, and those in the PC/C categories ate significantly fewer amounts of fruit and vegetables a day compared to non-smokers and participants at the A/M stages. The stage distribution and demographic characteristics were compared and no significant differences were seen. However, participants subgroup analysis showed in the preparation stage that had 4-11 years of education had significantly {P = 0.036) higher intake of fruit and vegetables at baseline when compared to other education groups while participants in the action/maintenance stage with a lower BMI had a higher intake of fruit and vegetable than participants in the same stage with a high BMI (F = 0.063) (data not presented). Most participants reported being at first SOC (52% PC/C versus 18% A/M; F = 0.001). At follow up visits A/M perceived stage represented the largest group 57% and 62% at 6 and at 12-months follow-up respectively. Our re-staging algorithm indicated that at baseline we should have had 40% participants at the PC/C stage versus 53%, 47% in the Preparation stage instead of 30% and 14% in the A/M instead of 18%. Likewise, at the 12-months follow-up visit our re-staging algorithm indicated that 10% of the participants should have been at the PC/C stage versus 18%, 69% in the Preparation stage instead 20%, and 21% in the A/M instead of 62% (data not presented). This re-staging algorithm indicated that most of the participants in the preparation stage were not eating more than five servings at the time of our measure yet perceived that they consumed the suggested amount of fruit and vegetables occasionally. The average prevalence intake of five servings a day at baseline was 26%. Statistical significant relationships were maintained in the multiple linear regression analysis models controlling for age, income, ethnicity, educational level, and SOC, and their interaction terms. Table 3 and Table 4 shows repeat measures analyses comparing the follow-up time points and self reported SOC. First stage (PC/C) and third stage (A/M) demonstrated significant fruit and vegetable reduction from Baseline to 6 and 12-month follow-ups. However when A/M stage was compared to PC/C through time, participants that categorized themselves in the PC/C stage demonstrated significant lower intake at each time point. 255 Fruit and Vegetables changes from 24-hour recalls and perceived movement across SOC through different follow-up visits Table 5 demonstrates participants' perception of SOC overtime, their movement across the stages, and change in fruit and vegetable consumption. From Baseline to 6- month follow up 57% ate and continue to eat more than five servings of fhiit and vegetables a day, yet 59% of this 57% classified themselves as moving forward in the SOC during the same time. Twenty eight percent either increased their intake or kept on eating more than five servings a day, while 15% decreased their intake to less than five servings a day after 24-hour recall data indicated an initial intake that was more than five servings. Sixty three percent of those participants that decreased their intake classified themselves as moving forward through the SOC. Participants that identified themselves as not changing SOC and who were in the A/M stage at baseline were more likely to have been eating more that five at baseline yet were consuming less than five at the 6-month follow-up visit. Participants that perceived no change from the PC/C (48%) stage were more likely to report eating less than five servings of fruit and vegetables a day (X^=17.2, p=0.009). Among the 62% of participants that reported eating less than five servings a day at baseline and maintaining this behavior overtime, 64%) perceived that they were moving forward in SOC. Sixteen percent of participants reported intakes that included more than five servings a day at baseline and 12-month intake less than five servings among participants in this group, 43% perceived no change across SOC. Lastly, 21% of subjects increased their intake to more than five with approximately 95% of these participants perceiving either no movement or forward movement through SOC. Mean change in fruit and vegetable intalce among the total analytical cohort was reduced over time and inversely associated with stage movement. The overall mean difference of fruit and vegetable consumption across visits and SOC (when grouping together all stages of change within each perceived movement) was only significant from 6-month to 12-month where the average difference of those participants that identified themselves as moving forward in the SOC had a significant increase of 1.18 servings a day {P = 0.0081) as compared to that of participants moving backward (- 0.76) or those not moving (-0.16) through stages (data not presented). While not statistically significant participants that perceived themselves as moving forward in stage were slightly increasing their intake of fruit and vegetables servings (0.34), while participants that perceived no movement (-0.54), or backward movement (-0.97), in SOC were eating significantly less fruits and vegetables {P = 0.036) particularly those participants from baseline to the 12-month follow-up that considered their stage movement as going backward (after controlling for visits and baseline fruit and vegetable consumption). 256 Discussion The first objective of the present study was to measure fruit and vegetable consumption and compare it to several sociodemographic factors and SOC. Older women, non-smokers those with lower BMIs, and at the highest SOC were eating significantly higher amounts of fruit and vegetables throughout visits. Self-efficacy, encouragement and support among participants were at a high point and no difference was seen at follow-up visits. At baseline PC/C represented the largest group among the SOC, suggesting that a large part of the adult population either did not recognize the need to increase their intake of fruit and vegetable, or were resistant, or yet were not conscious. Participant reported stage change but, for the most part, no positive intake changes were noted. We addressed the movement between stages and its capacity to predict change in the consumption of fruit and vegetables. The majority of the WISE WOMAN participants identified their stage as moving forward from PC/C and Preparation to higher SOC. At both follow-up visits more than 50% of the participants were represented in the higher SOC, yet in most cases their behavior was not representative of their stage, similar results have been demonstrated in previous diet, smoking, and exercise adoption research [25]. Substantial discrepancy was noted between the self-reported and actual diet, as has been demonstrated in other reports [34]. At baseline participants were more likely to report a SOC that was highly correlated with reported intake than at follow-up visits. In this study staging somewhat predicted change in fruit and vegetable consumption but not to the degree of the outcome expected. Apparently participants' self-ratings of diet were the foundation of wrong SOC classification, opposite to other studies which were more likely to have participants correctly self-rating their diets, particularly at higher SOC [25, 26], Participants that were eating less than 5 a day at baseline, and at 6 month and 12-month follow-up visits demonstrated a slight non significant increase in their finit and vegetable consumption, particularly those participants that were identified as not moving or moving forward in the SOC and were at A/M stage in all time points. Positive direction of the promoted behavior seen may indicate that even though the participants' perception of their staging was, more often than not. wrong, participants were consciously increasing their intake. Participants that increased their intake from less to more than five servings of fiuit and vegetable a day were more likely to correctly classify and move forward in the stage of change as compared to participants staged in lower levels of SOC who decreased their intake of fruits and vegetables through time [25, 26]. Contrary to other studies, dietary intake was related to stage at baseline further more than at other follow-up visits [7, 25, 26]. These findings may suggest that intention to take action to increase fruit and vegetable consumption and/or increase awareness was playing a key role in participant 25? perceptioB and self-rated score of their finit and vegetable SOC. Also we caanot rale out the possibility of inflation in the proportion of A/M stage due to the over-reporting of socially desirable behavior [35]. Individuals' ability to relate dietary intake can be affected by the level of education relative to the diet i.e. amounts of servings and what a serving represents. WISEWOMAN personnel described what a serving represented; yet, participants might still believe that their diets were high in fhiit and vegetables without truly understanding the fruit and vegetables serving concept. These findings may suggest that interventions should focus on strategies not only to accelerate readiness to change or behavior change but also on strategies that confirm comprehension of health awareness messages [16, 36]. Moreover, this study design did not provide feedback based on 24-hour recalls, feedback provided was based on self- rated diet. These results may propose that notifying, acknowledging, and making participants aware of their true liuit and vegetable intake may had possibly helped our capability to improve participants' diet behavior. Even though this was not a stage-based intervention, erroneous self- classification of SOC will lead to inappropriate stages of behavior intervention. The nutrient/food intake approach to categorize intervention participants in different stages of change has demonstrated to be superior yet, small and continuous serving changes during a pre-detemiined time period, may not be seen and methodological suggestions might be complicated [7]. In previous studies food-based algorithms which allowed participants to understand the goal behavior, have resulted in accurate stage classification [37, 38], our study showed differently. Appropriate proxies, algorithm equations, and guidelines should be developed and utilized when using SOC constructs in this population in order to design, deliver, and even later accurately evaluate dietary intervention. It has been previously stated that people are not likely to take action in six months; most certainly an 18 month intervention with a longer SOC algorithm where a perceivcd and actual diet classification of stages are compared might be particularly helpful in this population [7, 12, 24]. Our short scale for measuring self-efficacy demonstrated no difference between participants. Most fe!t able and had a positive attitude regarding eating more fhiit and vegetables, therefore we were not able to use this scale as predictor of increased fruit and vegetable consumption, contrary to other reports [39, 40], This study had several limitations our small sample size needs additional research. The limitations of the 24- liour diet recall include error in recall, poor estimation of serving sizes, cognitive aspects of dietary recall, while the fact that we had various recalls per participant strengthen our ability to assess correlations with other variables. Using a behavioral marker to clarify stage classification may aid in the application of the SOC model for intakes of fruit and vegetable. Also measurement, and correlations of barriers to fruit and vegetable consumption such as cost, taste, availability, and predilection of foods may help in the prediction of our associations and staging capability. However, future research can benefit from more extensive consideration of SOC in this population. 258 The design of this study did not provide for a SOC based inten/'ention nevertiieless our results indicate that it would have benefited to a great extent from such approach. Our interventions included a wide range of components that targeted dietary changes appropriate for people at all stages of behavior change, yet the SOC model was not included as no validation study on the use of SOC model on this particular population was found when this study was proposed. Initial perceived stages for the most part match assessed stage and given that participants followed and match their increased perceptions indicates that this model may work in this population. Constructs that include participants' thoughts and perceptions through a self-rated diet together with dietary intake measure, followed by personalized feedback to help raise awareness and motivate change possibly will be the most helpful tool to move this population through the SOC. To conclude, our findings provide unique prehminary findings on the categorization of SOC on the general perceived notion of change in fruit and vegetable consumption and actual intake practice in a female, uninsured, lower educated, with a lower income, predominantly Mcxican American population. There continues to be a need to find ways to more successfully encourage people to move forward through the stages of change and in fact improve behavior. Prospective designs that apply the proposed model and focus on the benefits of consuming adequate servings of fruit and vegetables to a similar population will provide useful information about aiming dietary changes. Table 1. WISE WOMAN participants that returned to all three visits their sociodemographics, perceived and 24-hour recall fruit and vegetable consumption and self-efficacy at baseline by ethnicity. Total Mexican American non-Hispanic white N Mean SD N Mean SD N Mean SD p value Age, y 130 56.9 4.5 92 57.1 4.5 38 56.5 4.6 0.44 Education, y 128 9.1 3.8 90 7.5 3.2 38 12.9 1.9 0.00 Income, $ 128 9858.1 4335.3 91 9860.2 4727.0 37 9852.8 3231.7 0.99 Household Number 127 2.3 1.4 89 2.6 1.5 38 1.6 0.7 0.00 Self-Efficacy 130 4.62 0.55 92 4.64 0.42 38 4.56 0.78 0.47 24-hour recall fruit and vegetables* 130 4.05 3.30 92 3.81 2.66 38 4.62 4.48 0.21 Self-perceived intake of fruit and vegetable* 130 3.26 2.48 92 2.88 1.34 38 4.21 3.99 0.01 *24-hmi7rcl^raiTd"sW-pcrc"eiv"ed intake ot truits and vegetables a day (corr 0752, p<0.0()l) K3 260 Table 2. Stages ofChange, Fruit and Vegetable consumption, and diet related variables of WISEWOMAN participants at Baselme. Prevalence >5 a Day N % Mean Median SD p values^ Socsodeinographics Factors Age 50-59 S9 22 3.62 2.92 2.53 60+ 41 32 4,97 3.79 4.44 0.022 Educatioii 0-3 44 27 4,02 2.9 3.03 4Ai 40 20 3.91 3.53 2.49 • 12+ 44 27 4.32 3.43 4.18 0.963 income <$4,999 20 25 3,86 3.45 2.7 S5000-9,999 53 26 3,84 3.18 2.75 >510,000 57 25 4,34 3.0i 3.94 0.727 Marital Status Married/Cohabitating 66 27 4.29 3.01 3.8 Siiigle/Divorced/Separat ed 44 21 3.62 3.5 2.29 Widowed 15 33 4.64 3.47 3.S5 0.445 Househoid Members 1 39 21 3.97 3.41 3.07 2-4 79 28 4.14 3.14 3.51 5+ 9 22 4.07 2.9 3 0.973 Employed Yes 46 22 ^ 4.42 3.23 4.57 No 84 26 3.S4 3.16 2.34 0.694 Curreet Smoker*' Yes IS n 2.97 2.46 2.27 No 112 26 4.22 3.44 3.41 0.05! High BMI Yes 99 23 3.77 3.14 2.4 No 30 33 5.2] 3.42 5.25 0.060 Ethnicity Mexican American 92 21 3.81 3.12 2.66 non-Hispanic white 3S 34 4.62 3.54 4.48 0,350 • Psycbosociai Factors Encouragejnent Yes 103 23 4.1 3.28 3.44 No 26 3! 3.S6 2.9 i 2.78 0.680 Support Yes 102 25 4.05 3.27 3.27 No 27 26 4.08 3.04 3.51 0.S74 FV will be good you? Yes 128 26 4.08 3.16 3.34 No ------FV make you fee! better? Yes 124 26 4.1 3.22 3.36 No 1 3.14 3.14 0 - Trying to lose weight? Yes 85 25 4.12 3-14 3.47 No 45 24 3.91 3.iS 2.97 0.756 Maintain weiglit? Yes 35 23 3.8 2.89 3.11 No iO 30 4.31 3.55 2.54 0.505 Stages of Change" PC/C 68 15 3.24 2.9 1.82 Preparation 39 26 3.S6 3.IS 2.66 A/M 23 52 6.74 5.08 5.64 0.002 FV=fruit and vegetables PC=?recoiiteraplation; C=CoiiiempIarion; A==Action; M=Maintefiance ''x~ =13.0, p< 0.001 ^Regression niodei adjusted for age, ethiucity, education, iiicoiiie, smoking, aiid marital .status. Table 3. WISEWOMAN fruit and vegetable consumption least square means and its relationship to visits, and perceived stage of change levels over time using repeat measures. Estimate of Fruit & Vegetable Effect Intake Error Pr>F HMO?- Baseline 1.985 0.092 6-month follow up 1.553 0.131 12-month follow up 1.629 0.134 Stages of Change 0.0002 PC/C 1.448 0.135 Preparation 1.716 0.120 A/M 2.004 0.114 '^ontroIEri^or smo^EiigrBMIT^ucation, arid"age 262 Table 4. WISEWOMAN fruit and vegetable consumption differences of least squares mean its relationsliip to visits and perceived stages of change using repeated measures.^ Estimate Error Pr > PC/C vs Preparation Baseline -0.108 0.130 0.407 6-months -0.191 0.264 0.470 12-months -0.504 0.276 0.070 PC/C vs A/M Baseline -0.582 0.152 0.000 6-months -0.496 0.243 0.043 12-months -0.589 0.238 0.014 Preparation vs A/M Baseline -0.475 0.165 0.004 6-months -0.305 0.203 0.134 12-months -0.085 0.217 0.694 PC/C 1 0.430 0.218 0.050 2 0.059 0.280 0.833 3 0.490 0.216 0.025 Preparation 1 0.347 0.194 0.076 2 -0.253 0.235 0.284 3 0.094 0.213 0.660 A/M 1 0.517 0.173 0.003 2 -0.034 0.152 0.825 3 0.483 0.172 0.006 PC/C vs Preparation 1 0.239 0.177 0.179 2 -0.444 0.27! 0.104 3 -0.014 0.196 0.943 PC/C vs A/M 1 -0.066 0.142 0.644 2 -0.530 0.236 0.027 3 -0.099 0.138 0.473 Preparation vs A/M. 1 0.042 0.159 0.792 2 -0.339 0.192 0.080 3 0.008 0.156 0.957 'Adjusted values for smoking and education 'Baseline vs. 6-month ^6-month vs. 12-month ^Baseline vs. 12-nionth PC=Precontemplation; C=Contemplation; A=Action; M=MaintenaBce ^Controlling for smoking, BMI, education, and age Table 5. 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In Press Journal of Women Health 2003. 31. Behavioral Measurement Shared Service. http://www.azcc.arizona.edu/laboratoi'y/l nieasurements.htm 2004 32. U.S. Department of Agriculture UDoHaHS: Dietary Guidelines for Americans. In., 5th edn; 2000. 33. Littell RC, Milliken GA, Stroup WW, Wolfinger RD: SAS system for mixed models. Gary, N.C.: SAS Institute Inc.; 1996. 34. Glaoz K, van Assema P: Are awareness of dietary fat intake and actual fat consumption associated? A Dutch-American comparison. Eur J Clin Nutr 1997, 51(51);542-547. 35. Kristal AR, Andrilla CH, Koepscll TD, Diehr PH, Cheadle A: Dietary assessment instruments are susceptible to intervention-associated response set bias. J Am Diet Assoc 1998, 98(I):40-43. 36. Glanz K, Kristal AR, Tilley BC, Hirst K: Psychosocial correlates of healthful diets among male auto workers. Cancer Epidemiol Biomarkers Prev 1998, 7(2): 119-126. 37. Ling AM, Horwath C; Defining and measuring stages of change for dietary behaviors: readiness to meet fruit, vegetable, and grain guidelines among Chinese Singaporeans. Journal of the American Dietetic Association 2000. 100(8):898-904. 38. Gulliver P, Horwath C: Women's readiness to follow milk product consumption recommendations; design and evaluation of a 'stage of change' algorithm. J Hum Nutr Diet 2001, 14(4):277-286. 39. Havas S, Heimendinger J, Reynolds K, Baranowski T, Nicklas TA, Bishop D, Duller D, Sorensen G, Beresford SA. Cowan A: 5 a day for better health: a new research initiative. Journal of the American Dietetic Association 1994, 94(1):32- 36. 40. Li R, Serdula M, Bland S, Mokdad A, Bowman B, Nelson D: Trends in fruit and vegetable consumption among adults in 16 U.S. states; Behavioral Risk Factor Surveillance System, 1990-1996. Am J Public Health 2000, 90(5);777-781. APPENDIX D: SUPPLEMENTAL TABLES Table D.l. Demographic characteristics of older AZ WISEWOMAN participants compared to NHANESIII participants with similar demographic characteristics by ethnicity. AZ WISEWOMAN NHANES III Mexican Non-Hispanic Mexican Non-Hispanic All All Characteristic Americans White Americans White N 361 260 88 266 138 54 Mean (SE) Mean age(years) 57.5(0.3) 57.6(0.3) 57.3(0.5) 57(1.1) 57.6(5.3) 57.3(1.0) Mean IncoiTie($) 9,755.3(277.8)'' 9,806.6(344.4)'' 9,972.8(467.0) 11,939,5(547.8) 13,210,5(970.4) 11,664.9(999.3) Mean years of education^ 9.3(0.2) 7,8(0.2)'' 13.2(0.2)'' 9.2(0.4) 5.7(0.5) 10.5(0.5) Family size (mean no. of 2.5(0.1) 2.9(0.1)'' 1.5 (0.1)'' 3 (0.2) 4.2 (0.3) 2.5 (0.2) persons)" Mean BMI (wt/m^) 29.5(0.3) 29.7(0.3) 29.3(0.8) 28.5(0.6) 28.9(0.5) 27.7(0.7) Mean systolic blood 124.8(0.9)'' 125.5(1.1) 122.4(1.7)" 135,3(2.4) 144.2(8.1) 133(3.2) pressure, mm Hg Mean diastolic blood 74.0(0.5)'' 76.3(0.6) 69.7(0.9) 80.9(1.2) 90.0(8.4) 80.6(1.5) pressure, mm Hg" The Student's t test was used for AZ WISEWOMAN data and NHANES equivalent test was used to determine ethnic differences in mean values between ethnic groups from each study. 'AZ WISEWOMAN & NHANES III within ethnic groups (t Test, P<.0001). 'Difference between both studies confidence intervals for each of the variables. If any of the upper or higher limits was within the range of the other study confidence interval's no difference was highlighted. K) On •<1 Table D.2. AZ WISEWOMAN participants compared to NHANESIII participants by ethnicity®. AZ WISEWOMAN NHANES III Mexica Non- Mexica Non- Characteristic 11 Hispani n Hispani All All Americ e Americ c ans White ans White N 361 260 88 262 138 54 -%- Married participants'"'' 43.2 50.4 27.3 46.6 54.0 47.0 BMI > 25" 77.3 80.4 68.2 63.9 74.5 66.7 High glucose levels* 15.2 15.8 13.6 17.8 23.0 7.4 High Cholesterol levels'"' 26.3 28.1 19.3 39.8 35.8 45.0 Take vitamins & minerals 48.8 49.4 47.7 35.7 37.7 35.2 Smoke 13.6 12.0 15.9 25.2 22.5 31.5 Percentages may not sum to 100% because rounding or missing data The Chi square test, P<0.05 was used to determine ethnic differences in categorical distribution of characteristics within each study. "AZ WISEWOMAN / /-Test 'Shanes in equivalent /-Test "These results are based on AZ WISEWOMAN laboratory values of glucose serum levels higher or equal to 110 nig/dL and cholesterol levels higher or equal to 240 mg/dL while for NHANES participants these values were self-reported. K) On OO Table D.3. Mean Dietary Intake of macronutiients, by ethnicity in AZ WISEWOMAN and NHANES III.' WISEWOMAN NHANES 111 Mexican Non-Hispanic Mexican Non-Hispanic All All Americans White Americans White RBA, AI' N=361 N=260 N=88 N=266 N=138 N=54 Macronutrients or AMDR^ Mean (SE) Mean (SE) Energy, k/caf*''= 1900 1322 (19.3) 1306 (31.9) 1444 (47.3) 1568 (75.6) 1569 (96.3) 1563 (112.8) Total fat, g 60 47 (0.9) 46.9(1.6) 50.9 (2.2) 58.9 (4.3) 54.8 (3.2) 62.8 (6.8) Total carbohydrate, g** 250 176 (2.9) 171.4(4.2) 192.3 (7.9) 198.2 (8.8) 204.4(15.8) 186.6(12.0) Total protein, g** 50 55.2 (0.9) 55.6(1.6) 60.7 (2.2) 60.3 (2.8) 65.8 (4.7) 59.6 (3.7) Animal protein, g* .. 36(0.8) 36.6(1.3) 39.1 (1.9) 40.3 (2.6) 42.7 (3.6) 41.2 (3.4) Vegetable protein, g*""" - 19(0.4) 18.7(0.6) 21.2(1.1) 19.3 (1.0) 22.6 (2.5) 17.4(1.2) Alcoho], g"*' - 0.5 (0.1) 0.3 (0.1) 0.9 (0.3) 3.5 (1.2) 2.5(1.1) 5.2(1.9) Cholesterol, mg 300 202.3 (5.5) 210.8(8.2) 183.1 (12.8) 224.6 (19.7) 226.3 (15.2) 238.6 (33.3) Total SFA.g' 20 or less 16(0.4) 16.3 (0.7) 16.3 (0.8) 19.6(1.3) 19.2(1.5) 21 (2.0) Total MUPA, g*' ~ 17.8(0.4) 17.7(0.6) 19.7(0.9) 22.8(1.8) 19.6(1.0) 24.5(2.9) Total PUFA, -• 8.9(0.2) 8.7(0.3) 10.7(0.6) 11.8(1.2) 11.4(0.9) 12.4(2.1) Total Dietary Fiber, g (20-25) 16.0(0.3) 16.0(0.5) 16.7(0.8) 14.4(0.6) 18.1(2.2) 13.5(1.0) Soluble Dietary Fiber, g 5.2(0.1) 5.2(0.2) 5.6(0.3) 5.0(0.2) 5.8(0.7) 4.7(0.3) Insoluble Dietary Fiber, g - 10.6(0.2) 10.6(0.3) 11.0(0.6) 9.3(0.4) 12.0(1.6) 8.7(0.7) % of calories as fat* (20-35%) 30.7(0.4) 32.3(0.5) 31.2(0.9) 29.0(1.5) 27.9(1.2) 29.0(2.4) % of calories as carbohydrate 54.3(0.4) 52.5(0.7) 53.3(1.1) 44.1(1.9) 45.8(2.9) 39.5(2.2) (45-65%) % of calories as protein (10-35%) 17.0(0.2) 17.0(0.3) 16.8(0.4) 13.3(0.5) 14.8(0.8) 12.3(0.5) 0.2(0.0) 0.2(0.0) 0.4(0.2) 1.2(0.5) 0.9(0.4) 1.9(0.7) % of calories as alcohol*" — SFA= Saturated fatty acids, MlIFA=Monounsaturated fatty acids, PUFA=Polyunsatiirated fatty acids 'Adapted fi-om DRl reports for women older than 51 years. Recommended Dietary Allowance (RDAs) are in bold type and Adequate intake (AIs) are in ordinary type followed by an asterisk (*).(93, 95, 99) ^Acceptable Macronutrient Distribution Ranges (AMDRs) are underlined for intakes of carbohydrates, proteins, and fats expressed as % of calories. WISEWOMAN ethnic differences 'p<0.05, ™p<0.01, ***p<0.001 NHANES ethnic differences '^p<0.05, '^^p^O.OI, ^'"^pi^O.OOl "Difference in both studies Confidence Intei'vais for Mexican Americans. 'Difference in both studies Confidence Intervals for non-Hispanic whites. 'Total Difference in both studies Confidence Intervals. "Averages reported are crude meaning that these are not adjusted for the different age distribution of these populations. ISJ a\vo Table D.4. Mean dietary Intake of micronutrients by ethnicity for women participating in WISEWOMAN and NHANES III. * WISEWOIVIAN NHANES III Mexican Non-Hispanic Mexican Non-Hispanic All Americans White All Americans White N=361 N=260 N=88 N=266 N=138 N=54 RDA or Micronutrients" \V Mean (SE) Mean (SE) Total vitamin A, lU 2330 6509.1 (273.4) 6587.7(378.1) 7174.9(638.4) 6152.8(722.2) 5266.0(570,2) 5137.3(938,6) Thiamin, mg*** 1.1 1.2(0.0) 1.1(0.0) 1.3(0,1) 1.2(0.1) 1.3(0.1) 1.2(0.1) Riboflavin, tng*** 1.1 1,3(0.0) 1.3(0.0) 1.5(0.1) 1.4(0.1) 1.5(0.1) 1.5(0.1) Niacin, mg*** 14 15.5(0.3) 15.4(0.5) 18.1(0.8) 17.1(0.7) 16.3(1.0) 17.7(1.0) Vitamin Bj, mg 1.5 1.5(0.0) 1,6(0,1) 1.6(0.1) 1.4(0.1) 1.4(0.1) 1.4(0.1) Vitamin B^, meg 2.4 3.3(0.2) 3,4(0.3) 3.5(0.5) 3.8(0.5) 3.3(0.4) 3.9(0.5) Folate, meg 400 231.8(5.6) 232,4(9,5) 256.9(15.2) 219.5(13.5) 263.1(33.8) 210.5(20.9) Pantothenic acid, mg ' 5* 3.5(0.1) 3.6(0.2) 4.0(0.2) 3.6(0.2) 3.7(0.2) 3.6(0.3) Vitamin C, mg 75 105.4(3,2) 101.8(4.3) 112,0(7.6) 69.1(10.6) 92.6(11.5) 65.0(18,2) Vitamin D, meg'' 15' 3.1(0.1) 3.2(0.2) 3,6(0.3) 4.7(0.8) 3.5(0.4) 6.1(1,4) Total Vitamin E, mg*'"'"'^ 15 6.0(0.2) 5.8(0,4) 7,5(0.5) 7.2(0.6) 5.9(0.5) 7.6(0.7) 'Adapted from DRI reports for women older than 51 years. Recommended Dietary Allowance (RDAs) are in bold type and Adequate intake (AIs) are in ordinary type followed by an asterisk (*) (93, 95, 96) "Averages reported are crude meaning that these are not adjusted for the different age distribution of these populations. WISEWOMAN ethnic differences "p^O.OS, **p<0.01, "^"piSO.OOI NHANES ethnic differences "pSO.OS, ""pSO.Ol, ""p<0.001 "No differences were seen in WISEWOMAN and NHANES III confidence intervals for both ethnic groups except for Vitamin C for all participants. ''Calciferol 'Total alpha-tocopherol equivalents to O-J Table D.5. Mean dietary intake of minerals by ethnicity for women participating in WISEWOMAN and NHANES III. WISEWOMAN NHANES III Mexican Non-Hispanic Mexican Non-Hispanic All Americans White All Americans White N=361 N=260 N=88 N=266 N=138 N=S4 RDA or Minerals Al' Mean (SK) Mean (SE) Calcium, mg 1200* 597.7(13.5) 600.2 (23.7) 668.7 (36.8) 581.0 (39.6) 721.0 (81.9) 605.3 (67.7) Potassium, mg*** 2000 2223.4 (37.6) 2185.8 (55.0) 2392.9 (88.7) 2187.6 (91.9) 2383.5 (128.7) 2249(150.1) Sodium, mg*** 2400 2262.6 (46.9) 2212.4(71.7) 2530.5 (108.7) 2465.3 (142.1) 2401.8 (150.3) 2327.0(195.4) Magnesium, mg*** 320 228.7 (4.2) 227.1 (6.1) 251.5 (11.1) 235.6(8.9) 260.2(18.7) 238.0(14.1) Phosphorus, mg** 700 890.7(15.9) 895.1 (26.3) 979.4 (40.8) 944.3 (41.5) 1107.3 (91.6) 928.0 (63.5) Iron, mg 8 11.4 (0.2) 11.3 (0.4) 12.7 (0.7) 11.3 (0.6) 11.5 (0.8) 11.2(1.1) Zinc, mg 8 7.8 (0.2) 7.8 (0.3) 8.7 (0.7) 8.4 (0.4) 8.8 (0.6) 8.3 (0.6) Copper, mg*** 0.9 1.0(0.0) 0.9 (0.0) 1.1(0.1) 1.0 (0.1) 1.0(0.1) 0.9(0.1) Selenium, meg***' 55 73.8(1.6) 72.3 (2.4) 87.7 (4.9) 89.7 (5.2) 84.5 (4.7) 93.0 (7.0) Caffeine, mg^ .. 131.1 (6.0) 121.3 (6.9) 149.8(15.1) 227.6 (27.5) 148.2 (21.1) 316.4(43.9) Water, mg***='= - 1956.6 (35.3) 1863.4 (51.5) 2057.4 (71.4) 1611.8(67.0) 1524.7 (37.2) 1735.0(99.9) 'Adapted fi'om DRI reports for women older than 51 years. Recommended Dietary Allowance (RDAs) are in bold type and Adequate intake (AIs) are in ordinary type followed by an asterisk (*).(93, 95, 97) "Averages reported are crude meaning that these are not adjusted for the different age distiHbution of these populations, WISEWOMAN ethnic differences *p<0.05, "'pSO.Ol, *^''p<0.001 NHANES III ethnic differences ''p<0.05, '^''^p<0.01, '^'^'"pSO.OOl 'Difference in both studies Confidence Intervals for Mexican Americans. 'Difference in both studies Contidence Intervals for non-Hispanic whites. 'Total Difference in both studies Confidence Intervals Table D.6. Mean dietary intake of fruits, vegetables and legumes by ethnicity for women participating in AZ WISEWOMAN and NHANES III." AZ WISEWOMAN NHANES III Non- Mexican Non-Hispanic Mexican Hispanic All Americans White All Americans White Fruits, Vegetables & Dietary N=361 N=260 N=88 N=266 N=138 N=S4 Legumes Guidelines Mean (SE) Mean (SE) 2 servings Fruit servings a day each day 1.9 (0.1) 1.8(0.1) 1.9 (0.1) 1.3 (0.2) 1.4 (0.3) 1.3 (0.4) 3 servings Vegetable servings a day each day 1,7 (0.1) 1.6(0.1) 2.0 (0.2) 2.7 (0.2) 2.4 (0.2) 2.8 (0.3) Legume sei-vings a day"*" 0.3 (0.0) 0.3 (0.0) 0.2 (0.1) 0.3 (0.1) 0.8 (0.2) 0.1 (0.1) Fruits, vegetables, & legumes 5 servings servings a day each day 3.8(0.1) 3.8 (0.1) 4.0 (0.3) 4.3 (0.4) 4.6 (0.4) 4.2 (0.6) 'Adapted t'roni DRI reiKirts I'or women older than .'il ycare. Rccommciidcci Dietary Allowance (RDAs) are in bold lypc and Adequate imakc (.-\lsl are in orciinarv ly[H: followed by an asterisk (*) (92, 93, 95). '"Averages reported are crude meaning that these are not adjusted for the different age distribution of these populations. WISEWOMAN ethnic differences *p<0.05, *''p<0.01, "^pSO.OOl NHANES III ethnic differences '^pSO.OS, '"''p<0.01, ^'"^p<0.001 "Difference in both studies Confidence Intervals for Mexican Americans. ''Difference in both studies Confidence Intervals for non-Hispanic whites. 'Total Difference in both studies Confidence Intervals KJ