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Transl Behav Med. Sep 2011; 1(3): 416–426.
Published online Jan 12, 2011. doi:  10.1007/s13142-010-0011-1
PMCID: PMC3196590
Long-term outcomes from a multiple-risk-factor diabetes trial for Latinas: ¡Viva Bien!
Deborah J Toobert, Ph.D.,corresponding author Lisa A Strycker, M.A., Diane K King, Ph.D., Manuel Barrera, Jr., Ph.D., Diego Osuna, M.D., M.P.H., and Russell E Glasgow, Ph.D.
Oregon Research Institute, 1715 Franklin Blvd, Eugene, OR 97403-1983 USA
Institute for Health Research Address Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237-8066 USA
Psychology Department, Arizona State University, Box 871104, Tempe, AZ 85287-1104 USA
University of Colorado Health Sciences Center, Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237-8066 USA
Dissemination and Implementation Science, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd., Room 6144, Rockville, MD 20852 USA
Deborah J Toobert, Phone: +1-541-4842123, Fax: +1-541-4341502, deborah/at/
corresponding authorCorresponding author.
Latinas with type 2 diabetes are in need of culturally sensitive interventions to make recommended long-term lifestyle changes and reduce heart disease risk. To test the longer-term (24-month) effects of a previously successful, culturally adapted, multiple-health-behavior-change program, ¡Viva Bien!, 280 Latinas were randomly assigned to usual care or ¡Viva Bien!. Treatment included group meetings to promote a culturally adapted Mediterranean diet, physical activity, supportive resources, problem solving, stress-management practices, and smoking cessation. ¡Viva Bien! participants achieved and maintained some lifestyle improvements from baseline through 24 months, including significant improvements for psychosocial outcomes, fat intake, social–environmental support, body mass index, and hemoglobin A1c. Effects tended to diminish over time. The ¡Viva Bien! multiple-behavior program was effective in improving and maintaining some psychosocial, behavioral, and biological outcomes related to heart health across 24 months for Latinas with type 2 diabetes, a high-risk, underserved population ( number, NCT00233259).
Keywords: Latina, Diabetes, Multiple behavior change, Self-management, Randomized controlled trial
Latinas with type 2 diabetes are an underserved population at high risk for coronary heart disease. Hispanic Americans, the fastest-growing ethnic population in the USA—and particularly Hispanic women (Latinas)—have a greater prevalence of type 2 diabetes and more diabetes complications than Anglos [1]. By 2050, the Hispanic population will triple, and this population is among the least affluent of US ethnic groups. Disparities in the distribution of health and health care in North America are largely attributable to race/ethnicity and socioeconomic status [2, 3], and their effects on the social determinants of health and health-related behaviors places low-income Latinas at greater risk for chronic diseases such as diabetes [4, 5]. Mexican-American adults are twice as likely as non-Hispanic whites to be diagnosed with diabetes [6]. Studies controlling for social economic status find reduced disparities for some health outcomes, but not for diabetes in Latinos [7, 8]. Emerging public health models advocate an appropriate response to diabetes disparities in health care, such as delivering culturally sensitive diabetes interventions [9].
The ¡Viva Bien! study was a multiple-behavior, coronary-heart-disease-risk-factor intervention designed for Latinas with type 2 diabetes. Prior research has identified the heart health benefits of “Mediterranean Diet”-style eating practices [10], being physically active [1116], managing stress [1719], and utilizing social–environmental support to initiate and sustain health-supporting behaviors [2024]. Most US adults, including Latinas, engage in multiple risk behaviors [25], but multiple-risk-factor intervention studies are rare [2628]. Studies investigating maintenance of multiple health behaviors are expensive, complicated, and infrequently reported. Yet, for individuals with type 2 diabetes, sustaining multiple healthful behaviors over a lifetime is critical for improving risk factors [29] and avoiding adverse consequences of illness progression, such as coronary heart disease [30].
Practical strategies and theoretical mechanisms for sustaining health behaviors over longer periods are not well established or understood. Just as medication for chronic illnesses generally is prescribed for long periods and may require periodic changes and dose adjustments to retain efficacy, health-behavior interventions may require long active treatment and similar dose adjustments to retain effects [31, 32]. Of the maintenance studies available, there is clear evidence that few improvements are sustained long-term [3337], and this research area is characterized by conflicting findings [15, 38, 39].
The purpose of this paper is to advance scientific knowledge and improve clinical practice regarding the long-term effects of multiple-behavior-change programs in an underserved and high-risk Latina population. The study documents the extent to which the ¡Viva Bien! intervention helped Latinas with type 2 diabetes make simultaneous changes in psychosocial factors and multiple lifestyle behaviors that were hypothesized to result in improved biologic and quality of life outcomes from baseline to 24 months.
Study Design
The ¡Viva Bien! program was a cultural adaptation and evaluation of an established, evidence-based lifestyle change program for an underserved population at high risk for heart disease: Latinas with type 2 diabetes [40]. Specific cultural adaptations are described in the appendix. The efficacy of this program was demonstrated previously in mostly non-Hispanic white women [41, 42]. The adaptation of ¡Viva Bien! addressed sociocultural, economic, and environmental contexts important for Latinas [40].
Patients were recruited from nine Kaiser Permanente clinics in the Denver, Colorado, metropolitan area, and one large community health center, the Salud Family Health Center, in Commerce City near Denver. Kaiser Permanente is a managed-care organization that serves about 450,000 patients in the Denver metropolitan area, about 17% of whom are Latino. Salud is a community health center that provides comprehensive primary health services to low-income patients. About 65% of Salud's patients are Latinos whose primary language is Spanish.
Inclusion criteria were self-identified Latina ethnicity, 30–75 years of age, diagnosis of type 2 diabetes for at least 6 months identified by electronic medical record codes and using the Welborn criteria [43], living independently, having a telephone, and the ability to read in either English or Spanish. Exclusion criteria included being on an insulin pump, being developmentally disabled, or having end-stage renal disease. Participants were recruited [44; Fig. 1) in four waves, with roughly one fourth of the sample participating in each wave.
Fig. 1
Fig. 1
CONSORT diagram of ¡Viva Bien! study participation
Letters in English and Spanish, signed by the project's Latino physician, were mailed to potential participants, along with self-addressed stamped postcards that could be returned to decline further contact or request information. Women who did not return postcards were telephoned by bilingual project recruiters, who described the program, confirmed eligibility, and invited qualified candidates to participate. Those who agreed were scheduled for baseline assessments. Those in the usual care condition received $25 gift cards for assessment completion; those in ¡Viva Bien! received the intervention at no cost to them and were not paid for assessment completion or for their time in the study.
Research procedures followed were approved by the Kaiser Permanente Denver, Colorado, and Oregon Research Institute institutional review boards, and were in accordance with the Helsinki Declaration of 1975, as revised in 2000. All participants gave written informed consent. Data were collected from 2006 through 2009 and analyzed for this report in 2010.
Treatment Protocol
Participants who completed baseline assessments (N = 280) were randomized to enhanced usual diabetes care or to the ¡Viva Bien! intervention. The ¡Viva Bien! program included a 2½-day retreat followed by meetings that were weekly for the first 6 months, semi-monthly for months 6–12, monthly for months 12–18, and bi-monthly for months 18–24. The program encouraged participants to (a) follow the Mediterranean diet adapted for Latino nationality subgroups, (b) practice stress-management techniques daily, (c) engage in 30 min of daily physical activity, (d) stop smoking, and (e) participate in problem-solving-based support groups. The purpose of the retreat was to introduce the program and practice new skills. The intervention continued with 4-h facilitator-led meetings, providing 1 h each of instruction and practice of the above components except for smoking, which was addressed individually due to the small number of smokers. The usual medical care condition at Kaiser Permanente Denver, Colorado, consisted of management of complications associated with diabetes, monitoring of other health factors, and specified frequencies of laboratory assays and specialty exams in compliance with the American Diabetes Association standards of care. The enhancement included a choice of one free Kaiser-Permanente Denver, Colorado class covering the areas targeted in ¡Viva Bien!.
Assessments were conducted at baseline and at 6, 12, and 24 months for all participants. The abbreviated form of the ARSMA-II [45] was used to measure bidirectional acculturation. In addition, questions about participant nativity and nativity of parents were asked to determine generational status. Problem-solving ability was assessed using the Diabetes Problem-Solving Interview [46]. Self-efficacy was measured with the Confidence in Overcoming Challenges to Self-Care instrument [47]. Social support was assessed using the UCLA Social Support Inventory [48]. The semi-quantitative food frequency questionnaire [49] was used to document percent of calories from saturated fat. Stress-management practice was assessed using a self-monitoring log to track daily minutes of yoga stretches, breathing exercises, progressive relaxation, and meditation and visualization. The stress-management practice score was the summed minutes across 7 days of these activities (square-root transformed for analyses) [41]. The Modified International Physical Activity Questionnaire was used to calculate the number of days per week participants engaged in exercise [50]. This measure has been previously validated [50] and in the present study correlated 0.34 (p = 0.007) at baseline in a subset of participants (n = 60) wearing ActiGraph (MTI Health Services) accelerometers for 7 days. The Brief Chronic Illness Resources Survey [51] provided frequencies of an individual's perceived social–environmental support for disease management. Measures of height and weight were taken on a sensitive digital scale (Detecto Electronics). Hemoglobin A1c assays were performed at the Kaiser Permanente Denver, Colorado Regional Reference Laboratory in Aurora, CO, and measured on a Bio-Rad Variant II Turbo liquid by high-pressure liquid chromatography. Ten-year coronary heart disease risk was assessed using the United Kingdom Prospective Diabetes Study logistic equation [52]. Hemoglobin A1c values and the coronary heart disease 10-year risk score were square-root transformed for analyses.
Descriptive analyses were used to determine whether transformations were needed. Chi-square or t tests were used to evaluate differences in participant characteristics between the two treatment conditions and between dropouts and those who completed the study at 24 months.
Long-term effects
Generalized estimating equations models [53] were used to compare long-term treatment effects on outcome measures from baseline to 24 months. Models were specified using a first-order autoregressive correlation structure, and separate models were conducted to examine treatment group interactions with both linear and quadratic trends. Linear-trend results are presented here, as model results were similar for linear and quadratic trends.
Wave was covaried in all analyses, as was age, which was found in univariate correlational analyses to be significantly associated with outcomes at baseline. Effect sizes (d) were calculated on the difference between the two treatment conditions at all follow-up time points.
Missing data
Mean percent (averaged across ten measures) of total observations missing at each assessment point were as follows: 10% usual care vs. 9% ¡Viva Bien! at baseline; 25% usual care vs. 27% ¡Viva Bien! at 6 months; 32% usual care vs. 39% ¡Viva Bien! at 12 months; and 39% usual care vs. 43% ¡Viva Bien! at 24 months. Generalized estimating equations analyses were performed two ways. First, a complete-case approach was used, in which participants with missing follow-up data on the outcome variable of interest were excluded from the analysis. Identical analyses were conducted after missing data were imputed using multiple imputation procedures via the expectation-maximization algorithm with NORM software [54]. The results were similar; therefore, only intent-to-treat (imputed) results are presented in the tables (with superscripts indicating differences from complete-case results).
Statistical analyses were performed using SPSS 12.0 (SPSS Inc., Chicago, IL).
Recruitment results have been reported previously [44]. The study recruited a diverse, relatively high-risk sample of Latina women (N = 280). About 51% of those confirmed eligible agreed to participate.
Participant characteristics are presented in Table 1. On average, participants were about 57 years of age, had been diagnosed with diabetes for almost 10 years, were obese, and had a baseline hemoglobin A1c level greater than 8. Approximately two thirds reported an annual family income of less than $50,000. The recruited sample varied by acculturation, with 40.8% mostly Anglo-oriented, 24.3% somewhat Anglo-oriented, 17.6% mixed Latino-and-Anglo-oriented, 4.8% somewhat Latino-oriented, and 12.5% mostly Latino-oriented [40]. Sixteen percent preferred Spanish to English, and health literacy scores were considerably lower than in our prior primary care-based diabetes projects. Most participants were born in the USA (79.6%) or Mexico (15.8%), with one to two women each reporting their birth country as El Salvador, France, Morocco, Brazil, Peru, Panama, Cuba, Puerto Rico, Guatemala, or Honduras. The participants' parents were also born primarily in the USA (mother = 72.1%; father = 69.8%) and Mexico (mother = 21.6%; father = 23.7%), with small percentages in many other European, Asian, and Latin American countries. Acculturation level was not significantly associated with outcomes at baseline. Despite randomization, there were significant baseline differences between conditions on age, body mass index, and years diagnosed with diabetes (which significantly correlated with age). Usual care participants were older, had diabetes longer, and had lower body mass index than ¡Viva Bien! participants.
Table 1
Table 1
Baseline characteristics of participants by treatment condition
Attendance at ¡Viva Bien! sessions varied. Weekly meeting attendance during the first 6 months averaged 65%, declined to 48% for meetings between 6 and 12 months, and averaged 46% for meetings between 12 and 24 months.
Attrition rates were 22.5% at 6 months, 30.0% at 12 months, and 38.6% at 24 months, with no significant differences between treatment conditions in attrition at any time point.
Relative to dropouts, study completers were older (mean years at baseline = 59.0 years [SD = 8.9] vs. 54.1 [SD = 11.1]; t(189) = 3.76, p < .001), had higher health literacy (mean score at baseline = 4.4 [SD = 0.8] vs. 4.1 [SD = 0.9]; t(196) = 2.65, p = .009), had higher numeracy scores (mean score at baseline = 3.7 [SD = 1.2] vs. 3.4 [SD = 1.2]; t(217) = 2.21, p = .028), had a lower prevalence of smoking (7.1% vs. 17.0%; χ2(1) = 6.6, p = .01), and had a lower proportion of taking insulin (24.0% vs. 41.0%; χ2(1) = 9.2, p = .01). Dropouts and completers did not differ significantly on body mass index, years diagnosed with diabetes, income, education, language preference, or acculturation.
Psychosocial Outcomes
There were large and consistent differences between conditions on improvement in the psychosocial variables hypothesized to be influenced by the intervention (Table 2). The ¡Viva Bien! condition improved considerably more than the usual care condition by the 6-month follow-up on measures of problem solving, self-efficacy, and perceived supportive resources. Gains were essentially maintained at 12- and 24-month follow-ups, with 24-month follow-up effect sizes ranging from no effect for self-efficacy to 0.75 for problem solving and perceived support.
Table 2
Table 2
Psychosocial outcomes at 6, 12, and 24 months (estimated means and SEs [n = 280])
Behavior Change
Between-condition effects were found across 24 months on two of the targeted behavioral outcomes (Table 3): percent calories from saturated fat and engagement in social–environmental support activities. Effect sizes ranged from 0.04 (for physical activity) to 0.33 (for percent calories from saturated fat) at the 24-month follow-up. The ¡Viva Bien! participants did not maintain their initial 6-month significant improvements relative to the usual care condition on practice of stress management. For physical activity, initial 6-month significant improvements relative to usual care also were not maintained, in part because the usual care condition improved on this outcome.
Table 3
Table 3
Behavioral outcomes at 6, 12, and 24 months (estimated means and SEs [n = 280])
Biological Outcomes
Biological outcomes across 24 months were inconsistent (Table 4). The ¡Viva Bien! condition improved significantly more than the usual care condition on body mass index, but early improvement in hemoglobin A1c was not maintained. Coronary heart disease risk as measured by the United Kingdom Prospective Diabetes Study logistic equation was not significantly improved. Biologic improvements generally decreased across the 2-year period.
Table 4
Table 4
Biological and quality of life outcomes at 6, 12, and 24 months (estimated means and SEs [n = 280])
There is a paucity of information on the long-term effects of multiple-risk-factor trials, especially in high-risk populations [15, 38]. The primary goal of this paper was to evaluate whether the effects of a multiple-behavior-change program, ¡Viva Bien!, adapted for an underserved and high-risk Latina population, sustained improvements on targeted diabetes self-management, psychosocial variables, and biologic outcomes after the intervention faded.
The ¡Viva Bien! intervention was initially intense, with a 2½-day retreat followed by 6 months of weekly 4-h meetings, but the study was also designed to maximize participant reach and generalizability of the outcomes. Few exclusion criteria were employed, and patients were recruited from two different health systems. The intervention components were delivered by a mix of bilingual clinical staff and community professionals and were evaluated systematically for their appropriateness and appeal to Latina participants in focus groups, a review by Latino/a professionals, and pilot testing prior to the intervention trial [40]. Cultural appropriateness was assured by systematically giving participants opportunities to inform and influence intervention components to ensure cultural fit while maintaining fidelity to the original intervention. The finding that attrition rates were not associated with language preference or acculturation suggests that the program was culturally relevant to most Latinas in the sample.
While the 38.6% 24-month dropout rate was disappointing, attrition did not differ significantly by treatment condition or key participant characteristics, and attrition analyses indicated that those unavailable for the 24-month follow-up were generally similar to those who continued participation. Compared with our previous lifestyle-change study with mostly Anglo women [55], the Mediterranean Lifestyle Program (MLP), from which ¡Viva Bien! was adapted, program attendance was higher (65% for 0–6 months and 47% for 6–24 months in ¡Viva Bien! vs. 54% for 0–6 months and 31% for 6–24 months). The ¡Viva Bien! attendance rates are in line with those reported in similar studies with this population, such as those reported in a review of multifactorial lifestyle interventions to prevent chronic illness (diabetes and coronary heart disease) by Angermayr et al. [56]. All studies in the review contained a stress-management component. In eight of the studies that explicitly reported attendance rates, most reported that participants attended more than 60% of the scheduled sessions.
The 24-month retention rate in ¡Viva Bien! was lower than in the MLP (61.4% in ¡Viva Bien! vs. 85.3% in the MLP). There are few studies with which to compare the ¡Viva Bien! retention rates directly (i.e., multiple-risk-factor programs with Latinas having type 2 diabetes, at 24-month follow-up). Somewhat comparable studies report retention rates ranging from 56% to 100%, although mostly for much shorter follow-up times (with a notable exception [57]). Silberman et al. [58] reported that 78.1% of the participants remained enrolled in the program at the end of 1 year. In the Angermayr et al. review [56], the proportion of participants terminating study interventions prematurely varied from 0% to 44%, depending on length of follow-up. At 24 months in the Diabetes Prevention Program Outcome Study [57], 81% of participants were still enrolled. In a program by Eakin et al. [59] targeting urban Latinos with multiple chronic conditions, the retention rate at 6 months was 81%. However, this intervention was much lower in intensity than either the MLP or ¡Viva Bien!. A dietary intervention targeting Latinas [60] found that at 12 months 79% of the original 357 study participants were available for follow-up analyses. Brown, Garcia, Kouzekanani, and Hanis [61] reported a 12-month retention rate of 90% in their study involving a culturally competent lifestyle intervention targeting Mexican-Americans with type 2 diabetes. Poston et al. [62] reported a 12-month retention rate of 66% in a study of 108 Mexican-American women testing a culturally tailored lifestyle modification intervention.
¡Viva Bien! employed a number of methods to maximize attendance and retention. These included family member involvement, expert presentations, practical, and relevant skill-based intervention components, friendly competitions, and active involvement. Social connection with staff and peers was strongly encouraged. Staff and peers made phone calls and sent cards to participants who missed sessions. Health benefits experienced in the program also exerted a strong influence to remain in the study. Transportation barriers were minimized by the provision of taxi service and by locating meetings in convenient community settings. Of those giving a reason for non-attendance, the most frequent was illness (9.9%), followed by work-related conflicts (4.5%), being on vacation (4.2%), or having a social conflict (3.7%). Anecdotal evidence from exit interviews suggested that as the in-person intervention sessions faded, intervention condition participants felt a diminished responsibility to themselves and to the program. Future studies in this population might improve adherence/retention by introducing maintenance strategies from the beginning of the program, maintaining the level of intensity throughout the intervention period and offering greater incentives for follow-up assessment participation.
Despite missing data arising from attrition, results of generalized estimating equation analyses using complete-case and imputed data were similar. ¡Viva Bien! participants compared with usual care significantly improved by the 6-month follow-up on the psychosocial measures of problem solving, self-efficacy, and perceived support, and these gains were maintained at 12- and 24-month follow-ups. Between-condition effects were found across 24 months on dietary patterns (percent calories from saturated fat) and use of social–environmental resources to support chronic disease self-management. Improvements in stress management and days per week exercised were sustained by ¡Viva Bien! participants; however, there were improvements in these factors by usual care participants by the end of 24 months as well, thus diminishing the longitudinal intervention effect. Effects of ¡Viva Bien! on biological outcomes were initially promising. These effects were not maintained, however, as participants in both conditions approached baseline levels by 24 months.
Although the treatment condition improved across the 24-month intervention, the challenge in sustaining physical activity is well documented [63, 64], and sustaining stress management over long periods is virtually undocumented. For behaviors that are not currently part of daily living, such as physical activity or stress management (as opposed to eating) to become habitual, it may be that the intervention must address not only individual behaviors, but also the home, neighborhood, job, and social environments, which may increase stress and promote sedentary lifestyles. While these environments may also encourage unhealthful eating, it is possible that changing eating habits (e.g., modifying food preparation techniques to reduce saturated fat) requires less effort to sustain, once mastered, than a daily walk or stress-management practices [65]. Recent evidence suggests that people with diabetes experience greater perceived exertion than those without diabetes, necessitating greater motivational and supportive resources than the general population to maintain physical activity [66]. And, in general, participation in regular physical activity among Hispanics tends to be lower than in non-Hispanic whites [67]. Thus, an ecological approach that includes personal, intrapersonal, organizational, and environment/policy changes to support healthful lifestyles, particularly among populations with increased risk and disproportionate burden for chronic conditions such as diabetes, may be required for sustained change in multiple health behaviors.
This practical trial has both methodological strengths and weaknesses, as well as implications for practice, policy, and research [68, 69]. Strengths include an intervention that addressed a multiple-risk-factor problem with a previously tested multiple-behavior-change intervention, cultural adaptation for a Latina population, a reasonably large and diverse Latina sample, use of multiple measures, multiple imputation procedures for handling missing data, and generalized estimating equation analyses across 24 months.
A possible limitation of our study was the use of primarily self-report measures for behavioral outcomes. Most of these measures have been validated against more objective standards in previous studies, but it is not known whether possible self-reporting inaccuracies influenced the observed results. The correlation (r = 0.34) in this study between the Modified International Physical Activity Questionnaire and accelerometer data, though moderate, is similar to findings of other studies correlating self-reports of activity and more objective indicators (e.g., our study [70] correlating 7-day pedometer step counts 0.31 with a 7-day diary physical activity in a sample of older women). Such results suggest that the two modes of physical activity measurement (self-report and pedometer/accelerometers) provide both common and unique information. Another limitation was that the comprehensive lifestyle intervention cannot be easily disentangled to understand the contribution of discrete elements. The efficacy of the core components of the lifestyle intervention (diet, physical activity, stress management, and social support) have been well established in the literature; less understood is how they work in concert.
Future Directions
The short-term effectiveness of multibehavioral interventions, such as ¡Viva Bien!, is encouraging, but the inability of behavioral interventions to sustain behavior change or improvements in biologic or quality-of-life outcomes over time continues to be a challenge [71]. More research is needed to develop and test novel and cost-effective interventions that can sustain the motivation and support needed to accomplish successful, lifelong diabetes self-management. Research that investigates characteristics of social and physical environments associated with sustaining multiple-health-behavior change is sorely needed [72].
The ¡Viva Bien! program succeeded in changing multiple key health behaviors. As contact faded after 6 months, so did the intervention effects. For people with chronic conditions, maintenance interventions that provide ongoing social, motivational, and problem-solving support may be as important as addressing long-term medication adherence. Such interventions may be best delivered through community organizations (e.g., faith-based, worksites, schools), neighborhoods (e.g., infrastructures that support activity; neighborhood groups that support norms for health), and technology (e.g., phone, social media, internet).
This study was supported by a grant from the National Heart, Lung, and Blood Institute (R01-HL077120).
The authors have no potential conflicts of interest relevant to this article.
We acknowledge the invaluable contributions of the assessment and intervention staffs of the ¡Viva Bien! project, including Cristy Geno Rasmussen, Alyssa Doty, Fabio Almeida, Sara Hoerlein, Carmen Martin, Angela Casola, Eve Halterman, and Breanne A. Griffin. We are deeply indebted to the 280 dedicated and committed women who participated in the study.
This research was supported by grant number R01-HL077120 from the National Heart, Lung, and Blood Institute.
Cultural adaptations of ¡Viva Bien! intervention components
  • Intervention Component: Initial 2½-Day Retreat
    The kickoff retreat started the program and built camaraderie between participants and staff. The retreat consisted of introductions and practice of all ¡Viva Bien! program pieces:
    • Mediterranean diet meals (catered)
    • Physical activity (aerobic and strength training)
    • Stress management
    • Social support groups
    • Smoking cessation
    Cultural Adaptations: The Mediterranean Diet was adapted to the tastes of the Latino culture (see below). Bilingual staff gave presentations in English and Spanish. English and Spanish PowerPoint slide shows and program pamphlets were provided, illustrated with photographs of Latina women.
  • Intervention Component: Meetings
    Weekly 4-h meetings were held for the first 6 months. Meetings were bimonthly for months 7–12 and further tapered from months 12–24. Meetings featured of 1 h each of:
    • Mediterranean diet (potluck)
    • Physical activity
    • Stress management
    • Social support groups
    Cultural Adaptations: After 6 months, family nights were added to involve family members in participants' activities and to celebrate their achievements. Family Nights were intended to increase the families' support for participants' intervention engagement. At the suggestion of participants who wanted to ask questions they were unable to ask their personal health care providers, we added presentations and question–answer sessions with the project's Latino physician.
  • Intervention Component: Mediterranean Diet
    Participants were encouraged to follow the Mediterranean diet emphasizing vegetables, fruits, legumes, nuts, cereals, olive oil, limited animal fat, and portion control.
    Cultural Adaptations: Latin American recipes were altered by the Latina project dietitian to conform to the ¡Viva Bien! diet. The goal was to lower the fat and calories while maintaining flavor with traditional ingredients and spices. Latinas represent a diverse group, and there is no typical “Latino diet,” so recipes from specific Latin American countries were modified using common staples. In this way, the program covered the wide range of ethnic Latin American foods. Potluck dinners were key to the diet component. The Latina dietitian conducted cooking demonstrations to show new methods for preparing typical foods. Participants were shown how to modify their favorite recipes by incorporating the principles of the Mediterranean diet into their usual foods. Attention was paid to acceptance and support from family members who might benefit from dietary changes. To help participants follow the diet, colorful pamphlets were created in English and Spanish and included photographs of common Latino foods and Latina women.
  • Intervention Component: Physical Activity
    The program recommended 30 min of moderate aerobic activity most days per week and the performance of ten strength-training exercises two times per week.
    Cultural Adaptations: At physical activity sessions during the retreat and meetings, participants could choose to walk outside or follow a trained instructor in an aerobics class led in both English and Spanish, with Latin (for example, salsa) style steps and music. Thus, women could determine for themselves which physical activities were culturally appropriate. Colorful pamphlets, available in English and Spanish, were created to support the physical activity component. The pamphlets included photographs of Latina women. Take-home exercise DVDs/CDs available in English and Spanish also were created for the program.
  • Intervention Component: Stress Management
    Participants were encouraged to practice stress-management techniques for at least 1 h per day, consisting of: 20 min of yoga stretches, 15 min of progressive deep relaxation, 15 min of meditation, and 5 min of directed or receptive imagery.
    Cultural Adaptations: Take-home stress-management CDs were created for the program in English and Spanish. The research team considered adapting the stress-management component out of concern that yoga and meditation practices may be seen as religious activities incongruent with Latina participants' cultural experiences. But, focus group participants did not raise objections, and the yoga and meditation components were retained.
  • Intervention Component: Social Support
    Group support constituted 1 h at each meeting. Support group sessions included structured mini units (for example, pleasant activities, goal setting, social support, problem solving, negative thoughts) and less-structured “check-in” sessions so that participants could discuss successes and barriers to making lifestyle changes.
    Cultural Adaptations: Participants were offered groups conducted primarily in English or Spanish to accommodate language preferences. Because the support-group structure was flexible, participants could choose topics that were culturally appropriate and personally relevant. Handout materials were available in English or Spanish.
  • Intervention Component: Smoking Cessation
    Participants who used tobacco were encouraged to set a quit date and stop.
    Cultural Adaptations: To help participants stop smoking, colorful pamphlets were created for the program in English and Spanish and featuring Latina women. Smoking cessation sessions were led by a bilingual facilitator.
Practice: A moderately intense lifestyle program focused on a healthful diet, exercise, stress management, social support, and smoking cessation can encourage Latinas with type 2 diabetes to reduce heart-disease risk behaviors, but program effects fade as contact fades.
Policy: Resources should be directed toward further investigation of social, motivational, and problem-solving support at multiple levels (e.g., personal, intrapersonal, organizational, and environment/policy) to help sustain healthful lifestyle practices, particularly for populations with increased risk and disproportionate burden for chronic conditions.
Research: Research is sorely needed to study lifestyle interventions designed for sustainability, and to better understand the social and physical environments associated with sustaining multiple-health-behavior change.
Contributor Information
Deborah J Toobert, Phone: +1-541-4842123, Fax: +1-541-4341502, deborah/at/
Lisa A Strycker, Phone: +1-541-4842123, Fax: +1-541-4341502, lisas/at/
Diane K King, Phone: +1-303-6141206, Fax: +1-303-614-1205, Diane.King/at/
Manuel Barrera, Jr., Phone: +1-480-9653826, Fax: +1-480-9658544, atmxb/at/
Diego Osuna, Phone: +1-303-6147589, Diego.Osuna/at/
Russell E Glasgow, Phone: +1-719-3723165, Fax: +1-719-3726395, russg/at/
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