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1.  The En Balance Spanish Diabetes Education Program Improves Apolipoproteins, Serum Glucose and Body Composition in Hispanic Diabetics 
Ethnicity & disease  2012;22(2):215-220.
We evaluated the changes in apolipoproteins, glycemic status, and body composition after 3 months using a culturally sensitive diabetes education program, En Balance, in diabetic Hispanics.
Thirty-four (9 males, 25 females) Hispanic diabetics participated in the En Balance program over three months. Body composition was determined by dual energy X-ray absorptiometry (DXA), fasting plasma glucose (FPG), A1c, and apolipoproteins (Apo) measured after 3 months participation. Differences were analyzed using paired t testing and relationships between changes in Apo, A1c, total cholesterol, body mass index and body composition by Spearman correlations.
Completion of En Balance resulted in a significant reduction in weight (80.31 ± 1.97 kg vs 81.25 ± 17.97 kg, P=.015), FPG (143.21 ± 57.8 mg/dL vs 166.41 ± 65.9 mg/dL P=.003), and A1c (7.08 ± 1.6% vs 7.87 ± 2.0%, P=<.001). DXA demonstrated reduction in total fat (29.54 ± 10.0 kg vs 30.24 ± 11.80 kg, P=<.001) and trunk fat (15.09 ± 5.6 kg vs 16.87 ± 5.4 kg, P=.001). High density lipoprotein significantly increased (48.85 ± 11.4 vs 44.65 ± 8.8, P=.002) and total serum cholesterol/high density lipoprotein ratio decreased (3.87 ± .98 vs 4.35 ± 1.0, P=.001). There were significant correlations at three months between changes in Apo A1 and A2 (r=.559, P<.001), Apo E and total cholesterol (r=.746, P<.001), between A1c and FPG (r=.563, P=.001) and BMI and body weight (r=.732, P<.001).
The En Balance program improved body composition, A1c, FPG, total cholesterol/HDL ratio and HDL. If these trends can be sustained, En Balance may serve as a unique educational paradigm for improving type 2 diabetes in Hispanics.
PMCID: PMC3894418  PMID: 22764645
Hispanics; Type 2 Diabetes; Diabetes Education Programs
2.  En Balance 
The Diabetes educator  2012;38(5):10.1177/0145721712457249.
This study was designed to assess the feasibility of culturally and language-sensitive diabetes education as a way to increase physical activity and to improve health/diabetes management in a group of Spanish-speaking Hispanics in the Inland Empire region of Southern California.
En Balance is a culturally sensitive diabetes education program designed for Spanish-speaking Hispanic adults. The 3-month educational intervention assessed 16 males and 23 females living in Riverside and San Bernardino counties of Southern California. Baseline and 3-month evaluations of physical activity were assessed using the validated Arizona Activity Frequency Questionnaire.
After 3 months on the En Balance program, there was a significant increase in moderate intensity physical activity energy expenditure (M = 368 ± 894 kcal/day, P < 0.01) and high intensity physical activity energy expenditure (M = 405 ± 2569 kcal/day, P = 0.05) compared to baseline and significant reductions in A1C (−0.90%, P = 0.01), total cholesterol (−13.44 mg/dl, P = 0.01), LDL cholesterol (−10.28 mg/dl, P = 0.03), and waist circumference (−1.52 cm, P = 0.04).
En Balance program resulted in significant mean increases in both moderate and high intensity physical activity energy expenditure among this group of Hispanic diabetic participants, indicating that despite a general pattern of low physical activity in this group, an intervention that stresses both nutrition and exercise in culturally sensitive ways can positively impact participant’s physical activity levels as well as impact nutritional changes.
PMCID: PMC3885415  PMID: 22968219
Hispanic; diabetes; education; physical activity; glucose control
3.  Association Between Dietary Fiber and Incident Cases of Colon Polyps: The Adventist Health Study 
Colorectal cancer (CRC) is a leading cause of cancer death in the United States. Most cases of CRC arise in adenomatous polyps. It has been estimated that 25%–35% of colon adenoma risk could be avoidable by modification of dietary and life-style habits.
We estimated the association between total dietary fiber and fiber intake from fruits, vegetables, and grains, and the risk of physician-diagnosed colon polyps among 2818 men and women who had undergone colonoscopy. Data were drawn from 2 cohort studies—the Adventist Health Study-1 (AHS-1) of 1976 and the Adventist Health Study-2 (AHS-2) conducted from 2002 to 2005. Dietary information was obtained from the self-administered questionnaire from AHS-1, while outcome was assessed from AHS-2 data. Multivariate logistic regression analysis was used to estimate the period risk of incident cases of polyps.
A total of 441 incident cases of colon polyps were identified. After adjusting for age, sex, body mass index, physical activity, education, and alcohol and meat consumption, total fiber intake was inversely associated with the risk of colon polyps (odds ratio [OR] for highest vs lowest quartile = 0.71, 95% confidence interval [CI] 0.51–0.99). This association showed a dose-response effect (p = .04). Analyses of various sources of fiber showed the most clear effect of fiber from vegetables including legumes (OR for highest vs lowest quartile = 0.65; 95% CI 0.47–0.90; p = .02).
In this population comprising a high proportion of vegetarians, persons who consumed low amounts of fiber, especially fiber contained in vegetables, had a higher risk of developing colon polyps.
PMCID: PMC3269152  PMID: 22295127
4.  Impacting obesity and glycemic control using a culturally-sensitive diabetes education program in Hispanic patients with type 2 diabetes 
Diabetes mellitus and obesity are prevalent in the Hispanic community. This group has not benefited greatly from diabetes interventions due to cultural, language and financial constraints. We designed a prospective cohort study to determine the clinical impact on adiposity and glycemic control in Hispanics with type 2 diabetes.
Research design and methods
The program conducted in Spanish by a multidisciplinary team of health care providers focused on improving glycemic control and complications through cultural lifestyle changes. Outcomes were changes in glycemic control by fasting insulin, glucose and HbA1c, body composition and selected adipokines, adiponectin, leptin and ghrelin. Body composition was measured by dual energy x-ray absorptiometry. Changes from baseline at three months were compared using paired t-tests and with Spearman’s correlations.
Glycemic control improved by HbA1c (7.9% ± 2.0% vs 7.1% ± 1.7%; P = <0.001), and fasting glucose (166.4 ± 66.0 mg/dl vs 143.2 ± 57.9 mg/dl; P = 0.003). Body weight (81.3 ± 17.9 kg vs 80.3 ± 18.0 kg; P = 0.002), waist circumference (101.6 ± 13.4 cm vs 99.1 ± 12.7 cm; P = 0.015), and truncal fat (16.5 ± 5.7 kg vs 15.9 ± 5.6 kg; P = 0.001) decreased. Only leptin (19.6 ± 15.0 ng/ml vs 16.3 ± 12.7 ng/ml; P = 0.002) was reduced and related to change in body weight (r = 0.392; P = 0.022).
Our program significantly improved glycemic control and decreased obesity in diabetic Hispanic subjects. The early benefits on glycemic control may be related to reductions in leptin through loss of adipose tissue. Success in impacting diabetes and related complications can occur in a culturally focused and multidisciplinary context.
PMCID: PMC3036541  PMID: 21318090
glycemic control; obesity; leptin; culture
5.  Improved Clinical Outcomes Using a Culturally Sensitive Diabetes Education Program in a Hispanic Population 
The Diabetes educator  2008;34(4):698-706.
The purpose of this study was to evaluate the effects of a culturally sensitive diabetes education program for Hispanics with type 2 diabetes.
This study is a prospective cohort study to test the impact of a comprehensive diabetes education program on blood glucose control on Hispanics with type 2 diabetes. The educational program focused on maintaining glycemic control and general aspects of managing diabetes and complications. The study participants were recruited by flyers placed in Hispanic markets and in ambulatory care clinics. A total of 34 Hispanic male and female subjects with type 2 diabetes participated in the study. The concentrations of glucose, insulin, hemoglobin A1c (HbA1c), total cholesterol, triglycerides, low-density lipoprotein and high-density lipoprotein (HDL) cholesterol were analyzed at baseline and at 3 months.
A significant mean change was observed for HbA1c, fasting plasma glucose, cholesterol/HDL ratio, and HDL after 3 months of education compared with baseline. There were significant reductions in weight, total fat, percent fat, trunk fat, and waist-to-hip ratio compared with baseline. After 3 months, subjects showed a significant positive correlation between changes in body mass index and insulin and weight, total fat, trunk fat, and fat free mass and insulin.
A culturally sensitive program conducted in Spanish had a significant impact on important clinical parameters in Hispanic subjects with diabetes in a relatively short time period. The study demonstrates the importance of designing education intervention studies that are sensitive to cultural diversity, particularly in at-risk diabetic subjects.
PMCID: PMC2779017  PMID: 18669812
6.  Comparing Self-reported Disease Outcomes, Diet, and Lifestyles in a National Cohort of Black and White Seventh-day Adventists 
Preventing Chronic Disease  2007;4(3):A62.
Few epidemiologic cohort studies on the etiology of chronic disease are powerful enough to distinguish racial and ethnic determinants from socioeconomic determinants of health behaviors and observed disease patterns. The Adventist Health Study-2 (AHS-2), with its large number of respondents and the variation in lifestyles of its target populations, promises to shed light on these issues. This paper focuses on some preliminary baseline analyses of responses from the first group of participants recruited for AHS-2.
We administered a validated and pilot-tested questionnaire on various lifestyle practices and health outcomes to 56,754 respondents to AHS-2, comprising 14,376 non-Hispanic blacks and 42,378 non-Hispanic whites. We analyzed cross-sectional baseline data adjusted for age and sex and performed logistic regressions to test differences between responses from the two racial groups.
In this Seventh-day Adventist (Adventist) cohort, blacks were less likely than whites to be lifelong vegetarians and more likely to be overweight or obese. Exercise levels were lower for blacks than for whites, but blacks were as likely as whites not to currently smoke or drink. Blacks reported higher rates of hypertension and diabetes than did whites but lower rates of high serum cholesterol, myocardial infarction, emphysema, and all cancers. After we eliminated skin cancer from the analysis, the age-adjusted prevalence of cancer remained significantly lower for black than for white women. The prevalence of prostate cancer was 47% higher for black men than for white men.
The profile of health habits for black Adventists is better than that for blacks nationally. Given the intractable nature of many other contributors to health disparities, including racism, housing segregation, employment discrimination, limited educational opportunity, and poorer health care, the relative advantage for blacks of the Adventist lifestyle may hold promise for helping to close the gap in health status between blacks and whites nationally.
PMCID: PMC1955428  PMID: 17572966

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