Developing a Culturally Responsive Lifestyle Intervention for Overweight/Obese U.S. Mexicans

Abstract

Introduction:

Hispanics are the largest minority group in the United States, constituting 18% of the population. Mexicans are the largest Hispanic subgroup and are at disproportionate risk for overweight/obesity. Lifestyle interventions targeting dietary change and physical activity have resulted in significant weight loss in several large randomized clinical trials in the general population, but few studies have tailored interventions to Mexican Americans. We conducted a community needs assessment from 2018-2020 in accordance with Domenech-Rodriguez and Wieling’s Cultural Adaptation Process (CAP) model to inform the development of SANOS (SAlud y Nutrición para todOS) (Health and Nutrition for All), a culturally-tailored, community-based diet and lifestyle education and counseling program that addresses overweight/obesity among U.S. Mexicans.

Methods:

Five Spanish-language focus groups were conducted until thematic saturation with 31 overweight/obese Mexicans in New York City about their knowledge, priorities, and preferences regarding diet, exercise, and evidence-based strategies for behavioral change. A grounded theory approach was used to analyze the data.

Results:

Five themes were identified: 1) A strong desire for tangible information related to diet and health, 2) Family as a primary motivator for behavior change, 3) Desire for group-based motivation and accountability to sustain intervention participation, 4) Belief in short-term goal setting to prevent loss of motivation, and 5) Time and workplace-related barriers to intervention adoption.

Conclusions:

Ecological factors such as the effect of acculturation on diet, family members’ role in behavior change, and socioenvironmental barriers to healthy dietary practices and physical activity should be considered when adapting evidence-based treatments for Mexican Americans.

Introduction

There are 59.9 million Hispanics in the U.S., the largest minority group.[1] Mexicans are the largest Hispanic subgroup in the U.S., representing nearly two-thirds of the Hispanic population.[2] U.S. Mexicans are among the highest risk groups for obesity. Over 78% of U.S. Mexican women and 81% of U.S. Mexican men are either overweight or obese, compared to 60.9% of non-Hispanic White (NHW) women and 73.2% of NHW men.[3] Obesity is a risk factor for many serious diseases and health conditions, including heart disease, hypertension, cancer, and diabetes.[4] U.S. Mexicans are 50% more likely than NHWs to die from diabetes.[5] Disproportionately high rates of obesity and diabetes have been found in groups migrating from poor to wealthy countries,[6] suggesting socioenvironmental factors (e.g., socioeconomic status, the built environment, availability of energy-dense foods and beverages) may play a role in the development of lifestyle changes that increase risk for obesity and associated health consequences among migrants.[7] Acculturation to the U.S. has had detrimental effects on the U.S. Mexican diet,[8-9] and U.S. Mexican women are less likely than any other ethnic subgroup to engage in leisure-time physical activity.[10-11]

Lifestyle interventions targeting dietary change and physical activity have demonstrated weight loss and concomitant health benefits in several landmark randomized clinical trials.[12-13] Five percent weight loss has been associated with reduced risk (and improved control) of diabetes and hypertension and decreased risk factors for cardiovascular disease.[14] A growing number of studies have investigated culturally tailored lifestyle interventions to reduce obesity among Hispanic and other underrepresented populations.[15-17] However, researchers have noted that many of these studies have methodological shortcomings, including treating Hispanics as a homogenous and monolithic group rather than tailoring interventions to subpopulations, lacking specificity regarding cultural adjustments, and not employing cultural frameworks in intervention development.[15, 17]

The present study describes a qualitative community needs assessment to guide the development of SANOS (SAlud y Nutrición para todOS) (Health and Nutrition for All), a community-based diet and lifestyle education and counseling program that addresses overweight/obesity among U.S. Mexicans in New York City (NYC). Our study was informed by the Cultural Adaptation Process (CAP) model,[18] which outlines three phases to culturally tailoring interventions for underserved groups: 1) initial work between stakeholders (i.e., community, intervention developers); 2) initial adaptation, including pilot work on intervention and outcome measures; and 3) adaptation iterations as needed. This Phase 1 CAP study employs focus group methodology, a long-established tool to assess the acceptability of behavioral interventions in culturally and linguistically diverse populations.[19] By asking U.S. Mexicans directly about their beliefs regarding weight, diet, and exercise; opinions regarding behavioral change strategies; and facilitators and barriers to healthy eating and physical activity; we can gain valuable insights on how to culturally tailor SANOS and maximize its effectiveness in this large, underserved, and at-risk population.

Methods

Study Design

This study was reviewed and approved by the Memorial Sloan Kettering Cancer Center (MSKCC) institutional review board. The study utilized a structured focus group guide. The focus groups and data analyses were conducted from November 2018 to April 2020.

Study Setting

Study participants were recruited via the Ventanillas de Salud (VDS; Health Windows) program at the Mexican Consulate in NYC. The VDS program, housed at Mexican Consulate locations throughout the U.S., is a joint initiative between the Mexican government and over 400 health-related organizations. Its mission is to address health disparities for individuals of Mexican origin in the U.S. by providing health screenings, health education and promotion, and assistance with health care access.[20] The New York Metropolitan area (NY) VDS is a local partnership of the MSKCC Immigrant Health and Cancer Disparities (IHCD) Center and the Mexican Consulate in NYC.

Study Participants

Convenience sampling was used to recruit individuals attending the VDS at the Mexican Consulate in NYC. Participant inclusion criteria were: self-identification as Hispanic/Latino, seeking services at the VDS, prefers to speak in Spanish, ≥ 18 years of age, obese (BMI ≥ 30 kg/m²) or overweight (BMI of 25 – 29.9 kg/m²). Exclusion criteria included being pregnant and/or breastfeeding; the presence of a chronic disease such as cancer, kidney disease, liver disease, etc.; having dietary restrictions; and/or having another family member already enrolled in the study. Individuals eligible and interested in participating completed a verbal consent in Spanish, and each received a $30 incentive.

Procedures

A focus group guide was developed in English by the research team, translated into Spanish by our Spanish-language staff translator, then back-translated into English, using well-established guidelines.[21] It included the following areas of inquiry: (1) Knowledge and attitudes related to overweight, obesity, exercise, and diet and the role of diet and lifestyle education programs such as SANOS to address overweight and obesity; (2) knowledge and preferences regarding evidence- and theory-based (Social Cognitive Theory [SCT]) strategies (e.g. modeling, motivational interviewing, self-monitoring, goal setting, and problem solving) to change diet and physical activity behaviors;[22-24] (3) Anticipated results following from eating more healthfully and being more active (outcome expectations in SCT);[25] and (4) Facilitators and barriers to intervention success, including recommendations for cultural tailoring.

All focus groups were conducted in-person by an experienced moderator (JG). Participants were first provided with a concise explanation of the planned 6-month SANOS program. In SANOS, individuals are randomized to different combinations of 4 overweight/obesity intervention components, including in-person diet/nutrition and exercise counseling, thrice weekly text messages on healthy diet and exercise, weekly telephone calls from a counselor, and self-monitoring tools.[26]

In total, five in-person Spanish-language focus groups were conducted at the VDS. Focus groups were conducted until saturation of themes was achieved.[27] All groups were audio-recorded, transcribed, and then translated into English by trained bilingual research staff.

Data Analysis

A five-person analysis team was comprised of a general internist/health disparities researcher (JL), a clinical research psychologist (FL), a clinical research manager (BN), a bilingual community outreach staff member (LP), and a medical anthropologist (KL). A grounded theory approach was selected as the most appropriate method of analysis for this formative study, as its central idea is that the theory is built from the data by an inductive process in which the data serve to generate rather than verify hypotheses.[28] In the first phase of the analysis, all team members independently analyzed two of the five focus group transcripts through a process of open coding; no preconceived themes were imposed on the data during this exploratory stage. The analytic team then met to discuss and reach consensus on key points present in the data and developed an initial draft of a coding guide.

All five focus group transcripts were then imported into NVivo, a qualitative analytic software program for data storage, coding and retrieval, and text analysis.[29] Three team members (BN, LP, KL) used NVivo to code each focus group transcript independently; this included marking passages of text with codes to be later used to compare sets of grouped responses by theme and subtheme. Coded transcripts were subsequently compared and areas of disagreement were resolved through regular consensus meetings that included all members of the team. This iterative process permitted reviewers to closely examine significant issues raised in the focus groups and to identify specific themes, subthemes, and subtopics. The coding guide was revised to include additional themes as a result of these consensus meetings. Once coded, all transcripts were merged, and frequently used codes sorted into categories. Through a final round of selective coding, the study team reviewed significant quotes within each code category, aggregated across all five transcripts, to facilitate the identification of major themes. Study authors then met to come to a consensus on the significance of themes, subthemes, and subtopics and to select and agree upon quotations to illustrate themes. Findings were discussed with the study team to inform SANOS program development.

Results

Focus groups lasted between 60-100 minutes each and included 5-7 participants per group, for a final sample of 31. 71% were female, mean age was 40.13 (SD=8.89), and mean BMI was 31.21 (SD=5.04). Eighty-one percent of participants had children under 18 in their household. Twelve received Supplemental Food and Nutrition Program (SNAP) vouchers, and 7 received WIC (Women, Infants, & Children) support.

Overall, participants perceived the SANOS program to be acceptable and relevant to their needs. Grounded theory analysis of the transcripts identified 5 key themes (Table 1):

Table 1.

Key Themes

Theme	Codes Associated with Theme	Illustrative Quotes	Suggestions for SANOS Program by Theme
1) A strong desire for tangible, culturally responsive information related to diet and health	Attitude - desire for knowledge Modeling: expert advice Cultural influences Contributor to Obesity: cultural Influences Contributor: lack of diet knowledge	“I'm not going to fill up with just strawberry' because I don't know what it contains. Depending on what's in it, it's the acid that our body also needs. But also, if I start eating a lot of grapes, if I have diabetes, it harms me […] I would say some pamphlets that explain what… what is contained in each vegetable […] for example, in my case I am a diabetic, I have been told less sweets, less juice, none of that.” (Focus Group 5) “Yes, for example a dish, as I was saying, for example a Mexican dish, right? I need a meat, usually we eat a giant steak with lots of sauce, mole, rice, etc. Then, I realize that when I eat that type of dish, my stomach… it's very heavy and I feel sluggish for about two days.” (Focus Group 5) “Because we can learn from them [SANOS], educate our children, our family or friends, we can tell them about it. And it's a root that will branch out to teach people and everyone.” (Focus Group 5)	Provide examples of both new and culturally familiar healthy recipes Include education on differences in portion sizes in U.S. vs. Mexico Provide information on where to access affordable fresh produce
2) Family as a primary motivator for behavior change	Contributor to Obesity: parent/ family influences Motivations: family or children’s health Modeling: family or parental modeling	“The family is the number one factor, even more here, that we don’t have many acquaintances. And to see my child […] change, that helps me […] Not only for me, also the whole family, [knowing] my children are going to live like this, it helps me [stick to the program] too.” (Focus Group 2) “For example, my grandmother always says, if you look thin, she says, ‘Ah, eat more, give her more to eat, she is very skinny […] you can ask yourself, for example, is that true or not, and what you do is eat more, so you don't look that way. Or they say, ‘You look sick,’ so you get discouraged. Instead of being told: ‘Oh, you look very pretty, wow, how did you accomplish that?’” (Focus Group 1) “And when my daughter now tells me: "Mom, what do I do, what do I eat?", What can I teach if I do not know anything?” (Focus Group 3) “[B]efore, we bought Mexican bread and it has too much flour. My daughters would eat one and would grab and eat another, and I saw it as normal. None of that was normal, everything was exaggerated. Now that I am learning to eat, there are more fruits, vegetables, more healthy things at home.” (Focus Group 3)	Encourage spousal attendance Provide information about partner support Teach parenting skills to encourage family changes in eating and exercise behaviors Hold joint or separate sessions for participants’ children Include recommendations for family-friendly physical activities
3) Desire for group-based motivation and accountability to sustain intervention	Motivations: social or group accountability Examples of modeling Social isolation Barrier: willpower	“A nice thing would be that, for example, groups, saying, "Hey, so-and-so, look, come with me, let's walk two blocks, let's meet and walk and afterwards we can drink a juice", it’s not so easy nor very expensive but… share [ideas], right? As a motivation, right?” (Focus Group 2) “Sometimes you only need a team, to be with someone, one more person. For example, at the gym, in my case, if I go to the gym alone, I give up, right? But if you have someone who is [unintelligible] "I'm losing weight," things like that, it motivates you more and you don't give up.” (Focus Group 3) “It's a good idea because if you have a family, then you do it as a group. But, for example, I am single and have no family, so I don't qualify; but the fact of doing it with a classmate, a friend, makes you support each other, which is what doing it in a group would mean, the support you receive from another person so that you do not easily leave the program.” (Focus Group 4)	Include group-based component, such as a WhatsApp support group, to facilitate group-based motivation and accountability among Mexican American peers
4) Belief in short-term goal-setting to prevent loss of motivation	Short term/ manageable goals Barrier: loss of motivation Contributor to Obesity: bad habits	“I’ve already done a lot of exercise, I’ve already been on a diet and I have not lost anything. I’m still the same and I feel the same physically and morally.” (Focus Group 1) “If I could do it for one day, I'll make an effort to continue doing it. Because as a reward you get to feel better and your clothes start to fit better. Then it is not so much in the long term; if you can discipline yourself for one day, surely… If you see that your sugar isn't going up, that one day helped you to do it a second day. They are not long-term goals, you can see them.” (Focus Group 3) “The word "goals" is similar to what we said about the word "diets", it's a word that when some people hear it, unfortunately, what comes to mind is… oh, they are like impossible challenges. Especially now that the New Year, Christmas is coming up… we ask ourselves, what are the goals for the year? We have to change such mentality. A goal does not have to be a goal from here to the end of the program, but rather start with short-term goals. Saying to ourselves: "Today I am going to walk two blocks, in a month I will walk ten blocks ". Not saying: "When I finish the program I will be running marathons". Because then we don't reach those goals, because if one doesn't set short-term goals… So, start the program with goals that are constructive in the long term.” (Focus Group 4)	Include weekly goal-setting in telephone calls with participants Include resources (weekly calendar or checklist) that encourage short-term goal-setting and monitoring Adapt text messages to include culturally syntonic weekly reminders regarding prespecified weekly goals (e.g. “Your goal this week is to limit to 2 tortillas at dinner”)
5) Time constraints influencing bad habits and creating barriers to intervention adoption	Barrier: work constraints Barrier: time constraints Contributor: bad habits	“I think an obstacle would also be that the mothers do not have time, because mother[s] are always working, always doing something and every time they finish their day they are tired and you’re going to do more exercise?” (Focus Group 2) “Well, I have the problem that at night, when I come to work, it's my kind of food, Mexican food, I have the problem that I eat a lot, I eat a lot, and well, it's not good to eat a lot at night because, like, the food does not digest well in the stomach.” (Focus Group 5)	Identify timesaving and cost-effective opportunities for physical activity (e.g. walking to the next transit location, completing equipment-free body weight exercises at home or at a public park) Identify strategies to maintain a healthy diet while at work, especially for restaurant workers Incorporate time management strategies into intervention to help participants prioritize exercise and dietary goals

Theme 1: Desire for tangible information related to health

Participants expressed positive attitudes towards engaging in a health intervention program, and wanted to learn new information related to diet and nutrition. Participants were interested in learning not just which dishes were healthy but why they were healthy. Specifically, they desired information about foods that could support the prevention and management of chronic conditions, such as diabetes. Participants felt that obesity was partially attributed to the challenges of acculturation, describing that, in Mexico, families typically consumed multiple portions each meal, but that this practice became problematic when exposed to an “American” (i.e. fast food) diet: “…the tradition of this country [USA], what they eat the most is pizza, hamburgers and breads […] in our country we are accustomed to eat a second or third portion. So, we must be careful.” (Focus Group 1). Through the gaining of knowledge about culturally familiar healthy food options, participants felt they could eat healthfully while still preparing appealing meals. Participants also expressed a preference for “expert” advice highlighting the connection between health behaviors and the prevention and management of chronic diseases. Many noted that the receipt of specific guidelines from a counselor would motivate them to take a program “seriously.”

Theme 2: Family as a primary motivator for behavior change

Participants discussed family dynamics as both a contributor to obesity and a motivation for behavior change. Participants reflected on the extent to which “bad habits” from childhood influenced their current eating habits and expressed worry at passing these habits onto their children. Some parents remarked how their children had experienced bullying due to their body size, while others worried about their children developing medical conditions (e.g., diabetes, depression) later in life. Because of this, setting a positive example for their family was a key motivator for participating in a program like SANOS: “…it is [about] educating myself because my children will learn from me.” (Focus Group 5).

Participants felt that family-based interventions would be key to sustaining participation, noting previous resistance from family members when attempting to adopt new diet or exercise habits on their own: “I try to eat healthier than before, but my husband and children don't want to change.” (Focus Group 4). Some participants noted how this familial resistance might be related to internalized cultural messages about body size, where “skinny” can mean “unhealthy.”

Family roles heavily influenced discussions across groups: mothers in particular noted pressure to “set an example” for the family, and the dual burden of work and childcare placed additional constraints on mothers’ ability to prepare healthy meals. However, because of mothers’ active roles in their children’s lives, participants felt that involving mothers in lifestyle interventions would catalyze behavior change for the entire family.

Theme 3: Group-based motivation and accountability to sustain intervention participation

Participants perceived obesity to be a socially isolating condition and found it especially difficult to make sustained changes in contexts where their choices would be rejected or ridiculed: “Sometimes with friends, you say, ‘I am going to eat a salad’ and [they say] ‘Why a salad? Are you crazy bro? That’s for cows, eat meat!’” (Focus Group 3). Facing external social pressures, participants suggested positive group-based motivation as a strategy to increase self-efficacy. Participants recommended program features that would encourage members to check in with one another, via text messaging or social media. In addition to being “fun,” participants noted that this would provide a forum to share difficult experiences and frustrations, sustaining motivation. Participants also shared that a group forum would enable them to envision their own goals as achievable, through opportunities to hear about inspiring and relatable models of lifestyle change.

Theme 4: Setting short-term goals to prevent loss of motivation

Across groups, participants worried that losing motivation would be a major barrier to participating in a program like SANOS. Based on previous experiences trying different diet or exercise programs, participants anticipated that they would quickly become de-motivated if they perceived that the intervention was not “working,” which usually occurred when they did not see immediate weight loss. Like the sentiments expressed in themes 2 and 3, participants noted that it was particularly difficult to sustain motivation in a social context that is either unsupportive or reinforces “old habits.”

During discussions about goal-setting, participants worried that barriers to change would cause them to fall short of a goal or milestone that they had set for themselves, further reducing motivation. To combat this, participants across groups spoke about the need to set short-term or manageable goals: “the goals have to be short-term because, let's say, when they make them too long-term, you get frustrated or think: "I've got a lot left to go!” (Focus group 3). Participants opted for an approach where they could incorporate modifications “little by little,” setting weekly goals or creating a schedule with a counselor. For many participants, setting achievable goals was perceived as an empathic approach to behavior change that would help them be less “hard on themselves” when struggling to break “bad habits” instilled over time.

Theme 5: Time constraints and workplace barriers

Throughout the focus groups, participants noted lack of time as both a contributor to obesity and a barrier to participation in a program like SANOS. Participants shared stories of busy work schedules with long hours and lengthy commutes, which impacted their ability to spend time grocery shopping or cooking healthy meals. As one participant explained, “the majority [of us] who are in the United States come here and most of the people have bad eating habits. Why? Because they usually eat what they get at the restaurant where they work and sometimes don’t have time to prepare a healthy meal” (Focus Group 3). Similarly, participants noted that their work schedules increased their stress levels, which made them more likely to indulge in unhealthy comfort foods; or, they felt too exhausted after work to engage in additional physical activity.

Echoing theme 2, participants who were mothers experienced constraints on their time and energy between work, childcare, and other household tasks, often noting that cooking meals and exercise were the first to be sacrificed. In discussing SANOS, participants expressed interest in developing strategies to help them organize their time so that they could have a few extra minutes each day to help them meet their diet and exercise goals. As one participant stated, “…if we organize ourselves, we will have those twenty minutes to exercise.” (Focus Group 5).

Discussion

The present study, which aimed to inform the development of a culturally tailored, community-based diet and lifestyle education and counseling program for U.S. Mexicans, described participants’ priorities, preferences, and factors they felt may influence behavior change related to diet and physical activity. All participants expressed positive interest in SANOS, echoing previous findings that culturally adapted lifestyle programs can achieve community buy-in.[17, 30] Many named avoidance or improved management of diabetes as important outcome expectations from SANOS. In accordance with SCT, lifestyle interventions should emphasize the prevention of illness (e.g. diabetes, CVD, and cancer) as a positive consequence of even modest weight loss.[14, 26, 31] Relatedly, participants expressed a need for concrete, expert recommendations regarding management of chronic conditions and weight loss, potentially reflecting insufficient physician communication of healthy lifestyle advice to members of the Hispanic community.[32]

Women and mothers in particular were described as potential catalysts for change, echoing literature suggesting maternal beliefs influence family dietary practices in the Hispanic community.[33-35] Participants’ interest in including family in SANOS, taken together with studies showing family-oriented interventions provide social support and opportunities for modeling healthy behaviors,[16, 36] suggest family-based interventions may be particularly efficacious for U.S. Mexicans. Encouraging spousal attendance, teaching parenting skills to encourage family lifestyle changes, and holding joint or separate classes for children[37] may increase SANOS’s relevance for this population.

Existing literature describes an association between acculturation and suboptimal dietary quality in the Hispanic population.[38] Our results suggest that acculturation’s negative effects on dietary practices may interact with participants’ socioeconomic limitations (more than half of participants received food SNAP or WIC support). Minority and low-income communities face numerous barriers to a healthy lifestyle, including working long hours for minimum wage, which increases the value of a convenient fast food diet,[39-40] and an environment often inconducive to a nutritious diet and physical activity (i.e. scarcity of quality supermarkets and green space in low-income and minority neighborhoods).[41-43] Eating energy-dense traditional and fast foods may also represent coping strategies for low-income families in times of stress.[44] SANOS should directly address socioeconomic barriers to participation (e.g. by providing information on where to access affordable fresh produce)[45] and identify timesaving and cost-effective opportunities for physical activity (e.g. walking to the next transit location). Text messaging and social media communication may be promising options to increase social support in a population facing significant time constraints; their use may be a scalable, cost-effective way to maximize reach and reduce participant burden for underserved communities.[46-47]

Limitations to the present study include sampling bias inherent in utilizing a convenience sample of voluntary participants. In addition, a gender skew in participants (22 of 31 were female) limits the generalizability of our conclusions. However, as many participants observed, mothers are often primary agents of dietary change in U.S. Mexican families,[33-35] so their opinions may be particularly vital in informing tailoring of SANOS. More research is needed on the weight management needs of U.S. Mexican and Hispanic men.[16] Nevertheless, our study yielded specific refinements (e.g. involving family members, including a social media forum for peer-facilitated accountability, providing guidance on how to prepare culturally familiar and nutritious meals) that may increase buy-in from community members and improve the effectiveness of SANOS. Results of this study provide the groundwork to inform the tailoring of SANOS and for further development of accessible, culturally responsive lifestyle interventions for this underserved population.