John

P Foreyt,

Amelie

ABSTRACT

Your

Cuidando

Heart)

turally

G Ramirez,

adapted

achieving

and

El Corazon

was designed weight

the

H Cousins

Taking

Care

effectiveness

and loss

Jennifer

(CEC;

to assess

weight-reduction

long-term

weight-reduction Americans 1-3

exercise

in Mexican

of

of a culprogram

sive,

for

Americans.

and

modified

information

techniques

and

traditional

group that received the and attended year-long classes; or 3) a family group a manual and attended classes that emphasized

for making

habits.

The

changes

family

and

in the

family’s

individual

eating

groups

greater weight losses than the information-only loss was greatest in the family-involvement the

information-only

comparison

had group

and

exer-

significantly

group. and

Am

group.

Weight least in

J Clin

obesity,

Obesity,

weight

reduction,

Mexican

American

culturally

adapted

Studies

treatment

obesity

greater

obesity status obesity

conducted

in south

have

in the United States is inversely (SES), at least in women (1-4), in Mexican

Americans

of this population of most

Texas

of

treatment

Mexican

program,

is related

United

States

El Corazon

(CEC;

Taking

Care ofYour

study,

to assess the effectiveness and exercise program

weight

The

(5).

CEC

program

the effectiveness of three different tions. One group of individuals 90-mm classes covering nutrition, during

a family-oriented and parenting changes. Both

low SES

in the research

the

year-long

intervention, strategies spouses

is one

(2).

was

ofthe

intervention.

developed

few pro-

to compare

sensitive intervena total of 24 weekly and behavioral techA second

which

included

partner

group

or participating

Am J C/in Nuir

with

family eating and exercising took part in the educational

l991;53:1639S-4lS.

family

members.

Printed

in USA.

The

these

changes

individuals

who

participated

in

support.

Interventions 1 participants eating

ofexercise; including

plan;

received

a weight-loss

information

and a description self-monitoring,

about

manual

nutrition

ofbehavior stimulus

and

modification control, and

containing the benefits principles, contingency

3, 6, and

12 mo and

to schedule

annual

measurements

after

the

first year. Reminder cards, telephone contact, and home visits were used to encourage this group to attend all measurement sessions. A summary and interpretation of their results were mailed and each family was given a stipend of $50 when they completed a measurement session. Group 2 participants attended 24 weekly 90-mm classes that nutrition

instruction

and

was provided ment focus maintenance Measurements

instruction, activities,

and

food

demonstrations,

behavioral

education.

exercise Child

care

but spouses were not encouraged to attend. Treatfor this group was on the individual. Six monthly classes were provided to enhance compliance. at 0, 3, 6, and 12 mo were taken, with annual thereafter. Each person received a summary, in-

measurements

terpretation,

and

$25

for completing

each

measurement

session.

was

support

sessions. These two approaches were compared with a group that received only the weight-loss manual, without attending classes

weight

maintain

Participants were married Mexican American women with at one child between the ages of 3 and 6 y. All the women were between the ages of 18 and 45 y and were 20% above their ideal body weight. Most ofthe participants lived in households with an annual income of < $20 000 and the mean educational level for the population was tenth grade.

included

Heart)

ofa culturally adapted for achieving long-term

culturally attended exercise,

for making and children

is

characteristics

of the relatively

designed weight-reduction loss

obesity

Americans

a demonstration

grams

that

The reasons for uncertain. Because

to specific

would family

greater

management. Booklets were mailed after the initial assessment visit with a cover letter inviting participants to call the patient coordinator with any questions concerning the eating plan. Participants were then asked to return for measurement sessions at

related to socioeconomic it may be that greater

or is a consequence

The Cuidando

niques

found

risk factor for Mexican Americans. obesity in Mexican Americans are

and would

the inten-

achieve

methods

and

Group

Introduction

a major

than

without

who received

would

least

the CEC

WORDS

reductions

successfully program

Subjects

Nutr

l99l;53:l639S-4lS.

KEY

serum-lipid

the

individuals

intervention

recipes

2) an individual

in fat content;

same manual that received cising

exercise

and

was that obese

family-oriented

more

CEC

used a family-oriented approach to achieve lifestyle change in behavior. Participants were assigned to 1) a booklet-only cornparison group that received a manual including behavior change, nutrition,

for the study

hypothesis

© 1991 American

I From Baylor College of Medicine, Houston, and Administration and Community Health Promotion, South Texas Health Research Center, University ofTexas Health Science Center at San Antonio. 2 Supported by National Institutes of Health HL-27341.

3

6535 Society

Address

reprint

Fannin,

Mail

for Clinical

requests Station

Nutrition

to JP Foreyt, F-i#{174},Houston,

Nutrition Research TX 77030.

Clinic,

1639S

Downloaded from https://academic.oup.com/ajcn/article-abstract/53/6/1639S/4732423 by East Carolina University user on 05 January 2019

Cuidando El Corazon-a intervention for Mexican

FOREYT

1 640S Group 3 participants attended group 2 with the same nutrition vided. However, the classes were band,

wife,

and

preschool-age

size was limited classes.

The

more

healthful

cising work

attending

with

children

encouraged

eating

and

each

Class

habits

in the

children.

toward

DiClemente’s

behavioral

Participants

were

encouraged

improved

to

dietary

habits

the

Six monthly classes.

period,

followed

incorporated

survey

measured

Relapse

(7). The

problem-solving

skills

needed

for losing

weight

(6). treatment

may

of

be different

from

those needed to maintain weight loss (8). The most sucweight-loss programs appear to be those that gradually increase the responsibility of the participants for maintaining

cessful

high-risk

2) problem

playing wards

classes

such

as holidays

situations,

solving

specific

developing

maintenance to

cope

situations

cognitive

and regular

with

techniques

and

high-risk

in which

exercise

focused

social

1) idenevents;

3) role and 4)

situations;

a slip had occurred;

for handling

were

on

setbacks.

Self-re-

also emphasized.

All questionnaires

were

research-staff information

educational employment,

achievement, and marital

initial

individually members. questionnaire

family status.

administered A

by trained

brief self-administered was developed to assess

income, Sex and

language preference, age were also assessed

measurement.

An acculturation rating scale for Mexican Americans, which has been tested for reliability and validity (9), was used. Acculturation is a composite of variables, including language spoken in the

home,

educational

Wide

achievement,

variability

exists

and

generation

in acculturation

to assess the perceptions garding obesity, weight

and practices of adult loss, and nutrition.

The Family Adaptability (FACES) III questionnaire report,

of family adaptability that well-functioning middle

range

ofboth

1985)

in this

for

people of has been corre-

Mexican origin living in the United States and lated negatively with obesity in Mexican American A knowledge, attitudes, and behavior questionnaire

published

women (10). was given participants

re-

and Cohesion Evaluation Scales (DH Olson, J Portner, Y Lavee, unwas

administered

and cohesion. families, that adaptability

and

to assess

The study is, families cohesion,

the

nature

hypothesis was scoring in the would

be more

at making changes in the family program than would the individuals, whereas the reverse would be true for families who scored outside the middle range of these dimensions. A family-structure questionnaire provided information about the number of individuals living in the household, the relationship of each person in the household, and the importance of successful

and

Prochaska

and

measurement

Nutrition

used

Examination

population called

group

200

randomly

re-

food

Survey

over the selected

in the community the respondent’s 1) knowledge

annually. The and awareness risk factors; 2) sources of

cardiovascular-disease nutrition,

exercise,

and

cardiovascular

characteristics.

measurements in the CEC project were lipid changes. Glucose-tolerance tests because of the relationship between obesity and diabetes in this population (12). We monitored blood pressure and measured fitness level by using the Bruce submaximal treadmill protocol performed by exercise physiologists. specialists

In dealing with any population, cultural factors need to be investigated first. Cultural subgroups within the United States vary with respect to attitudes regarding obesity and attitudes toward certain foods. Some foods may be linked to traditions or religious rituals; other foods may be strictly taboo or restricted by men

only.

For

example,

advertising

agencies

use sex to sell products to the Anglo population, but because we know that sexuality is not publicly discussed by many Mexican Americans, a better approach is to focus on the family. Obesity and a high-fat diet are linked with hypercholesterolemia and other health problems. But Mexican American women are often uncomfortable doing something for themselves (even if it typically

bilingual background

country.

for

stages

(1 1). Seven-day

families

concerning

for consumption

Assessment

at the

It also

self-efficacy and

by following

interviewers

and 3) demographic Physiological-outcome weight loss and plasma were conducted annually

Cultural

behavioral changes. Discussions in these tifying

and

support,

a food-frequency and

decisions. consumption.

changes,

model

health;

the 6 mo of weekly

specific

to try to minimize relapse after treatment is a serious problem in the behavioral

strategies obesity

classes

sessions

social

obtained

Health

American

and and

behavior

and

bilingual

information

maintenance

These

were

collected

Hispanic

Mexican

sessions

subjects’

exercise

(HHANES) was administered. To monitor changes in the target

of obesity

Maintenance

information purchasing

stages-of-change

were

study

and increased activity levels into their lifestyles. Measurement sessions and rewards were the same as those for group 2.

and

of change

cords in

ofthe

eating

processes

health on food

Measurements making

to adopt

The

for

questions

separate

habits.

incorporating

members

members

was expanded to include partner-support techniques training aimed at developing good eating and exer-

as a family

family included

attending

all family

exercising

session.

AL

is for their

health),

such

as losing

weight

by eating

a low-fat

diet.

A persuasive approach was used for this group that focused on the benefits oflosing weight to the family. In CEC the primary objective ofthe exercise component was to encourage participants to begin a program of brisk walking three or more times per week, with a gradual increase in the distance walked. Instructions for adults included: 1) beginning an exercise program; 2) monitoring physical activity through heart rate; 3) exercises for stretching, warming up, and cooling down; 4) cardiovascular benefits ofexercise; 5) indoor exercises; and 6) exercising precautions during periods of high heat and humidity, which occur most ofthe year in the project area. The children ofgroup 3 families were taught game-oriented exercises and were urged to walk together. Walking is an activity that can be done without stepping out of cultural norms in an obvious way. However, some participants reported that their husbands were jealous and kept them from walking around the neighborhood. To solve this problem, the church hall was used regularly for walking and exercising with videotapes. Ethics The study was approved by the Institutional Review for Human Research at Baylor College of Medicine.

Board

Downloaded from https://academic.oup.com/ajcn/article-abstract/53/6/1639S/4732423 by East Carolina University user on 05 January 2019

component and parent

child

to six couples,

intervention

the same number of classes as and exercise information prodesigned for families, with hus-

ET

CUIDANDO

and discussion

Results

In a primary obese

study

females

in the

of weight three

loss in the CEC

treatment

groups

project,

were

available

for

assessment

did

weight

or demographic

is typical

for low-income

needs

to be done

not

differ

from

variables. minority

to improve

assessed this

subjects,

1

(including Those un-

those

Although

for

work

in

attrition obviously

participation.

The weight

family and individual groups had significantly greater losses than the information-only comparison group. Of importance for the cultural, family-related hypothesis of the project

was

pothesis

the

that

ment

group

univariate

weight

loss would

followed

by the

information-only clinically our

considering subjects

that was

not

this the

most

with

population

the

hy-

and

Although other

least

not.

However,

behavioral

middle-class

in the

a few achieved did

research,

ethnic white

minority volunteers

in other weight-loss research projects. Perhaps the study planted a seed in the community that, if nurtured by health educators in the school

nouncements, True

cultural

system

could change

and

reinforced

have requires

a more years

by media

significant or decades.

public-service

effect

over

2. DieM AK, Stern MP. Social health problems of Mexican Americans: obesity, gallbladder disease, diabetes mellitus, and cardiovascular disease. Adv Intern Med 1989;34:73-96. 3. Garn SM, Bailey SM, Cole PE, et al. Level of education, level of income, and level of fatness in adults. Am I Clin Nutr 1977;30: 72 1-5. 4. Goldblatt PB, Moore ME, Stunkard Al. Social factors in obesity.

JAMA

1965;l92:

an-

time. U

References 1. Burnight RG, Brownell KD. Behavioral modification: the state of the art. In: Frankle RT, Yang MU, eds. Obesity and weight control: the health professional’s guide to understanding and treatment. Rockville, MD: Aspen Publishers, Inc, 1987:225-40.

1039-44.

5. Foreyt JP, Goodrick GK, Bolton MP, Cousins JH, Ramirez AG. Weight control: Cuidando El Corazon. In: White L, Tursky B, Schwartz GE, eds. Psychology in health care: role, achievements, and challenges in interdisciplinary programs. New York: Erlbaum (in press). 6. Marlatt GA, Gordon JR. Determinants the maintenance of behavior change.

SM, eds. Behavioral

in the family-involve-

oflow-income,

as the

supported

group

participants

favorably same

that

be greater

group.

losses,

compared

analysis

individual

comparison

significant

results

trend

1 64 1 S

CORAZON

medicine:

changing

of relapse: In: Davidson

implications for P0, Davidson health lifestyles. New York:

Brunner/Mazel, 1980:410-52. 7. Foreyt JP, Goodrick GK, Gotto AM. Limitations of behavioral treatment ofobesity: review and analysis. J Behav Med 198 l;4:l5974. 8. Abrams DB, Follick MI. Behavioral weight-loss intervention at the worksite: feasibility and maintenance. I Consult Gin Psychol l983;8l:226-33. 9. Cuellar I, Harris L, lasso R. An acculturation scale for Mexican American normal and clinical population. Hispan I Behav 5th 1980;2:l99-2l7. 10. Hazuda HP, Haffner SM, Stern MP, Eifler CW. Effects of acculturation and socioeconomic status on obesity and diabetes in Mexican Americans. Am I Epidemiol l988;128:l289-30l. 1 1. Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditional boundaries of therapy. Homewood, IL: Dow Jones-Irwin, 1984. 12. Stern MP, Gaskill SP, Hazuda HP, Gardner LI, Haffner SN. Does obesity explain prevalence ofdiabetes among Mexican Americans?

Results 272-7.

of the San Antonio

Health

Study.

Diabetologia

1983;24:

Downloaded from https://academic.oup.com/ajcn/article-abstract/53/6/1639S/4732423 by East Carolina University user on 05 January 2019

initial

168

tracked

y. Ofthese, only 86 came in for complete assessment fasting blood glucose and lipids) at 6 and 12 mo.

rate

EL