A nutrition-focused review of the interventions in US-living Latino communities with type II diabetes

Abstract

Type 2 diabetes (T2D) is a chronic, debilitating disease that disproportionally affects the Hispanic/Latino community residing in the United States. Optimal nutrition therapy is fundamental to the proper management of T2D and must be culturally adapted to facilitate permanent behavior change in this population. This review selected and assessed the nutrition components of interventions aimed to improve T2D outcomes in US-based Latinos/Hispanics, published from 2002 to 2023. An overview of the participant characteristics, nutrition intervention, and dietary assessment and outcomes is included. Nutrition interventions in this community benefit from the inclusion of bicultural registered dietitian nutritionist (RDNs) to assure the counseling team promotes culturally tailored nutrition recommendations based on current dietary guidelines. Nutrition assessment and outcomes should be captured with the use of validated dietary assessment tools and dietary quality indices appropriate to their target population. Standardizing these practices will facilitate intervention comparability and replicability and ultimately better target the needs of this community.

1 Introduction

Culturally appropriate dietary recommendations are particularly important for the Latino community in the United States, which is both disproportionally affected by T2D and carries rich culinary traditions that vary according to their country of origin. Indeed, the prevalence of diagnosed diabetes among US-living adults of Hispanic origin is of 11.7% (compared to 6.9% in their non-Hispanic White counterparts); and that prevalence varies depending on the Hispanic ethnicity subgroup (Puerto Rican at 13.3%, Mexican at 11%, Dominican at 9.4%, and Cuban at 9.0%) (1). Furthermore, the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) landmark study reported a mere 1.7% of participants met the Ideal diet criteria for cardiovascular health (2). Although common staple foods can be found in most Latin American countries, each nation has its own culinary traditions that are upheld after these groups migrate to the United States (3). There is consequently an urgent need for medical nutrition therapy (MNT) tailored to the cultural background of each patient to effectively address the disproportionate health disparities within the US Latino community.

Optimal nutrition therapy is one of the cornerstones of type 2 diabetes (T2D) prevention and management. Indeed, strong evidence supports MNT carried out by a registered dietitian nutritionists (RDNs) can effectively reduce hemoglobin A1c (HbA1c) by 2.0% in patients with T2D (4). The American Diabetes Association’s (ADA) consensus recommendation on dietary patterns for T2D management include emphasizing consumption of non-starchy vegetables, minimizing added sugars and refined grains, and choosing whole foods over highly processed foods whenever possible. However, this is not a “one size fits all approach,” as dietary habits and food choices are influenced by many factors outside of health management, such as cultural and personal preferences, socioeconomic status, the food environment, etc. (5). Consequently, successful diabetes self-management education and support (DSME/S) should tailor its nutrition component to the individual’s environment and cultural background.

Tailored nutrition interventions are necessary for an overall successful DSME/S, however the process and impact of the current interventions remain understudied in this population. Reviews on interventions for US-based Latinos with T2D have studied the effectiveness of their cultural components (6), the use of community health workers (CHW) (7), the emotional well-being in Latinos (8), and even “innovative approaches” on T2D disease progression (9); however, no review has focused on assessing the interventions’ nutrition component and dietary outcomes. Consequently, we conducted a scoping review of nutrition interventions targeting Hispanic/Latino communities in the United States with T2D, aiming to identify key characteristics that are either commonly shared or notably absent in these interventions.

2 Methods

2.1 Literature search

We comprehensively searched five electronic databases including PubMed, EMBASE, Cochrane, CINAHL, ERIC, and PsycINFO using combinations of the following keywords: (nutrition OR nutrition intervention OR nutrition trial OR diet OR diet intervention OR diet trial OR nutrition program OR diet program OR medical nutrition therapy) AND (Hispanic OR Latino OR Mexican OR Puerto Rican OR Dominican OR Central American OR South American OR Cuban) AND (type 2 diabetes OR type 2 diabetic OR diabetes OR diabetic OR T2DM OR T2D). We further applied the following filters: clinical trials and controlled clinical trials for article type, English for article language, Humans for study species, and publication date within the last 20 years (2002–2023).

Article titles were combined, and duplicates were removed using Endnote (version 20.4) before transferring titles to Rayyan where independent title and abstract screening took place by two reviewers (MG and MS-G). The reviewers discussed conflicted articles and the final list was re-transferred to EndNote where full text articles were stored for handsearching individual bibliographies and developing the study’s reference list. Studies were excluded if the study population was not diagnosed with T2D or exclusively self-identified Hispanic/Latinos living in the US. We included all primary, secondary, and pilot studies with nutrition/diet related outcomes. We then further excluded if the intervention protocol lacked a well-documented nutrition intervention or if the measurements captured by the intervention lacked any sort of nutrition/diet related outcome. We reviewed the references of the articles selected for full text screening for inclusion.

2.2 Data extraction

Data collected from each article included information pertinent to the intervention’s participants, frameworks, and outcomes. Specifically, participant location (both geographical and intervention environment), mean age, sex, education, income, health insurance status, and acculturation metrics were extracted from the articles’ study characteristics tables. Intervention information included sample size, intervention period and number of sessions, background on the counselor delivering the intervention, and control group treatment (if any). We also reported if the researchers specified their intervention as a pilot study, the use of a particular framework or model for targeted behavior change, the number/h and description of nutrition education sessions, and the specific culturally tailored components of the interventions. Finally, the dietary outcomes, the specific tools used to measure those dietary outcomes, and changes in HbA1c and/or weight were also captured in this review. We reported both significant and non-significant changes in HbA1c and weight due to the inclusion of both pilot studies and full-scale interventions, as well as the fact that clinically significant outcomes do not always overlap with statistical significance (10).

3 Results

3.1 Study selection

The search and study selection process are described in Figure 1. The combined search of the five databases yielded 1,339 abstracts, 292 of which were identified as duplicates and 953 were further excluded by the title/abstract screening. Out of 94 articles assessed by full text screening, 17 fit our inclusion criteria (11–27). We then included an additional seven articles (28–34) that were referenced by the included articles and one additional secondary analysis (35) from our included articles with interesting nutrition/diet related outcomes. A total of 25 articles (18 primary analyses and seven secondary analyses) are included in this review. Of note, at least 47 studies assessed during the full text screenings of articles found in the database and reference searches had to be excluded because no dietary outcome of any kind was captured by the intervention.

Figure 1

3.2 Participant characteristics

A summary of the general reported characteristics of participants in our selected interventions is reported in Table 1. Sample sizes ranged from 21 to 300 participants, mean ages ranged from 49.3 to 62.6 years, and female participants ranged from 55 to 100% of the participants. Most of the studies were carried out in participants with Mexican ethnical origin living predominantly in California, Texas, and Chicago; followed by participants with Puerto Rican and Dominican ethnical origins mostly living in Connecticut and Massachusetts. Nine studies reported at least 88% of their participants were born outside of the US. A part from ¡Viva Bien!, Spanish was the primary or home language for 61–97% of the participants in the 12 studies that reported this metric. Six studies measured acculturation, where three reported an average score ranged from 0 to 1.6 out of five (36) and the other three reported 48–100% of the participants with a “low” acculturation score. In terms of education, only four out of the 16 studies capturing this metric reported most participants attaining 12 or more years of education. In terms of income, only two studies reported most of their participants had an annual household income above $20,000/year. Finally, participants received the intervention exclusively in a community setting (churches and libraries) for two studies, exclusively in outpatient or health clinics in 10 studies, or a mixture of the two in 4 studies. Two studies carried out part of their interventions in participant homes.

3.3 Intervention characteristics

Key characteristics of the 25 interventions are summarized in Table 2. Eight studies labeled themselves as pilot studies. Intervention periods ranged from 1.2 to 24 months, and five to 36 sessions. Most of the interventions were carried out in 3–6 months with 10–12 sessions. In terms of control groups, three did not receive any treatment at the time of the intervention; two exclusively received education material, seven received either DSME/S or usual care, and three received a combination of education material with either DSME/S or usual care. Three studies did not report having a control group (two of them being pilot studies).

Descriptions of the counselors carrying out the intervention and level of detail about the intervention itself ranged widely across studies. Counselors were referred to as “educator/facilitator” or “lifestyle community coach” with no further specifications in two studies. Six studies reported using counselors with no background in healthcare, such as lay leaders, promotaras, and Community Health Workers (CHWs). Of these, two reported their counselors had diabetes or had a close family member/friend with diabetes (Imagínate una Buena Salud and Amigos en Salud), and four studies had bilingual/bicultural counselors (11, 28, 30, 33). Seven studies had teams of counselors who were exclusively healthcare workers and three had teams that combined healthcare workers and layleaders. Registered dietitian nutritionists (RDNs) were reported to be part of six of these counseling teams and part of the training/coordinating team of three additional interventions (12, 16, 26). The training or use of motivational interviewing (MI), a patient-centered, goal-oriented counseling technique recently adopted in the dietetic profession (37), was reported in a total of five studies (11, 12, 14, 16, 26).

In terms of intervention frameworks and components, Social Cognitive Theory (SCT) was reported to be used in five interventions, and other models included Social Learning Theory, the Transtheoretical Model, Behavior Change Theory, and Self Determination Theory. Furthermore, all interventions mentioned the use of culturally tailored components, although the descriptions of these components ranged extensively. Whereas some interventions simply stated they used culturally relevant tools (14, 16, 30), other interventions extensively elaborated their cultural considerations (32). Most of the culturally tailored components mentioned were adapting and providing culturally relevant recipes, availability of the material in Spanish, and encouragement of family members or close friends to participate as a support person.

Finally, although very few studies reported the number of sessions/h dedicated to nutrition education/counseling, most of the interventions provided a description of their nutrition component. We summarized a total of nine nutrition topics and strategies commonly used throughout the included interventions in Table 3. Only eight out of the 18 primary studies (44%) reported using three or more of these nutrition components. The most popular nutrition education topics included promoting a food labels, healthy dietary pattern, and portion control; as they were mentioned in seven, six, and five interventions, respectively. Four studies explicitly mentioned carbohydrate monitoring/elucidating the effects of macronutrients on human physiology (12, 16, 19, 31). Encouragement for reducing consumption of “low-fat” foods was reported in five studies (18, 19, 22), but only two distinguished between the different types of dietary fat (16, 26). Promotion of dietary fiber was mentioned in three studies (16, 19, 26). Three interventions mentioned carrying out cooking demonstrations (22, 32, 33), three mentioned taking a trip to the grocery store (16, 21, 32), and one reported using food models and hand measurements (34). Finally, despite the large number of studies stating to use behavior change models, only two interventions specifically mentioned the use of goal setting as part of their nutrition intervention (13, 32). Short descriptions based on the information reported by each intervention were summarized in Supplementary Table S1.

3.4 Nutrition intervention impact and outcomes

Lastly, the reported dietary assessment tools and the general direction of dietary outcomes from each of the included studies are summarized in Table 4. Half out of the 18 primary studies used subscales of the Summary of Diabetes Self-Care Activities (SDSCA) measure, the Behavioral Risk Factor Surveillance System BRFSS, self-developed questionnaires, or did not report their assessment tool. The dietary assessment tools used by the other half of the interventions included short dietary screeners, 24-h recalls, and food frequency questionnaires (FFQs). Only two interventions reported using dietary assessment tools validated in a Mexican American group (19, 24).

Dietary outcomes widely vary and cannot be easily compared since they were captured by different assessment tools. The SDSCA subscales’ and BRFSS’s scope was limited to capturing frequency of fruits and vegetables (FVs) and fatty food intake frequency (11, 14, 30). The studies using screeners captured additional information depending on the researcher’s nutrition components of interest: EnForma-Diabetes used the PREDIMED screener to measure changes in a Mediterranean dietary pattern and intake of SSBs, seafood, and pulses; the researchers using the Screener for Mexican Americans (19) focused on capturing dietary fiber and fat intake; and Unidas por la Vida used the Block Alive screener to capture glycemic load as well as FV and saturated fat (SFA) intake. Finally, researchers using 24-h recalls or FFQs could take a wider range of dietary components (total energy, macronutrients, micronutrients) (24, 32) and calculate overall diet quality scores (16, 26). ¡Viva Bien! and Dialbest used 24-h recall and FFQ as their assessment tools respectively, but only reported diet quality and SFA intake, respectively.

Changes in HbA1c and one or more anthropometric measures (body weight, waist circumference, or BMI) are reported in Supplementary Table S2. These outcomes were reported in 88 and 72% of the primary interventions, respectively. Changes in HbA1c ranged from −1.4 to +1.2%, where significant changes ranged from −0.3 to −1.4%. Of note, changes in HbA1c ranged from −0.3 to −0.93% in the four interventions in which RDNs were part of the counseling team. Additionally, the three interventions with the highest significant change in HbA1c (−0.85 to −1.22%) and a nutrition intervention description reported using 3,4, and 6 of the 9 nutrition topics reported in Table 3. In terms of anthropometric measures, changes in body weight captured in 5 studies ranged from −2.3 to +0.6 kg; changes in waist circumference captured in 5 studies ranged from −0.98 to −4.2 cm; and changes in BMI captured in 7 studies ranged from −2.04 to +0.6 kg/m². Interestingly, six interventions studied correlation or mediation effects between diet and clinical outcomes, where notably Dialbest reported food label use mediated reduction in mean HbA1c levels and decreases in SFA intake significantly correlated with decreases in HbA1c in ¡Viva Bien! and En Balance.

4 Discussion

The present review summarized the current evidence in the development and impact of nutrition-related components on diabetes self-management interventions in US-living Hispanic/Latinos. We described the characteristics of the participants, rigorously searched for pertinent intervention details in the primary analyses/supplemental information/published protocols whenever available, and thoroughly examined the nutrition assessment tools and dietary outcomes presented in each intervention. We observed a widespread adoption of culturally tailored strategies and nutrition-related components in the interventions studied. However, it is essential for future research to acknowledge several limitations and inconsistencies identified in our findings related to protocol development, intervention implementation, and nutrition assessment (Figure 2).

Figure 2

The level of information provided on the intervention’s content, development, and execution ranged quite extensively between studies. For example, although all researchers claimed their intervention was culturally tailored, reports on how these interventions were adapted to the Latino community ranged from simply “providing culturally relevant resources” to descriptions of many culturally relevant practices (e.g., culturally relevant resources, ethnic appropriate recipes, socializing and family-oriented settings). Tailoring individual nutrition needs on personal and cultural preferences is an essential goal of nutrition therapy (5). A recent systematic review assessing the effectiveness of culturally tailored diabetes prevention strategies in several minority populations found that interventions were most effective when they incorporated culturally relevant targeting strategies in the four domains of facilitators, language, location, and messaging (FiLLM conceptual framework) (38). Given the diversity of cuisines and cultures within the US Latino population itself, tailoring nutrition interventions to specific cultural practices and preferences is crucial for their effectiveness, and transparency in reporting these culturally adapted strategies is essential for the validity and reproducibility of the research. Varying levels of detail were also found for the description of the nutrition component of the intervention, ranging from simply stating its presence to elaborating a detailed description for each nutrition session. It is consequently difficult to compare the nature of the interventions between the different studies due to this lack of consistent reporting. There is a pressing need for greater emphasis on standardizing the description of interventions to ensure a level of detail that facilitates comparison, replication, and compliance with the latest dietary and DSME/S guidelines (Figure 2, Protocol Development).

This review underscores the importance for researchers to meticulously consider their selection of dietary assessment methods during protocol development (Figure 2, Nutrition Assessment). Utilizing a tool that is not only validated for dietary assessment but also tailored to the specific population and aligned with the intervention outcomes is crucial for accurately capturing dietary intake. The BRFSS is a surveillance system created by the CDC to track state and national level data on fruit and vegetable intake, and consequently may not be the most ideal tool to capture individual changes of overall dietary pattern (39, 40). Significant correlations of the SDSCA subscales with 3- or 4-day food records and FFQs were previously demonstrated, which suggest the SDSCA is an adequate tool to approximate general and specific diet (41). However, the Spanish version of the SDSCA was validated in a Hispanic community based in Spain (42), which is not representative of the varied Latino ethnicity subgroups present in the US. The use of FFQs has been validated to assess food intake during dietary interventions studies (43), however the use of an FFQ developed for the general population likely results in biased estimates if applied in minority populations, as demonstrated by Tucket et al in Hispanic adults (44). EnBalance demonstrated a good example of examining detailed changes in dietary intake using the Southwestern FFQ, which was previously validated for the Hispanic population (45). RDN-administered 24-h recalls, although high in participant and researcher burden (46), can help accurately capture complete dietary intake by inclusion of ethnic foods not captured in FFQs and overcome issues of participant literacy reported by several interventions (16, 26, 29). Additionally, they can also be used when a dietary assessment tool validated in the target population is not available. Investigating the dietary habits of the Hispanic/Latino population requires meticulous attention to cultural factors. Incorporating cultural adaptation into dietary assessment tools is imperative to ensure the accuracy and reliability of dietary intake evaluations within this ethnic group.

In addition to cultural adaptation, the selection of an appropriate dietary assessment method should prioritize monitoring dietary habits relevant to the management of T2D. The latest nutrition therapy goals set forth by the ADA (2019) emphasize the support of healthful eating patterns and nutrient dense foods in appropriate portion sizes balanced in macronutrients and reduced in alcohol, sodium, and nonnutritive sweeteners (47). It may therefore be preferable to prioritize assessment of overall diet intake over reports of a single nutrient or food group intake. The use of appropriate diet quality indices (DQI) should be considered in future interventions to approximate overall diet quality, as they are easily reproducible and comparable, analytically simple to compute, and result in meaningful, interpretable measures that can be associated with health outcomes (48) (Figure 2, Nutrition Assessment). Furthermore, a recent meta-analysis demonstrated that DQIs were effective at measuring change in diet quality in adults with and without chronic health conditions participating in RCTs with a dietary intervention (49). The Alternative Healthy Eating Index (AHEI) score, one of the validated DQI’s from the meta-analysis, was used in Latinos en Control to accurately capture participant dietary patterns from three administered 24-h recalls. This intervention successfully captured both general dietary patterns and intakes of specific nutrients in their primary analysis (26) and the researchers were consequently able to run interesting associations between dietary and anthropometric outcomes in their subsequent secondary analysis (27). The intervention carried out by Latino en Control exemplifies proper selection of nutrition assessment methods and outcomes for future interventions.

Finally, RDNs are an integral part of both the development of these interventions and overall T2D prevention and management strategies. The Academy of Nutrition and Dietetics have accumulated compelling evidence supporting MNT’s effectiveness in the management of several chronic conditions, including obesity and T2D (50, 51). Additionally, RDNs receive extensive training in applying MI in patient counseling sessions, which promotes the use of compassion and collaboration to illicit patient internal motivation and instigate sustainable behavior change (52) (Figure 2, Intervention Implementation). RDNs who are part of the US Latino community or have familiarity with its culture and culinary traditions are uniquely positioned to tailor MI, nutritional counseling, and other strategies effectively to this group. Indeed, the use of culturally targeted facilitators, individuals from the same cultural and social background as the targeted group, has been shown to lead to successful diabetes prevention interventions in several ethnic minority groups, including Hispanic/Latino population (38). However, given the shortage of bicultural healthcare professionals, ensuring that non-Latino/Hispanic providers are familiar and competent to provide socially oriented recommendations is equally important. Culturally competent care of RDNs and the rest of primary care team is fundamental for successful interventions by promoting patient trust, adherence to treatment plans, and ultimately reducing health disparities among minority groups (53, 54). This practice is particularly important in diabetes care, which requires individualized treatment plans and nutrition strategies that must be tailored to personal and cultural preferences, literacy and numeracy, access to healthful food choices, and ability to make behavioral changes of the target population (5).

5 Conclusion

This review describes the nutrition components of interventions aimed to improve T2D outcomes in US-based Latinos/Hispanics. Our results highlight the importance of selecting cultural adapted dietary assessment tools monitoring dietary habits relevant to the management of T2D. The inclusion of bicultural RDNs in the counseling team assures the promotion of culturally tailored nutrition recommendations delivered with methods facilitating behavior change to promote a successful nutrition intervention. Figure 2 aims to guide investigators in developing effective nutrition interventions for the Latino/Hispanic community with T2D, while also ensuring their methods and findings are clearly reported to the broader research community. These guidelines could be applied to other populations as well. Standardizing these practices will aid in facilitating intervention comparability and replicability, ultimately leading to improved health outcomes in this high-risk population.

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