Content uploaded by Marino De Leon
Author content
All content in this area was uploaded by Marino De Leon on Sep 17, 2014
Content may be subject to copyright.
En Balance Participants Decrease Dietary Fat and Cholesterol
Intake as Part of a Culturally Sensitive Hispanic Diabetes
Education Program
Lorena M. Salto, Zaida Cordero-MacIntyre, Lawrence Beeson, Eloy Schulz, Anthony Firek,
and Marino De Leon
From the Loma Linda University, Center for Health Disparities and Molecular Medicine, Loma
Linda, California (Ms Salto, Dr Cordero-MacIntyre, Dr De Leon); Loma Linda University, School of
Public Health, Department of Epidemiology and Biostatistics, Loma Linda, California (Ms Salto,
Dr Beeson); Loma Linda University, School of Medicine, Loma Linda, California (Dr Schulz, Dr De
Leon); JL Pettis Memorial VA Medical Center, Endocrinology, Loma Linda, California (Dr Firek);
Loma Linda University, School of Public Health, Department of Nutrition, Loma Linda, California
(Dr Cordero-MacIntyre)
Abstract
Purpose—The purpose of this study was to assess dietary intake habits of Mexican American
Hispanic adults participating in the En Balance diabetes education program.
Methods—En Balance is a 3-month culturally sensitive diabetes education intervention for
Spanish-speaking Hispanics. Of the 46 participants enrolled, 39 mainly Mexican American
Hispanic adults with type 2 diabetes completed the En Balance program. Participants lived in the
Riverside and San Bernardino counties of California, and all participants completed the program
by June 2008. Dietary intake was assessed at baseline and at 3 months using the validated
Southwest Food Frequency Questionnaire.
Results—Clinically important decreases in glycemic control and serum lipid levels were
observed at the end of the 3-month program. The baseline diet was characterized by a high intake
of energy (2478 ± 1140 kcal), total fat (87 ± 44 g/day), saturated fat (28 ± 15 g/day), dietary
cholesterol (338 ± 217 mg/day), and sodium (4236 ± 2055 mg/day). At 3 months, the En Balance
group mean intake of dietary fat (P = .045) and dietary cholesterol (P = .033) decreased
significantly. Low dietary intakes of docosahexaenoic acid, eicosapentaenoic acid, and vitamin E
were also observed in these adults with type 2 diabetes.
Conclusions—The En Balance program improved glycemic control and lipid profiles in a group
of Hispanic diabetic participants. En Balance also promoted decreases in dietary fat and dietary
cholesterol intake.
According to 2007 prevalence statistics, diabetes affected about 24 million people
nationwide, or about 7.4% of the US population.1 Diabetes disproportionately affects
minority groups such as Native Americans and Alaska Natives, Blacks, and Hispanics. In
2007, the nationwide prevalence rate for physician-diagnosed diabetes in Hispanics was
10.4% overall and 11.9% for Mexican Americans.1 Hispanics suffer more from diabetic
complications when compared to national rates and when compared to non-Hispanic whites.
1
Correspondence to Marino De Leon, 11085 Campus Street, Loma Linda, CA 92350 (madeleon@llu.edu).
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav.
NIH Public Access
Author Manuscript
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
Published in final edited form as:
Diabetes Educ
. 2011 ; 37(2): 239–253. doi:10.1177/0145721710394874.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Hispanic diabetes health disparities are prevalent at the national, state, and county level in
California.2 California is home to the largest population of Hispanics in the United States
(ie, 31% of the Hispanics in the US).3 The Hispanic population of California is
overwhelmingly Mexican (84%).3 In countywide comparisons, Hispanics still have higher
rates of diagnosed diabetes when compared to non-Hispanic whites.2 Along with having
higher rates of diagnosed diabetes, Hispanics in California are largely uninsured.2
The US Census Bureau projects that Hispanics will comprise 24% of the population by
2050.4 When compared to non-Hispanic whites, Hispanics continue to bear a
disproportionate burden of disease, disability, and death from certain health conditions.5
Limited access to health care, underdiagnosis, low rates of blood glucose self-monitoring,
and low income and education may contribute to the diabetes health disparities seen in the
Hispanic population. Low literacy and, specifically, low health literacy may be the
underlying obstacle to surmount when working with disadvantaged populations.6–9
Culturally appropriate diabetes education interventions are well received by Hispanic
groups,10,11 and several have been designed and implemented with the aim of improving
glycemic control,11–14 increasing diabetes knowledge and self-efficacy,15–17 or both.18–20
Nonetheless, few diabetes education studies have adequately characterized and addressed
the dietary intake patterns of disadvantaged Hispanics. Assessing dietary patterns in
Hispanics with diabetes is increasingly relevant given the documented protective effects that
nutrients such as docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) have
against cardiovascular disease.21–23 Mexican American adult estimates for DHA and EPA
intake vary: according to 2002 dietary intake estimates,24 0.04 to 0.08 g per day for DHA
and 0.02 to 0.04 g per day for EPA; according to 2008 dietary intake estimates,25 0.05 g per
day for EPA and 0.09 g per day for DHA. As with other dietary intake trends, higher
education and acculturation have been associated with higher intakes of DHA and EPA.26
Recent comparisons report lower omega-3 fatty acid consumption in Hispanics when
compared to non-Hispanic whites and African Americans.27,28
In light of the projected Hispanic population growth and because alarming diabetes health
disparities continue to exist, it is imperative to design effective, culturally competent
diabetes intervention programs that address the lifestyle habits that are at the core of the
diabetes and obesity epidemics in Hispanics. The purpose of this study was to assess the
dietary intake habits of Mexican American Hispanic adults participating in the En Balance
diabetes education program. The program objectives are to improve glycemic control,
change dietary habits, and increase physical activity in underserved San Bernardino County
Hispanics with type 2 diabetes.
Methods
Sample and Setting
A total of 39 Hispanic adults between 25 and 75 years of age with self-reported type 2
diabetes completed this 3-month intervention study. The Southern California En Balance
participants were all San Bernardino and Riverside county residents. Program recruitment
efforts specifically targeted Hispanic disadvantaged adults with type 2 diabetes by posting
recruitment flyers in local grocery stores and by publishing a program hotline in newspaper
articles, as well as through announcements in a Spanish radio station and through physician
referrals from local medical clinics. The participants were initially screened through
telephone interviews and excluded if they had a previous clinical history of drug or alcohol
abuse, steroid use, and psychological or other major systemic disease that could affect
program compliance, such as end-stage renal disease. The participants were also interviewed
in person by a research staff member to determine diabetes history, medication use, and diet
and physical activity habits. The En Balance program was conducted in 2 phases: 26
Salto et al. Page 2
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
participants finished the program in the first phase and 13 finished in the second. Of the
original 46 participants enrolled, 39 completed the En Balance diabetes education program.
The participants that dropped out of the program did so for different reasons: 2 traveled out
of the country during the most active part of the program; another 2 experienced changes in
their work schedules, which could not accommodate the program meetings; another was
diagnosed with a serious liver disease; and the last 2 stopped coming to the program
meetings. All participants agreed to and signed a Health Insurance Portability and
Accountability Act–compliant informed consent form. The study was approved by the Loma
Linda University Institutional Review Board.
Data Collection
Baseline and 3-month data collection included fasting blood serum samples; bioelectrical
impedance analysis; anthropometric measurements for weight, height, and waist and hip
circumferences; and dual-energy X-ray absorptiometry (Hologic Fan Beam, Discovery A
Software Version, Hologic Inc, Bedford, MA) values for all 39 participants. Blood serum
samples were tested at the Loma Linda University Medical Center laboratory to determine
fasting blood glucose, A1C, insulin, and lipid profiles (high-density lipoprotein [HDL], low-
density lipoprotein [LDL], total cholesterol, and triglycerides). All anthropometric
measurements were taken twice for reliability, using Lohman’s standardized techniques.29
Weight and height were assessed using a balance scale (Detecto, Web City, Missouri) and a
wall-mounted stadiometer (Holtain Ltd Crymych, Dyfed, England), respectively. The
validated University of Arizona Southwest Food Frequency Questionnaire30 was
administered to the En Balance participants during organized questionnaire clinics. All
dietary intake records were analyzed using the Metabolize Nutrient Analysis System 2.5.31
The En Balance Diabetes Education Program Approach
The En Balance approach has been described elsewhere.32,33 Briefly, the En Balance
Diabetes Education Program is a hands-on, culturally competent diabetes education program
for Hispanics. After baseline data collection, the study participants attended a
comprehensive diabetes education program hosted at the Loma Linda University School of
Public Health. Hispanic professionals (registered dieticians, dentists, physical therapists, and
nurses) conducted all classes in Spanish. Clinics were scheduled on Sundays, and classes on
weekday evenings, to accommodate participants’ work schedules. Research staff also
arranged transportation for participants who were otherwise unable to make the clinic or
class appointments. The diabetes education program consisted of four 2-hour presentations.
The En Balance participants were taught how to self-monitor their glucose levels and record
their blood glucose levels in a log. All participants received free glucose monitors, strips,
and lancets. Nutrition topics were taught using a hands-on, culturally relevant approach
using food models and comparable hand measurements. Recommendations for changes in
diet focused on smaller portion sizes and choosing healthier alternatives within culturally
specific food groups, rather than forgoing traditional dishes.
Data Analysis
Statistical analyses were performed using SPSS 17.0. Power calculations suggested that 44
participants were necessary to have at least 80% power to detect a 13% decrease in fasting
blood glucose. However, the effective power was reduced to 75% based on the 39
participants who completed the program. Type 1 error was set at α = .05 for statistical
significance. In this experimental design, the participants are their own controls. Paired-
samples t tests, independent-samples t test, and Wilcoxon signed-rank tests were used to
compare baseline and 3-month means; χ2 was used to compare categorical data. The data are
shown as mean ± SD. Spearman’s correlation coefficient was used to determine the linear
relationship between blood serum changes and dietary changes.
Salto et al. Page 3
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Results
Overall, the mean age of the participant group was 53.95 ± 11.21 years; the mean weight
was 81.62 ± 17.66 kg; and the mean body mass index was 31.67 kg/m2. Men made up about
41% of the study sample, and the primary language for most of the group (89.7%) was
Spanish. Height and body mass index were significantly different between men and women
(see Table 1); the difference in their height largely accounts for the difference in their body
mass index. About 48.7% of the participants had less than a high school education, and the
majority completed their education outside of the United States.
The group of 39 participants had an average baseline fasting blood glucose of 167.9 mg/dL,
a baseline A1C mean of 8.5%, and an insulin mean of 13.7 uU/mL (Table 2). The
participants made positive clinical improvements in all three blood glucose management
markers. At 3 months, the A1C mean decreased (−0.894%, P = .008) and the insulin mean
increased 3.01 uU/mL (P = .05) for the group. Total, LDL, and HDL cholesterol means
decreased 13.43 mg/dL (P = .005), 10.28 mg/dL (P = .030), and 2.84 mg/dL (P = .012),
respectively. Body weight and body mass index means did not change appreciably from
baseline to 3 months.
Table 3 summarizes changes in food frequency questionnaire dietary intake values at the end
of the En Balance Diabetes Education Program. Eight food frequency questionnaire records
were excluded from the nutrient intake statistical analyses because they underestimated total
nutrient intake (ie, energy estimates fell under 1000 kcal) or because they overestimated
dietary intake (ie, energy estimates exceeded 5000 kcal) and were inconsistent with age,
occupation, and body mass index. Subsequent dietary intake analyses were performed with
the data from the remaining 31 participants. The group consistently decreased overall dietary
intake by the end of the 3-month program. The group decreased its mean intake of protein (P
= .058) and dietary cholesterol (P = .033) in line with the total decrease in energy intake (see
Table 3). Although not statistically significant, the group means for carbohydrates, energy,
and saturated fat decreased (see Table 3).
Table 4 displays the dietary fat intake profile for the En Balance participants at baseline and
3 months, by sex and as compared to recommended national guidelines.34 Total fat intake
was high for both men and women at baseline when compared to the acceptable
macronutrient distribution range (see Figure 1).35 At 3 months, men’s and women’s mean
total fat intake fell within recommended guidelines (see Table 4 and Figure 1). Saturated fat
intake was high for men and women at baseline, but men decreased their mean intake as a
group and achieved normal mean intake levels at 3 months. Linoleic and α-linolenic acid
intake varied between men and women (see Figure 2). DHA and EPA mean intake was low
for the men and women of the program when compared to the adequate intake
recommendations set forth by the Workshop on the Essentiality of and Recommended
Dietary Intakes for Omega-6 and Omega-3 Fatty Acids (see Figure 3).36 Only the En
Balance men were well within the recommended guideline to consume less than 10% of
calories from saturated fat.
Table 5 summarizes the En Balance participant anti-oxidant intake profile. In general, the
antioxidant intake for this group was well above the dietary reference intakes for both sexes,
with the exception of vitamin E. Intake of vitamin E was lower than the Dietary Reference
Intake recommendations for both sexes at baseline, and it was particularly low at 3 months
(see Table 5).35 Both sexes decreased their overall antioxidant mean intake, except that men
increased vitamin A and beta carotene intake at 3 months. The 3-month mean increase in
vitamin A and beta carotene observed in the En Balance male group was due to 2 influential
Salto et al. Page 4
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
outliers. Only the vitamin C decrease in women was statistically significant from baseline to
3 months (see Table 5).
Table 6 summarizes selected correlations between changes in blood serum values and
dietary intake variables at 3 months. At the end of the 3-month En Balance diabetes
education program, changes (ie, 3 months minus baseline) in serum A1C were positively
correlated to changes in percentage calories from saturated fat (P = .036). Changes in serum
total cholesterol values were negatively correlated to changes in calcium, phosphorus, zinc,
vitamin A, and vitamin C intake. Likewise, changes in serum LDL cholesterol were
negatively correlated to changes in calcium, phosphorus, zinc, vitamin A, vitamin C and
arachidonic acid intake, as well as energy, linolenic acid, and arachidonic acid intake (see
Table 6).
Discussion
The En Balance Effect on Glycemic Control and Body Composition
The participants of the En Balance Diabetes Education Program were able to improve
glycemic control and serum lipid management levels. Although the decrease in fasting blood
glucose from baseline to 3 months was not statistically significant (mainly due to power
considerations), the decrease was clinically important. As a group, the participants were able
to lower total cholesterol and LDL cholesterol. HDL cholesterol also decreased, due to the
overall total cholesterol decrease, but this HDL decrease was relatively small. The
participants did not improve in mean triglyceride levels. This finding is consistent with what
the American Diabetes Association calls “the most common pattern of dyslipidemia in type
2 diabetes patients”: elevated triglyceride levels and decreased HDL cholesterol levels.37
According to the American Diabetes Association, the initial therapy for elevated triglyceride
levels is better glycemic control. The En Balance Diabetes Education Program approach was
effective in accomplishing similar clinical improvements in a previous Hispanic participant
group (n, 34).32 Note, however, that the En Balance participants (n, 38) did not lose weight
at the end of the 3-month program. In the CoDE program (ie, the Community Diabetes
Education program) for Mexican Americans, body mass index did not significantly change
from baseline to 12 months in spite of significant improvements in A1C at 12 months.14 In
another diabetes intervention tailored for Mexican Americans, significant weight loss was
not necessarily associated with significant A1C decreases.20
Cultural competency is a term that has been used to define diabetes education programs that
provide interventions that are accessible to the community and reflect the cultural
characteristics and preferences of that community.18 Brown et al documented similar
glycemic management success using a culturally competent diabetes education program for
Mexican Americans along the Texas-Mexico border.13,15,16,18 Although the En Balance
participant group (n, 39 for clinical data) was smaller than the group sample in the Starr
County study (n, 256), En Balance participants experienced similar significant
improvements in A1C levels.18 They successfully improved glycemic control in a 3-month
interval with only 8 hours of diabetes education, whereas the Starr County intervention
required 52 contact hours.18 Culica et al found that A1C was significantly reduced (P < .01)
in patients who participated in a low-cost, culturally appropriate 12-month CoDE
intervention that targets Mexican Americans.14 Another diabetes management program,
called Project Dulce, reported improved clinical outcomes similar to the En Balance
findings on A1C and total cholesterol in a group of 210 high-risk Hispanics with type 2
diabetes.19
Salto et al. Page 5
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Food Frequency Questionnaire Use in Hispanics
Although other culturally competent diabetes education programs have reported positive
clinical changes, En Balance is one of the first, to our knowledge, to report detailed changes
in dietary intake and lifestyle habits. The survey instrument used, the University of Arizona
Southwest Food Frequency Questionnaire, was validated for a Hispanic population in
Arizona; it is an adaptation of the Arizona Food Frequency Questionnaire,30,38 which is a
version of the Health Habits and History Questionnaire, developed at the National Cancer
Institute.38 The questionnaire contains foods common in the Southwest region of the United
States, and it is printed in Spanish with English translation. The complete adult
questionnaire includes a list of about 159 foods, and it asks for frequency and portion size
(in small, medium, and large).30 The Arizona Food Frequency Questionnaire and the
Southwest Food Frequency Questionnaire have been used in other studies.39,40
The use of food frequency questionnaires in minority populations warrants special attention.
41–43 The Southwest Food Frequency Questionnaire has been validated in a mainly Mexican
American Hispanic group; it lists commonly consumed Mexican foods; and it reports dis-
attenuated correlations that range from r = .55 for energy means to r = .68 for protein.30 Due
to the overall low literacy of the participants and the length of the questionnaire, special
clinics were organized to administer the questionnaire by interview. Validation of food
frequency questionnaires and low literacy among disadvantaged Hispanics are well-
documented concerns that can be addressed by administering questionnaires through
interview.43–45 Eight of 39 En Balance participants still did not accurately estimate food
intake, and their records were excluded from the nutritional analyses.
Nutritional Intake Patterns in Mexican Americans
The baseline nutritional profile of the En Balance participants characterizes an overall group
diet that is high calorie, high fat, high cholesterol, and high sodium (see Table 3). However,
this group of En Balance participants consumed higher-than-recommended levels of fiber
and certain antioxidants, such as vitamin C, vitamin A, and selenium (see Tables 3 and 5),
and the mean intakes for these antioxidants remained within the recommended values at 3
months.35 The group made clinically important nutritional intake decreases in the major
macronutrients: energy in total calories, carbohydrates, protein, total fat, dietary cholesterol,
and saturated fat (see Table 3). Of these mean decreases, only total fat (P = .045) and dietary
cholesterol (P = .033) were statistically significant, but more important, the decreases
measured at 3 months bring the group mean intake of total fat and cholesterol within
recommended ranges.35 Other researchers who have attempted to characterize the Mexican
American diet have found that, traditionally, it is characterized by a high intake of fiber as
well as cholesterol and a greater proportion of energy from fat.46,47 If primary language and
country of birth (see Table 1) are used as a proxy for acculturation in the En Balance group,
then the fiber and vitamin A baseline and 3-month intakes support previous findings that
Mexican Americans born in Mexico and those that are less acculturated consume more fiber
and higher levels of vitamin A.48–50 However, choosing a healthier traditional Mexican diet
may be confounded by the overall low literacy and low English literacy of the En Balance
participants.8,9,26,51 The baseline and 3-month male and female mean intakes of vitamin E
were lower than dietary reference intake recommendations but comparable to the low
national estimates of intake across ethnic groups, according to data from the National Health
and Nutrition Examination Survey, 2005–2006.25,35 Likewise, the baseline En Balance
participant mean intake of sodium was much higher than the recommended adequate intake
values, and it exceeded tolerable upper intake levels but was similar to the general high-
sodium American diet.25,35
Salto et al. Page 6
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
The total fat, saturated fat, and dietary cholesterol decreases at 3 months may account for the
significant decreases in serum levels of LDL, HDL, and total cholesterol, despite the lack of
significant weight loss in the participant group. Although the decrease in carbohydrate
intake at 3 months was not statistically significant, the mean decrease of 44 g per day is
roughly equivalent to a reduction of 3 starch servings or 3 corn or flour tortillas a day,
according to the American Diabetes Association exchange system.52 These results imply
that the En Balance participants responded to program recommendations to decrease tortilla
intake to 1 per meal. The group decrease in serum A1C probably resulted from this decrease
in carbohydrate intake. Also, the positive correlation between change in A1C and change in
percentage calories from saturated fat, from baseline to 3 months (see Table 6), suggests that
those who decreased their A1C levels also decreased their intake from saturated fat. The
largest percentage decreases in dietary intake, from baseline to 3 months, came from total fat
(−18%), saturated fat (−17%), and dietary cholesterol (−23%) (see mean differences, Table
3). In comparison, carbohydrate and protein intake decreased by 13% and 15%, respectively.
Notably, the group decrease in serum LDL levels at 3 months was negatively correlated with
several dietary intake variables, including energy, vitamin A, vitamin E, vitamin C,
linolenic, and arachidonic acid, suggesting that for those who decreased in LDL levels,
intake of those nutrients increased. An increase in vitamin C intake, from baseline to 3
months, was significantly correlated to a decrease in LDL, HDL, and total cholesterol serum
levels.
Fatty Acid Intake Profile
The baseline dietary intake profile of the En Balance group of type 2 diabetes participants
shows a diet that exceeds the recommended intake of total fat and saturated fat. At baseline,
the En Balance group mean and the means for men and women (when analyzed separately)
were well above the recommended intakes according to the Dietary Guidelines for
Americans that advise that total fat intake should be within 44 g to 78 g of fat and saturated
fat should be less than 22 g of total intake, based on a 2000-kcal diet (see Table 3 and Figure
1).34 These findings are consistent with the Action for Health in Diabetes (Look AHEAD)
trial, which found that overweight adults with type 2 diabetes were consuming too much fat,
saturated fat, and sodium.53 The En Balance male mean intake of linoleic acid, already at
the minimum adequate intake guideline recommendation at baseline, fell below the adequate
intake guideline at 3 months, and although the male mean intake for α-linolenic acid did not
change from baseline to 3 months, the mean intake reflects a lower-than-recommended
intake of α-linolenic acid.34 These findings suggest that dietary interventions should be
tailored for male Hispanics who might be consuming low intakes of polyunsaturated fatty
acids. The overall En Balance group mean intake of DHA and EPA is alarmingly low (about
108 mg and 38 mg per day, respectively). Furthermore, the male mean intake of DHA and
EPA was lower than that of females at baseline (about 70 mg and 30 mg per day vs 120 mg
and 40 mg per day). En Balance men increased DHA intake, and women decreased DHA
intake at 3 months. Low intakes of omega-3 fatty acids in Hispanics were also reported by
the Action for Health in Diabetes (Look AHEAD) study, where Hispanics had a combined
DHA + EPA intake of 152 mg per day.28
Dietary recommendations for DHA and EPA are not well established. In 1999, the
Workshop on the Essentiality of and Recommended Dietary Intakes for Omega-6 and
Omega-3 Fatty Acids made recommendations for adequate intake for adults—namely, a
DHA + EPA intake of 0.65 g per day; DHA, at least 0.22 g per day; and EPA, at least 0.22 g
per day.36 The En Balance mean intakes are compared to those recommendations.
According to the Dietary Guidelines for Americans, the range of DHA + EPA intake that
results in the lowest risk of the coronary events is 246 mg per day to 919 mg per day, which
roughly translates to a recommendation of 2 servings of fish high in omega-3 fatty acids per
Salto et al. Page 7
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
week.34 Others who have reviewed the scientific evidence suggest that a therapeutically
protective intake should be between 250 mg and 500 mg per day of DHA + EPA.54,55 In a
2007 position statement, the American Dietetic Association and the Dieticians of Canada
recommended a weekly intake of 8 oz (227 g) of fatty fish, or about 500 mg of DHA + EPA
per day.56 To date, no dietary reference intakes have been nationally established.57
Even by the most conservative recommendations for cardiovascular disease protection, the
En Balance group of Hispanic participants with type 2 diabetes was consuming very low
intakes of DHA and EPA at baseline. The men of this group were at high risk for nutritional
deficiencies due to their already low α-linolenic acid intake and the demonstrated low
conversion of α-linolenic acid to DHA or EPA. A high-calorie, high-fat, high-cholesterol
and high-sodium diet, and low DHA and EPA intakes-coupled with uncontrolled diabetes,
obesity, and uninsured status—makes this group of disadvantaged adults with type 2
diabetes particularly vulnerable to diabetic complications and cardiovascular disease.
Yet the En Balance results demonstrate that Hispanic adults with type 2 diabetes can make
significant clinical improvements in glycemic control, serum lipid profiles, and dietary
intake as part of a culturally competent diabetes education program that uses few health care
resources.
Study Limitations
The En Balance Diabetes Education Program study had several limitations. First, the results
may not apply to the population at large, due to the small sample size and convenience
sampling method and because only Hispanics were chosen for the program. Second, the
program followed the participants for only 3 months, and it is not clear if the positive
clinical and dietary changes were sustained beyond then. Finally, dietary intake was
assessed via a food frequency questionnaire that was validated for use in this population but
is not free from response bias and errors in estimating dietary intake.
Conclusion
The culturally competent and language-sensitive En Balance Diabetes Education Program
was able to improve glycemic control and lipid profiles in a group of Hispanic participants
with type 2 diabetes. En Balance also promoted decreases in dietary fat and dietary
cholesterol intake, which could prevent future diabetic complications or comorbid
conditions in this group of disadvantaged diabetic adults. More studies and a longer follow-
up are needed to see if Hispanic adults with type 2 diabetes can make lasting lifestyle
changes in their dietary intake habits.
Implications for Diabetes Educators
A culturally relevant approach to diabetes education may lead to meaningful decreases in
dietary fat and cholesterol intake when Hispanic adults with type 2 diabetes are taught to
focus on smaller portion sizes and healthier choices within culturally specific food groups.
Dietary interventions should address the low DHA and EPA intakes prevalent in this
population group, by stressing consumption of a variety of culturally sensitive food choices
that include walnuts, almonds, and fatty fish, such as salmon, tuna, and sardines.
Acknowledgments
This study was funded by National Institutes of Health award No. 5P20MD001632 through the Loma Linda
University Center for Health Disparities and Molecular Medicine.
We would like to thank Gina Wheeler for her valuable input in discussing the concept of this article.
Salto et al. Page 8
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
References
1. Centers for Disease Control and Prevention. Estimates of Diagnosed Diabetes Now Available for all
US Counties. Atlanta, GA: Centers for Disease Control and Prevention; 2008.
2. University of California San Francisco, Institute for Health and Aging. California Diabetes Program:
Diabetes in California Counties. Sacramento, CA: California Department of Public Health; 2009.
3. Pew Hispanic Center. Latinos in California, Texas, New York, Florida and New Jersey [fact sheet].
[Accessed December 8, 2010]. http://pewhispanic.org/files/factsheets/10.pdf. Published March 19,
2004
4. US Census Bureau. Facts for features: Hispanic Heritage Month 2007: Sept 15–Oct 15 2007.
[Accessed December 8, 2010]. http://www.census.gov/newsroom/releases/pdf/cb07-ff14.pdf.
Published July 16, 2007
5. Centers for Disease Control and Prevention, Office of Minority Health, Office of the Director.
Health Disparities Experienced by Hispanics: United States. Atlanta, GA: Centers for Disease
Control and Prevention; 2004.
6. Kanjilal S, Gregg EW, Cheng YJ, et al. Socioeconomic status and trends in disparities in 4 major
risk factors for cardiovascular disease among US adults, 1971–2002. Arch Intern Med. 2006;
166(21):2348–2355. [PubMed: 17130388]
7. Lopez-Quintero C, Berry EM, Neumark Y. Limited English proficiency is a barrier to receipt of
advice about physical activity and diet among Hispanics with chronic diseases in the United States.
J Am Diet Assoc. 2009; 109(10):1769–1774. [PubMed: 19782177]
8. Thompson FE, McNeel TS, Dowling EC, Midthune D, Morrissette M, Zeruto CA. Interrelationships
of added sugars intake, socioeconomic status, and race/ethnicity in adults in the United States:
National Health Interview Survey, 2005. J Am Diet Assoc. 2009; 109(8):1376–1383. [PubMed:
19631043]
9. Klohe-Lehman DM, Freeland-Graves J, Anderson ER, et al. Nutrition knowledge is associated with
greater weight loss in obese and overweight low-income mothers. J Am Diet Assoc. 2006; 106(1):
65–75. [PubMed: 16390668]
10. Mauldon M, Melkus GD, Cagganello M. Tomando Control: a culturally appropriate diabetes
education program for Spanish-speaking individuals with type 2 diabetes mellitus. Evaluation of a
pilot project. Diabetes Educ. 2006; 32(5):751–760. [PubMed: 16971708]
11. Gagliardino JJ, Etchegoyen G. A model educational program for people with type 2 diabetes: a
cooperative Latin American implementation study (PEDNID-LA). Diabetes Care. 2001; 24(6):
1001–1007. [PubMed: 11375360]
12. California Medi-Cal Type 2 Diabetes Study Group. Closing the gap: effect of diabetes case
management on glycemic control among low-income ethnic minority populations: the California
Medi-Cal Type 2 Diabetes Study. Diabetes Care. 2004; 27(1):95–103. [PubMed: 14693973]
13. Brown SA, Blozis SA, Kouzekanani K, Garcia AA, Winchell M, Hanis CL. Dosage effects of
diabetes self-management education for Mexican Americans: the Starr County Border Health
Initiative. Diabetes Care. 2005; 28(3):527–532. [PubMed: 15735182]
14. Culica D, Walton JW, Prezio EA. CoDE: Community Diabetes Education for uninsured Mexican
Americans. Proc (Bayl Univ Med Cent). 2007; 20(2):111–117. [PubMed: 17431443]
15. Brown SA, Hanis CL. Culturally competent diabetes education for Mexican Americans: the Starr
County Study. Diabetes Educ. 1999; 25(2):226–236. [PubMed: 10531848]
16. Brown SA, Blozis SA, Kouzekanani K, Garcia AA, Winchell M, Hanis CL. Health beliefs of
Mexican Americans with type 2 diabetes: The Starr County border health initiative. Diabetes
Educ. 2007; 33(2):300–308. [PubMed: 17426305]
17. Lorig KR, Ritter PL, Jacquez A. Outcomes of border health Spanish/English chronic disease self-
management programs. Diabetes Educ. 2005; 31(3):401–409. [PubMed: 15919640]
18. Brown SA, Garcia AA, Kouzekanani K, Hanis CL. Culturally competent diabetes self-
management education for Mexican Americans: the Starr County border health initiative. Diabetes
Care. 2002; 25(2):259–268. [PubMed: 11815493]
19. Philis-Tsimikas A, Walker C. Improved care for diabetes in under-served populations. J Ambul
Care Manage. 2001; 24(1):39–43. [PubMed: 11189795]
Salto et al. Page 9
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
20. Vincent D, Pasvogel A, Barrera L. A feasibility study of a culturally tailored diabetes intervention
for Mexican Americans. Biol Res Nurs. 2007; 9(2):130–141. [PubMed: 17909165]
21. Stirban A, Nandrean S, Gotting C, et al. Effects of n-3 fatty acids on macro- and microvascular
function in subjects with type 2 diabetes mellitus. Am J Clin Nutr. 2010; 91(3):808–813.
[PubMed: 20071644]
22. Adkins Y, Kelley DS. Mechanisms underlying the cardioprotective effects of omega-3
polyunsaturated fatty acids. J Nutr Biochem. 2010; 21(9):781–92. [PubMed: 20382009]
23. Jung UJ, Torrejon C, Tighe AP, Deckelbaum RJ. n-3 Fatty acids and cardiovascular disease:
mechanisms underlying beneficial effects. Am J Clin Nutr. 2008; 87(6):2003S–2009S. [PubMed:
18541602]
24. Bialostosky K, Wright JD, Kennedy-Stephenson J, McDowell M, Johnson CL. Dietary intake of
macronutrients, micronutrients, and other dietary constituents: United States 1988–94. Vital
Health Stat 11. 2002; 245:1–158. [PubMed: 15787426]
25. US Department of Agriculture, Agricultural Research Service. Nutrient Intakes From Food: Mean
Amounts Consumed per Individual, by Race/Ethnicity and Age, One Day, 2005–2006.
Washington, DC: US Department of Agriculture; 2008.
26. Lora KR, Lewis NM, Eskridge KM, Stanek-Krogstrand K, Travnicek DA. Correlation of omega-3
fatty acids intakes with acculturation and socioeconomic status in Midwestern Latinas [published
online ahead of print January 23, 2010]. J Immigr Minor Health.
27. He K, Liu K, Daviglus ML, et al. Associations of dietary long-chain n-3 polyunsaturated fatty
acids and fish with biomarkers of inflammation and endothelial activation (from the Multi-Ethnic
Study of Atherosclerosis [MESA]). Am J Cardiol. 2009; 103(9):1238–1243. [PubMed: 19406265]
28. Belalcazar LM, Reboussin DM, Haffner SM, et al. Marine omega-3 fatty acid intake: associations
with cardiometabolic risk and response to weight loss intervention in the Look AHEAD (Action
for Health in Diabetes) study. Diabetes Care. 2010; 33(1):197–199. [PubMed: 19841042]
29. Lohman, TG.; Roche, AF.; Martorell, R. Anthropometric Standardization Reference Manual.
Champaign, IL: Human Kinetics; 1988.
30. Taren D, de Tobar M, Ritenbaugh C, Graver E, Whitacre R, Aickin M. Evaluation of the
Southwest Food Frequency Questionnaire. Ecol Food Nutr. 2000; 38:515–547.
31. Arizona Cancer Center. Metabolize Nutrient Analysis System [version 2.5]. Tucson, AZ:
University of Arizona; 2004.
32. Metghalchi S, Rivera M, Beeson L, et al. Improved clinical outcomes using a culturally sensitive
diabetes education program in a Hispanic population. Diabetes Educ. 2008; 34(4):698–706.
[PubMed: 18669812]
33. Ojo E, Beeson L, Schulz E, et al. Effect of the En Balance, a culturally and language-sensitive
diabetes education program on dietary changes and plasma lipid profile in Hispanic diabetics. Int J
Body Compos Res. 2010; 7:S69–S76. [PubMed: 21318091]
34. US Department of Health and Human Services. Dietary Guidelines for Americans, 2005. 6.
Washington, DC: US Government Printing Office; 2005.
35. Otten, JJ.; Pitzi Hellwig, J.; Meyers, LD. The Dietary Reference Intakes: The Essential Guide to
Nutrient Requirements. Washington, DC: National Academies Press; 2006.
36. Simopoulos AP, Leaf A, Salem N Jr. Workshop statement on the essentiality of and recommended
dietary intakes for omega-6 and omega-3 fatty acids. Prostaglandins Leukot Essent Fatty Acids.
2000; 63(3):119–121. [PubMed: 10991764]
37. Haffner SM. Management of dyslipidemia in adults with diabetes. Diabetes Care. 2003; 26(suppl
1):S83–S86. [PubMed: 12502625]
38. Thompson FE, Byers T. Dietary assessment resource manual. J Nutr. 1994; 124(11 suppl):2245S–
2317S. [PubMed: 7965210]
39. Martinez ME, Marshall JR, Graver E, et al. Reliability and validity of a self-administered food
frequency questionnaire in a chemoprevention trial of adenoma recurrence. Cancer Epidemiol
Biomarkers Prev. 1999; 8(10):941–946. [PubMed: 10548325]
40. Jones LA, Gonzalez R, Pillow PC, et al. Dietary fiber, Hispanics, and breast cancer risk? Ann N Y
Acad Sci. 1997; 837:524–536. [PubMed: 9472361]
Salto et al. Page 10
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
41. Coates RJ, Monteilh CP. Assessments of food-frequency questionnaires in minority populations.
Am J Clin Nutr. 1997; 65(4 suppl):1108S–1115S. [PubMed: 9094906]
42. Teufel NI. Development of culturally competent food-frequency questionnaires. Am J Clin Nutr.
1997; 65(4 suppl):1173S–1178S. [PubMed: 9094917]
43. Block G, Wakimoto P, Jensen C, Mandel S, Green RR. Validation of a food frequency
questionnaire for Hispanics. Prev Chronic Dis. 2006; 3(3):A77. [PubMed: 16776878]
44. Mayer-Davis EJ, Vitolins MZ, Carmichael SL, et al. Validity and reproducibility of a food
frequency interview in a Multi-Cultural Epidemiology Study. Ann Epidemiol. 1999; 9(5):314–
324. [PubMed: 10976858]
45. Kristal AR, Feng Z, Coates RJ, Oberman A, George V. Associations of race/ethnicity, education,
and dietary intervention with the validity and reliability of a food frequency questionnaire: the
Women’s Health Trial Feasibility Study in Minority Populations. Am J Epidemiol. 1997; 146(10):
856–869. [PubMed: 9384206]
46. Carrera PM, Gao X, Tucker KL. A study of dietary patterns in the Mexican-American population
and their association with obesity. J Am Diet Assoc. 2007; 107(10):1735–1742. [PubMed:
17904933]
47. Murtaugh MA, Herrick JS, Sweeney C, et al. Diet composition and risk of overweight and obesity
in women living in the southwestern United States. J Am Diet Assoc. 2007; 107(8):1311–1321.
[PubMed: 17659896]
48. Guendelman S, Abrams B. Dietary intake among Mexican-American women: generational
differences and a comparison with white non-Hispanic women. Am J Public Health. 1995; 85(1):
20–25. [PubMed: 7832256]
49. Dixon LB, Sundquist J, Winkleby M. Differences in energy, nutrient, and food intakes in a US
sample of Mexican-American women and men: findings from the Third National Health and
Nutrition Examination Survey, 1988–1994. Am J Epidemiol. 2000; 152(6):548–557. [PubMed:
10997545]
50. Neuhouser ML, Thompson B, Coronado GD, Solomon CC. Higher fat intake and lower fruit and
vegetables intakes are associated with greater acculturation among Mexicans living in Washington
State. J Am Diet Assoc. 2004; 104(1):51–57. [PubMed: 14702584]
51. Fitzgerald N, Damio G, Segura-Perez S, Perez-Escamilla R. Nutrition knowledge, food label use,
and food intake patterns among Latinas with and without type 2 diabetes. J Am Diet Assoc. 2008;
108(6):960–967. [PubMed: 18502226]
52. American Diabetes Association. Choose Your Foods: Exchange Lists for Diabetes. Chicago, IL:
American Dietetic Association; 2008.
53. Vitolins MZ, Anderson AM, Delahanty L, et al. Action for Health in Diabetes (Look AHEAD)
trial: baseline evaluation of selected nutrients and food group intake. J Am Diet Assoc. 2009;
109(8):1367–1375. [PubMed: 19631042]
54. Gebauer SK, Psota TL, Harris WS, Kris-Etherton PM. n-3 fatty acid dietary recommendations and
food sources to achieve essentiality and cardiovascular benefits. Am J Clin Nutr. 2006; 83(6
suppl):1526S–1535S. [PubMed: 16841863]
55. Harris WS, Mozaffarian D, Lefevre M, et al. Towards establishing dietary reference intakes for
eicosapentaenoic and docosahexaenoic acids. J Nutr. 2009; 139(4):804S–819S. [PubMed:
19244379]
56. Kris-Etherton PM, Innis S. American Dietetic Association, Dietitians of Canada. Position of the
American Dietetic Association and Dietitians of Canada: dietary fatty acids. J Am Diet Assoc.
2007; 107(9):1599–1611. [PubMed: 17936958]
57. Kris-Etherton PM, Grieger JA, Etherton TD. Dietary reference intakes for DHA and EPA.
Prostaglandins Leukot Essent Fatty Acids. 2009; 81(2–3):99–104. [PubMed: 19525100]
Salto et al. Page 11
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Figure 1.
En Balance participants’ dietary intake of total fat and saturated fat (in grams per day)
compared with recommendations from the Dietary Guidelines for Americans.34
aCalculations based on a 2000-kcal diet and on the upper limit of the Dietary Guidelines for
Americans: total fat, 20% to 30% of calories; saturated fat, < 10% of calories.
Salto et al. Page 12
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Figure 2.
En Balance participants’ dietary intake of linoleic acid and α-linolenic acid (in grams per
day) compared with the adequate intake guidelines.
aBased on the lower limit of the adequate intake recommendation for the En Balance age
group (25–75 years).
Salto et al. Page 13
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Figure 3.
En Balance participants’ dietary intake of DHA and EPA (grams per day) compared with
adequate intake guidelines for adults.
DHA, 22:6 docosahexaenoic acid; EPA, 20:5 eicosapentaenoic acid.
aAdequate intakes recommendations for adults from the Workshop on the Essentiality of and
Recommended Dietary Intakes for Omega-6 and Omega-3 Fatty Acids.36
Salto et al. Page 14
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Salto et al. Page 15
Table 1
En Balance Participant Characteristics at Baselinea
Men (n, 16) Women (n, 23)
Age, years
25–34 0.0 8.7
35–44 18.8 0.0
45–54 43.7 43.5
55–64 12.5 30.4
65+ 25.0 17.4
Mean ± SD 52.63 ± 9.91 54.87 ± 12.16
P.122
Weight,b kg
50–64 12.5 18.2
65–79 56.3 27.3
80–94 25.0 31.8
95–109 0.0 4.5
110+ 6.2 18.2
Mean ± SD 78.26 ± 12.51 84.07 ± 20.56
P.401
Height, cm
145–154 0.0 50.0
155–164 31.3 40.9
165–174 50.0 9.1
175+ 18.7 0.0
Mean ± SD 168.0 ± 6.53 155.32 ± 6.23
P< .001**
Body mass index,b kg/m2
18.5–24.9 25.0 4.5
25.0–29.9 56.3 31.9
30.0–39.9 18.7 36.3
40.0+ 0.0 27.3
Mean ± SD 27.56 ± 3.30 34.66 ± 7.06
P.022*
Primary language
Spanish 93.8 87.0
English 6.2 13.0
P.492
Birthplace
United States 0.0 13.0
Mexico 93.8 78.3
Puerto Rico 6.2 4.4
Dominican Republic 0.0 4.3
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Salto et al. Page 16
Men (n, 16) Women (n, 23)
P.374
Highest level of education
No formal education 6.3 4.3
Some/finished primary 25.0 34.8
Some/finished junior high 18.7 8.7
Some/finished high school 18.8 26.1
Some/finished collegec25.0 17.4
Some/finished master’sc6.2 0.0
Missing data 0.0 8.7
P.620
an, 39. In percentages unless noted otherwise. P values are based on χ2 test.
bFor weight and body mass index: n, 38.
cSix finished college in Mexico; 2 attended a US community college; 1 obtained a US graduate degree.
*P < .05.
**P < .001.
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Salto et al. Page 17
Table 2
Changes in Serum Blood Glucose Profiles, Serum Blood Lipid Profiles, Weight, and Body Mass Index After 3
months of the En Balance Diabetes Education Programa
Variables Baseline Three Months Mean Difference P
FBG (mg/dl) 167.90 ± 82.46 154.26 ± 70.16 −13.64 0.134
A1C, % 8.53 ± 2.58 7.63 ± 1.71 −0.894 .008*
Insulin, uU/mL 13.72 ± 11.31 16.73 ± 13.33 3.01 .050*
Cholesterol, mg/dL
Total 191.38 ± 34.30 177.94 ± 40.98 −13.43 .005*
LDL 120.67 ± 32.27 110.38 ± 34.80 −10.28 .030*
HDL 49.74 ± 10.48 46.90 ± 9.97 −2.84 .012*
Cholesterol:HDL 3.99 ± 1.05 3.94 ± 1.12 −0.048 .679
Triglycerides, mg/dL 166.21 ± 83.67 170.79 ± 102.77 4.59 .641
Body weight, kg 81.62 ± 17.66 81.62 ± 17.11 −0.003 .993
Body mass index, kg/m231.67 ± 6.73 31.45 ± 6.47 −0.218 .246
aBoth sexes: n, 39. The data are shown as mean ± SD. P value is based on Wilcoxon signed–rank test for A1C and LDL; otherwise, P value is
based on paired-samples t test. FBG, fasting blood glucose; LDL, low-density lipoprotein; HDL, high-density lipoprotein. For body weight and
body mass index: n, 38.
*P < .05.
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Salto et al. Page 18
Table 3
Changes in Selected Food Frequency Questionnaire Dietary Intake Variables After 3 Months of the En
Balance Diabetes Education Programa
Variables Baseline Three Months Mean Difference P
Energy, kcal 2478.89 ± 1140.39 2084.96 ± 741.48 −393.92 .065
Carbohydrate, g 331.10 ± 160.42 286.28 ± 119.66 −44.82 .161
Protein, g 105.38 ± 45.75 89.32 ± 30.60 −16.06 .058
Total fat, g 87.27 ± 44.42 71.06 ± 26.46 −16.20 .045*
Total fiber, g 39.46 ± 18.92 37.97 ± 23.01 −1.49 .327b
Cholesterol, mg 338.63 ± 217.50 259.41+ ± 163.21 −79.22 .033b*
Saturated fat, g 28.00 ± 15.45 23.09 ± 9.12 −4.91 .073
Monounsaturated fatty acid, g 33.79 ± 17.89 27.38 ± 10.26 −6.41 .136b
Polyunsaturated fatty acid, g 17.27 ± 8.25 13.95 ± 5.88 −3.31 .112b
Linoleic acid, g 15.37 ± 7.36 12.31 ± 5.22 −3.06 .112b
α-Linolenic acid, g 1.50 ± 0.83 1.30 ± 0.58 −0.20 .232b
Palmitic acid, g 15.60 ± 8.24 12.91 ± 4.92 −2.69 .158b
Arachidonic acid, g 0.17 ± 0.09 0.13 ± 0.10 −0.04 .158b
DHA, g 0.108 ± 0.139 0.090 ± 0.095 −0.017 .922b
EPA, g 0.038 ± 0.046 0.033 ± 0.033 −0.005 .891b
Vitamin E, mg 13.45 ± 9.39 10.07 ± 4.66 −3.38 .100b
Vitamin C, mg 226.6 ± 156.4 197.72 ± 106.11 −28.88 .327b
Vitamin A, μg 2125.0 ± 1985.8 2402.7 ± 2773.1 277.7 .668
Beta carotene, μg 6741.5 ± 5855.5 7282.1 ± 6046.2 540.56 .493b
Selenium, μg 130.01 ± 60.25 107.16 ± 40.14 −22.85 .112b
Sodium, mg 4236.6 ± 2055.7 3650.7 ± 1304.1 −585.8 .272b
Calories, %
Total fat 31.48 ± 5.71 30.89 ± 4.46 −0.59 .628
Saturated fat 10.05 ± 2.35 10.10 ± 2.08 0.099 .845
Monounsaturated fatty acid 12.13 ± 2.81 11.90 ± 1.81 −0.231 .678
Polyunsaturated fatty acid 6.33 ± 1.27 5.93 ± 1.06 −0.398 .129
Protein 17.31 ± 2.89 17.60 ± 3.26 0.284 .654
Carbohydrates 53.39 ± 7.93 54.09 ± 8.13 0.700 .666b
Alcohol 0.166 ± .370 0.198 ± 0.613 0.032 .775b
aBoth sexes: n, 31. All values are based on per day. The data are shown as mean ± SD. Eight food frequency questionnaire records were excluded
from these analyses owing to total calorie underestimation (< 1000 kcal) or overestimation (> 5000 kcal) at baseline or 3 months. DHA, 22:6
docosahexaenoic acid; EPA, 20:5 eicosapentaenoic acid.
bP value based on Wilcoxon signed–rank test; otherwise, P value based on paired-samples t test.
*P < .05.
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Salto et al. Page 19
Table 4
Sex-Specific Fat Intake Profile for the En Balance Participants at Baseline and 3 Monthsa
Lipid Intake Recommended Baseline Three Months P
Men: n, 13
Total fat 44–78b80.91 ± 29.32 68.82 ± 22.80 .279
Saturated fat ≤ 22b25.29 ± 9.09 21.22 ± 7.65 .311
Linoleic acid 14–17c14.46 ± 5.29 12.16 ± 5.05 .382
α-Linolenic acid 1.6c1.36 ± 0.68 1.34 ± 0.55 .753
DHA 0.22d0.07 ± 0.05 0.10 ± 0.09 .650
EPA 0.22d0.03 ± 0.02 0.03 ± 0.03 .600
Calories, %
Total fat 20–35e31.84 ± 6.58 29.75 ± 4.93 .552
Saturated fat ≤ 10f9.97 ± 2.08 9.25 ± 2.25 .507
Monounsaturated fatty acid NR 12.53 ± 3.27 11.71 ± 1.76 .807
Polyunsaturated fatty acid NR 6.35 ± 1.42 5.85 ± 1.13 .507
Women: n, 18
Total fat 44–78b91.86 ± 53.12 72.68 ± 29.37 .248
Saturated fat ≤ 22b29.96 ± 18.79 24.44 ± 10.04 .327
Linoleic acid 11–12c16.02 ± 8.65 12.42 ± 5.48 .231
α-Linolenic acid 1.1c1.60 ± 0.93 1.27 ± 0.62 .094
DHA 0.22d0.12 ± 0.17 0.08 ± 0.08 .557
EPA 0.22d0.04 ± 0.05 0.03 ± 0.03 .616
Calories, %
Total fat 20–35e31.23 ± 5.18 31.72 ± 4.02 .557
Saturated fat ≤ 10f10.02 ± 2.58 10.71 ± 1.77 .231
Monounsaturated fatty acid NR 11.85 ± 2.48 12.04 ± 1.88 .983
Polyunsaturated fatty acid NR 6.32 ± 1.20 5.99 ± 1.03 .112
aWith the exception of calories, values based on grams per day. The data are shown as mean ± SD. P value is based on Wilcoxon signed–rank test
comparing En Balance baseline and 3-month values. DHA, 22:6 docosahexaenoic acid; EPA, 20:5 eicosapentaenoic acid; NR, no recommendation
established.
bCalculations based on a 2000-kcal diet and on the Dietary Guidelines for Americans34: total fat, 20% to 35% of calories; saturated fat, < 10% of
calories.
cAdequate intakes for age: ≥ 19 years.
dAdequate intake recommendations for adults from the Workshop on the Essentiality of and Recommended Dietary Intakes for Omega-6 and
Omega-3 Fatty Acids.36
eAcceptable macronutrient distribution range based on the Dietary Reference Intake recommendations.
fBased on the Dietary Guidelines for Americans34: saturated fat < 10% of calories.
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Salto et al. Page 20
Table 5
Sex-Specific Antioxidant Intake Profile for the En Balance Participants at Baseline and 3 Monthsa
Antioxidant Intake Recommended Baseline Three Months P
Men: n, 13
Vitamin E, mg 15b,c13.19 ± 9.77 10.32 ± 4.81 .552
Vitamin C, mg 90b208.73 ± 172.12 229.60 ± 123.78 .552
Vitamin A, μg900b,d1815.12 ± 1645.48 3264.11 ± 3868.18 .196
Beta carotene, μg NR 7648.05 ± 7440.54 9512.80 ± 7829.29 .196
Selenium, μg55b119.78 ± 40.76 108.93 ± 36.89 .600
Women: n, 18
Vitamin E, mg 15b,c13.64 ± 9.39 9.89 ± 4.68 .078
Vitamin C, mg 75b239.51 ± 147.75 174.70 ± 87.84 .018*
Vitamin A, μg700b,d2348.88 ± 2218.51 1780.65 ± 1425.40 .286
Beta carotene, μg NR 6086.84 ± 4510.71 5671.04 ± 3832.85 .500
Selenium, μg55b137.40 ± 71.39 105.88 ± 43.35 .112
aNR, no recommendation established. Values based on per day. Data are shown as mean ± SD. P value is based on Wilcoxon signed–rank test
comparing En Balance baseline and 3-month values.
bRecommended dietary allowances.
cVitamin E recommendations expressed as α-tocopherol
dVitamin A recommendations expressed as retinol activity equivalents.
*P < .05.
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Salto et al. Page 21
Table 6
En Balance Spearman Correlation Coefficients Using Laboratory and Dietary Intake Change (Δ) Variablesa
Δ Variables Δ A1C, % Δ Cholesterol, mg/dL Δ HDL, mg/dL Δ LDL, mg/dL Δ Triglycerides, mg/dL
Energy, kcal .078 (.675) −.318 (.081) −.115 (.537) −.372
*
(.039) .160 (.391)
Alcohol, g −.026 (.888) .106 (.570) −.316 (.083) .017 (.929) .461* (.009)
Calcium, mg .143 (.443) −.410
*
(.022) −.080 (.669) −.463
*
(.009) .233 (.207)
Phosphorus, mg .093 (.619) −.377
*
(.037) −.082 (.661) −.410
*
(.022) .122 (.514)
Zinc, mg .067 (.719) −.411
*
(.022) −.176 (.344) −.456
*
(.010) .093 (.620)
Vitamin A, mcg (RE) −.101 (.587) −.488
*
(.005) −.349 (.054) −.502
*
(.004) .156 (.402)
Vitamin E, mg (ATE) −.007 (.969) −.315 (.085) −.311 (.089) −.371
*
(.040) .190 (.306)
Vitamin C, mg −.239 (.196) −.368
*
(.042) −.362
*
(.045) −.436
*
(.014) .226 (.222)
Linolenic acid, g −.102 (.585) −.290 (.113) −.243 (.188) −.363
*
(.044) .199 (.283)
Arachidonic acid, g .040 (.832) −.338
*
(.005) −.177 (.340) −.363
*
(.045) −.116 (.534)
Calories, %
Saturated fat .378* (.036) −.011 (.953) .101 (.588) −.014 (.942) −.136 (.467)
Protein −.169 (.362) −.099 (.597) .146 (.434) .013 (.943) −.489
*
(.005)
Carbohydrate −.178 (.337) .105 (.573) −.057 (.759) .067 (.720) .369* (.041)
Alcohol −.037 (.843) .154 (.408) −.330 (.070) .084 (.653) .467* (.008)
aChange variables equal 3-month minus baseline for selected variables. P values in parentheses. Both sexes: n, 31. Eight food frequency questionnaire records were excluded from this analysis owing to total
calorie underestimation (< 1000 kcal) or overestimation (> 5000 kcal) at baseline or 3 months. All other laboratory and dietary intake change variables were not statistically significant. HDL, high-density
lipoprotein; LDL, low-density lipoprotein; RE, retinol equivalents; ATE, α-tocopherol equivalents.
*P < .05.
Diabetes Educ. Author manuscript; available in PMC 2011 March 22.
