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Abstract

Introduction: Type 2 diabetes mellitus (T2DM) prevalence continues to increase among Hispanic/Latino adults. The purpose of this study was to explore and analyze literature on culturally tailored nutrition interventions to identify how to best implement a whole food plant-based (WFPB) culinary intervention to improve health outcomes for Hispanic/Latino adults at risk for developing or diagnosed with T2DM. Methods: A methodological review was performed by searching PubMed, CINAHL Complete, PsycINFO, and Food Science and Technology Abstracts. Inclusion criteria consisted of peer-reviewed articles in English, from January 2009 to January 2020, using the search terms: “Hispanic adults or Latino adults”, “culturally tailored or ethnic”, “diabetes”, “dietary or nutrition”, “intervention”, and “vegan or plant based”. Studies included adults at risk for/diagnosed with T2DM. Results: Of 1,474 articles retrieved, 15 met the inclusion criteria. Four main themes were identified: participant interest, feasibility of intervention, development and implementation of intervention, and impact of the intervention. Conclusion: Further research should focus on culturally tailored nutrition interventions and use of a WFPB diet to reduce risk for T2DM in Hispanic/Latino adults. Continued discussion should be patient- and community-centered to promote equity, health, and disease prevention through the use of culturally tailored methods and design, not only limited to curriculum and language.

Keywords

prevention chronicity diabetes mellitus type 2 cultural adaptations health promotion Latino populations plant based

Introduction

In the United States, Hispanic/Latino individuals are 1.4 times more likely to die from diabetes and 1.2 times more likely to be obese than non-Hispanic whites due to social determinants of health and systemic oppression due to allocation of power and resources (CDC, 2018, 2019a; Kapitan, 2016; Walker et al., 2016; Weinstein et al., 2017). Every year more than $300 billion are spent on diabetes medication and symptom management (ADA, 2018). According to NIH (2016), risk factors for developing type 2 diabetes mellitus (T2DM) include being overweight/obese, age 45 or older, Hispanic/Latino, having a family history of diabetes, high blood pressure, low levels of high-density lipoprotein cholesterol or high triglycerides, history of gestational diabetes, poor nutrition during pregnancy, being physically inactive, history of heart disease or stroke, depression, or polycystic ovary syndrome.

Previous studies have shown that culturally tailored interventions have high rates of sustainability, and participation in home meal preparation can improve self-efficacy and diet quality, while lowering adiposity (Hu et al., 2016; Mills et al., 2017; Wolfson et al., 2020; Wolfson & Bleich, 2014). In addition, studies have also shown that a whole food plant-based (WFPB) diet is sustainable, economical, and can potentially reverse T2DM, lower blood pressure and cholesterol, and help to promote insulin sensitivity by controlling blood sugar three times more effectively than a traditional diabetic diet that limits carbohydrates and calories (Alexander et al., 2017; Kahleova et al., 2018; McMacken & Shah, 2017; Sabaté & Soret, 2014).

Background

Hispanic/Latino Individuals and Diabetes

Hispanic/Latino individuals and their health are disproportionately impacted by various factors. These factors may include macroeconomics, privilege and/or discrimination (e.g., access to nutritious food, immigration status, structural and institutional racism), cultural values, income, education and literacy, occupation, and social support systems, including health services (Hobbs, 2018; Velasco-Mondragon et al., 2016). For example, an individual's educational and literacy level may impact their personal income, which may in turn impact their ability to access nutrition, food, and health services. Social determinants of health such as socioeconomic status, cultural background, employment, and foreign-born or unauthorized status place Hispanic/Latino individuals at greater risk for adverse social and health outcomes (Paz & Massey, 2016; Vega et al., 2009). Among working adults, 32% of Hispanic/Latino individuals are uninsured, which may also have a large impact on health care access (Levy & Sidel, 2013).

Hispanic/Latino adults need access to resources that may assist them in being proactive to prevent T2DM now. Among the overall U.S. population, estimates for 2018 reported that approximately 34.1 million adults (13%), aged 18 years or older, had diabetes (CDC, 2020). Without lifestyle modification, it has been predicted that there will be an annual rate of 5%–10% progression from prediabetes to diabetes (Levy & Sidel, 2013). In addition, studies have found that medication nonadherence and diabetes complications are higher when comparing Hispanic/Latino individuals to non-Hispanic white individuals (CDC, 2019b; Fernandez et al., 2017). By being proactive and making changes early on, individuals may possibly prevent or delay the onset of diabetes and potential complications, which could be physically and financially beneficial.

The Hispanic/Latino population in the United States is not a homologous/unified group (Beltrán, 2010). Subgroup differences in health outcomes may be related to age, gender, nativity, immigration status, skin color, living in a segregated neighborhood or low-income household, occupational status, health insurance status, or living in a county/state with high immigration enforcement and anti-immigrant/anti-Latinx sentiment (Martínez & Rhodes, 2020). Therefore, when studying Hispanic/Latino populations, if possible, it is best to specify any subgroups and how those differences are related to health behaviors and health outcomes. For example, low socioeconomic status is often linked to poor health status. Notwithstanding, Hispanic/Latino individuals often have a lower socioeconomic status and insured rates, when compared with other populations. However, Hispanic/Latino individuals are often found to have a longer life expectancy and better maternal child health outcomes when compared with non-Hispanic white individuals (Abraído-Lanza et al., 2005; Ruiz et al., 2013). The U.S. National Health and Nutrition Examination Survey, 2011–2016, showed the prevalence of total diabetes was highest, 24.6% (95% CI: 21.6%−27.6%), among the Mexican subgroup, 21.7% (95% CI: 14.6%−28.8%) among the Puerto Rican subgroup, and 20.5% (95% CI: 13.7%−27.3%) among the Cuban/Dominican subgroup (overall p <.001) (Cheng et al., 2019).

Hispanic/Latino Individuals and Nutrition

Although researchers continue to discover and identify connections between food and health outcomes, health care professionals may not always feel adequately trained on how to incorporate nutrition into their clinical practice when educating patients on lifestyle modification (Crowley et al., 2019). Nutrition in health care education should not be viewed as alternative medicine but should be included as a foundation for prevention and health promotion. Physical activity and a healthy, balanced diet have been found to be an integral part of T2DM prevention with previous studies showing successful management and reversal of T2DM through a WFPB diet (Al-Mrabeh et al., 2019; Barnard et al., 2009). This option often reduces sodium and fat, while increasing fiber through the consumption of fruits/vegetables without requiring special equipment. A WFPB diet includes whole, minimally processed foods and avoids animal products (e.g., meat, milk, eggs, and cheese), while focusing on plants (e.g., fruits/vegetables, whole grains, legumes, and nuts/seeds) (Campbell & Campbell, 2016, p. 237; Tuso, 2013). Refined foods (e.g., added sugars, salt, white flour, and processed oils) are limited/avoided, and locally sourced, organic food is used as much as possible. While Hispanic/Latino adults often report higher consumption of fruits/vegetables when compared with other ethnic groups, they also often report the highest intake of solid fats and added sugars (Hammons et al., 2019).

Knowledge Gaps

With the growing number of diabetes cases among Hispanic/Latino individuals and the associated costs, there is an urgent need for improved health care access with a focus on health promotion and disease prevention. While previous research and current nutritional/dietary interventions often focus on individuals already diagnosed with T2DM, little research has focused on reducing T2DM risk factors using a WFPB intervention in at-risk Hispanic/Latino adults (Ramal et al., 2018; Singh et al., 2019). To improve diabetes self-care in minoritized populations, culturally tailored interventions have been cited as being beneficial (Whittemore, 2007). Although Hispanic/Latino individuals are often described as a minority group, it should be noted that they are the second largest racial/ethnic group, after white non-Hispanic individuals (Noe-Bustamante et al., 2020).

Questions often surround the design of a culturally tailored intervention and implementation. While existing interventions provide education on healthy food choices, few interventions are culturally tailored to focus on reliable access to and hands-on preparation of healthy food, including food preferences and behaviors. Additionally, barriers such as needing childcare and transportation to facilitate participation in clinical and community-based interventions are not always addressed (Barajas et al., 2016; Doshi et al., 2020).

Aim

The purpose of this integrative review was to explore and analyze literature on culturally tailored nutrition interventions to identify how to best implement a plant-based diet using a WFPB culinary intervention to improve health outcomes for Hispanic/Latino adults at risk for developing or diagnosed with T2DM.

Methods

Data Sources and Search Criteria

For the purpose of this review, the key search terms were “Hispanic adults” or “Latino adults”, “culturally tailored” or “ethnic”, “diabetes”, “dietary” or “nutrition” and “intervention”, and/or “vegan”, or “plant based”. The term, “adults”, was used to exclude studies focused on children/adolescents. These key terms were used in full-text searches in PubMed, CINAHL Complete, PsycINFO, and Food Science and Technology Abstracts. Inclusion criteria included primary research articles in peer-reviewed journals, published in English, from January 2009 to January 2020 with key terms. The year 2009 was selected due to research conducted in the same year reporting that eggs are associated with an increased risk of T2DM (Djoussé et al., 2009). In the same year, Beyond Meat (2022), a Los Angeles-based producer of plant-based meat substitutes, was founded and the Poison-Free Poultry Act was introduced into Congress (2009). Inclusion criteria for studies consisted of adult participants, aged ≥18 years, at risk for or diagnosed with T2DM, with a culturally tailored intervention related to diet/nutrition. Unpublished manuscripts (e.g., abstracts and dissertations), as well as secondary sources, were excluded.

Search Strategy

The search strategy resulted in an initial 1,474 articles for review. After duplicates were removed, 871 article titles and abstracts were scanned for relevance and ability to be retrieved, using the inclusion/exclusion criteria for the search (e.g., primary research, key terms, published in English). From there, 818 articles were excluded, and 53 full articles retained. The inclusion/exclusion criteria for the studies were then applied (e.g., ≥18 years, culturally tailored intervention related to diet/nutrition) and 25 articles were excluded after full text screen with an additional 13 articles being excluded after data extraction, resulting in a total of 15 articles (Figure 1). Articles included consisted of seven quantitative studies, five qualitative studies, and three mixed methods studies.

Figure 1.

Adapted PRISMA flow diagram of search strategy and study report selection (Moher et al., 2009).

The need for and importance of culturally tailored interventions for Hispanic/Latino adults in reducing T2DM risk factors was identified (Figure 1). From these articles, four main themes presented: participant interest, feasibility of intervention, the development and implementation of intervention, and the impact of intervention (Table 1). Database searches revealed systematic reviews for culturally tailored and culturally competent interventions for Hispanic/Latino individuals in relation to T2DM (McCurley et al., 2017; Whittemore, 2007), but did not reveal any integrative reviews.

Table 1.

Selected Studies for Review According to Theme.

Author(s) (Year)	Aim	Sample/Design	Timeframe/Modality/Cultural Tailoring/Diet	Location	Results	Rigor (Methodological or Theoretical)/Relevance(high or low)
Theme 1: Participant Interest
Peña-Purcell et al. (2018)	To use PhotoVoice to examine AfricanAmericans and Latino adults daily experiences of managing diabetes	N = 19 adults with type 2 diabetes (10 AfricanAmericans and 9 Latino adults to form 4 focus groups) Exploratory Descriptive study Focus groups PhotoVoice Facilitated in Spanish language Participants were recruited from community clinics that predominantly serve economically disadvantaged individuals 86% of participants were female urban and suburban location individual focused	3 weeks; 90 min orientation session; 2 weeks to collect/take photos; two focus groups; one follow-up meeting Community-based; Language Increase fruits/vegetables and decrease fat and sugar	Texas A&M AgriLife Extension Brazos County office in Bryan and a Houston church in Texas	Four categories emerged: (1) daily life living with T2DM, (2) negative and positive emotions, (3) supports and barriers, and (4) needs. The social determinants of health influencing diabetes self-care were observed in discussions and photos—this included the built environment to promote a healthy lifestyle, social support, and education	Rigor: High Relevance: High
Vincent et al. (2014)	To report the results of a community-based, culturally tailored diabetes prevention program for overweight Mexican American adults on weight loss, waist circumference, diet and physical activity self-efficacy, and diet behaviors	N = 58 (≥25 years with an American Diabetes Association risk assessment score ≥10, BMI ≥25 kg/m²) Quantitative Randomized two-group attention control trial Facilitated in Spanish and English ∼75% of participants were born in Mexico 77.6% female 56.9% reported an annual income of $20,000 or less urban location individual focused	5 months—8 weekly 2 h sessions, followed by a maintenance phase of 3 monthly 1h sessions Community-based; Promotora; Fotonovela; Language; Exercise (walking/dancing); Support person; Group meal sharing Cooking demonstrations of low-fat traditional foods; Fruit/vegetable	Community rooms of churches in the Tucson metropolitan area, Arizona	Significant intervention effects for weight, waist circumference, body mass index, and diet self-efficacy, with the intervention group doing better than the control group. The effects did not change over time.	Rigor: High Relevance: High
Theme 2: Feasibility of Culturally Tailored Interventions
Brown et al. (2015)	To conduct focus groups with Hispanic employees to obtain input into adaptation of previous diabetes self-management education interventions for use as a workplace diabetes prevention program	N = 36 (7 males; 29 females; ages 22–65) Focus group Pilot test RCT Facilitated in Spanish and English Hispanic participants, Mexican American subgroup 81% female participants rural location individual focused	Focus groups; one session Discussed need for cultural tailoring (e.g., related to learning different when growing up, fiesta foods, cooking with lard) Suggested programs on healthy cooking; Increased Fruits/vegetables; Natural remedies	Starr County, Texas	Workplace programs are an ideal solution for Hispanic employee to learn about diabetes and healthy behaviors, given their busy schedules, family responsibilities, and limited resources	Rigor: Low Relevance: High
Sorkin et al. (2014)	To evaluate the feasibility of a pilot, dyad-based lifestyle intervention, the Unidas por la Vida program, for improving weight loss and dietary intake among high-risk Mexican American mothers who have type 2 diabetes and their overweight/obese adult daughters	N = 89 (mother–daughter dyads; mothers with T2DM and their adult daughters with obesity/overweight) RCT Facilitated in Spanish and English Latinas, Mexican American subgroup low-income urban location family focused	16-week intervention consisting of four group meetings, eight home visits, and telephone calls by a lifestyle community coach Recipe demonstration with modified recipes; Exercise (dancing); Family-based intervention Focus on decreasing saturated fats and glycemic load while increasing fruit/vegetable consumption	Community locations throughout California (e.g., local college athletic facilities)	Individuals in the intervention group lost significantly more weight at T2 (p < .003) compared with the control participants. Intervention participants were also more likely to be eating foods with a lower glycemic load and less saturated fat. The intervention group also reported a significant increase in health-related social support and social control and a decrease in undermining.	Rigor: High Relevance: High
Theme 3: Development and Implementation of Culturally Tailored Interventions
Coffman et al. (2013)	To develop and pilot test nutrition and physical activity education tools for immigrant Latina women who have T2DMand low health literacy levels	N = 26 (Latina women with T2DM and low health literacy level) Focus group Logbooks Facilitated in Spanish and English urban location individual focused	Classes were 2.5 hours in length and held one week apart (total of two classes). Language; Exercise (walking) Limit carbohydrates and increase vegetable consumption	Large Southeastern U.S. city and included two service agencies known in the Latino community	Participants reported that the pedometers and logs helped them increase vegetable consumption and physical activity.	Rigor: High Relevance: High
Kerber et al. (2014)	To obtain qualitative information regarding usual dietary patterns of Latino adults from Pomona, California, and utilize this data in the development of a tailored nutrition intervention	N = 17 (Hispanic/Latina women ages 30–70, from a low SES community) Qualitative Focus groups Surveys Facilitated in Spanish language urban location individual focused	Three focus groups (45 min long) over a 6-week period Language, Community-based; Discussion of cultural foods and their preparation (e.g., shopping, frying/oil use) Use of fresh fruits/vegetables/legumes; cooking with less oil	Pomona, California	All participants were considered less acculturated to the U.S. participants reported that traditional recipes and family preferences have the greatest influence on foods prepared, however they tend to be less healthy items. Motivators for eating healthy included maintaining family health and preventing weight gain. Barriers included conflicting meal schedules among family members and individual food preferences.	Rigor: High Relevance: High
Theme 4: Impact of Culturally Tailored Interventions
Alcazar et al. (2017)	The purpose of this study was to explore the adoption of Brighter Bites healthy eating strategies in low-income Spanish-speaking families as well as barriers to the sustainability of improved dietary behaviors using Photovoice	N = 5 Spanish-speaking mothers/women Qualitative (Photovoice) Facilitated in Spanish language Hispanic participants low-income urban location family focused	16-week school-based program that delivers produce and nutrition education to high-need areas Community-based, Language Increase fruits/vegetables	One predominately Hispanic public school in Texas	Themes that emerged during the produce distribution period included: cost savings, increased variety and accessibility of fresh produce, and ability to practice healthy eating. Themes that emerged when the produce distribution was no longer in session included: increased costs, lack of variety, the continued effect of Brighter Bites, and innovative ways to cook with produce.	Rigor: Low Relevance: High
Brown and Hanis (2014)	To provide an overview of a 20-year research program aimed at testing diabetes self-management education interventions culturally tailored for Mexican American adults residing in an impoverished rural community on the Texas–Mexico border	N = >1100 individuals (64% female; BMI ≥; with elevated A1C) Facilitated in Spanish and English Hispanic participants, Mexican American subgroup impoverished, rural location individual focused	Interventions varied over 20 years, including questionnaires, instrument validation, weekly education sessions, support groups, focus group interviews Menu, Family-based, Community-based, Promotora, Language, Social Support Dietary recommendations based on favorite cultural foods—not interested in learning complicated dietary counting strategies (e.g., carbohydrates)	Starr County, Texas	Postintervention reduction in A1C ranged from 1.4 to 1.7% points. Individuals who attended ≥50% of intervention sessions achieved a 6% point reduction in A1C. Focus group interviews indicated that a traditional Promotora model was not acceptable to the participants who wanted knowledgeable health professionals, although Promotoras could provide logistical support (e.g., transportation).	Rigor: High Relevance: High
Carrasquillo et al. (2017)	To compare a community health worker intervention with enhanced usual care in addressing T2DM among Latino participants	N = 300 (135 men and 165 women; ages 18–65; A1C ≥8.0) Single-blind, RCT Latino participants, 38.3% Cuban subgroup; 80% living in the United States for longer than 10 years with 46.7% becoming citizens 55% female participants predominantly uninsured urban location individual focused	Median of 4 home visits and 20 telephone calls over 52 weeks Use of a community health worker Nutritional intake discussed and fruits/vegetable intake (at 2.6 servings/day)	Two public hospital outpatient clinics in Miami-Dade County, Florida	After adjusting for baseline values and covariates, participants in the community health worker group had an A1C level that was 0.51% lower than that of participants in the enhanced usual care group. The reduction in SBP of 4.62 mmHg did not meet the preplanned target of 8 mmHg and was not statistically significant in unadjusted models. No significant differences in LDLC levels or any of the preplanned secondary outcomes were observed.	Rigor: High Relevance: Low
Hammons et al. (2019)	To assess whether participation in a culturally tailored nutrition education program increases diet quality of Hispanic mothers	N = 65 mothers with children ages 6–18 years old RCT Facilitated in Spanish and English Hispanic participants, Mexican or Puerto Rican subgroup urban location family focused	Conducted from 2016 to 2018 and included nine cycles of implementation; 1 workshop/week x 6 weeks with weekly reminder text messages and phone calls Language; Adapt curriculum for cultural foods and to groups' needs; Family-based; Facilitate social support Increase fresh fruit/vegetable consumption; increase whole grains; lower sodium, sugar, and fat intake	Multistate (e.g., California and Illinois)	There was a significant change in diet quality categorization after participating in the workshops (p <.001, effect size 0.39). No changes were found in the control group.	Rigor: High Relevance: High
Hu et al. (2016)	To test efficacy of a family-based, culturally tailored intervention for Hispanic adults with type 2 diabetes and their family members	N = 186 (with T2DM) Quasi-experimental with two groups Facilitated in Spanish and English Hispanic participants 59% female participants 53% annual household income less than $10,000 and 29% insured rural location family focused	Weekly group sessions (1.5 h/week) for a total of 8 weeks with a total of 12 h with bilingual and bicultural RNs Used ethnic food models and modified ethnic recipes	Rural counties in Central North Carolina	Intervention patients improved in diabetes knowledge and diabetes self-efficacy over time, but did not sustain at 6-month follow-up. A1C was lower at 1-month follow-up. Family members had improvements in diabetes knowledge and physical health-related quality of life.	Rigor: Low Relevance: High
Ko et al. (2016)	To evaluate the impact of an 8-week community-based nutrition education program combined with food baskets on fruit and vegetable consumption among Latino adults	N = 40 (1 male; 39 female; mean age 37.8 years, overweight/obese) Mixed methods Pre–post intervention study Facilitated in Spanish and English Latino participants, 70% Mexico—country of origin 98% female participants 49% of participants had an annual household income of less than $20,000 and 70% uninsured urban location individual focused	Every other week x 8 weeks for four sessions (90 min each—30 min discussion/40 min cooking, 20 min Q&A) and one intervention discussion Bilingual and bicultural community health educator; take-home food basket with ingredients used in cooking demonstration; Language Increase fruit/vegetable consumption	Seattle Metropolitan area, Washington	Participation in the intervention was significantly associated with increased knowledge, food efficacy, and vegetable consumption.	Rigor: High Relevance: High
Ramal et al. (2018)	To determine the impact that a high-fiber, low-fat diet, derived from mostly plant-based sources, when coupled with support has upon self-management of type 2 diabetes mellitus in Latino adults from medically underserved areas	N = 32 Latino adults with A1C >6.4 Experimental randomized controlled community pilot study with focus groups Facilitated in Spanish language 80% female participants low-income urban location individual focused	5-week education program with follow-up support for 17 randomly assigned experimental group participants through focus groups held at participating clinics—1, 3, and 6 months post-education Language; Modification of ethnic foods Plant based	San Bernardino County, California	Mean A1C levels decreased from baseline to 6 months for both groups: control, μ₁ = 9.57, μ₂ = 9.49; experimental, μ1 = 8.53, μ2 = 7.31. The experimental group demonstrated a statistically significant reduction in mean A1C levels (p = .002) when compared to the control group.	Rigor: High Relevance: High
Spencer et al. (2011)	To test the effectiveness of a culturally tailored, behavioral theory-based community health worker intervention for improving glycemic control	N = 164 (African-American and Latino adults) Randomized, delayed control group design Facilitated in Spanish and English 70% of participants were Latino of Mexican origin >50% female participants >50% of participants had an annual median household income of $11,500 urban location individual focused	80 h of training over 6 months with diabetes education classes every 2 weeks—11 2 h group sessions, 2 60 min home visits, 1 clinic visit Use of community health workers; Language Discussed specific dietary measures on topics of fruit/consumption; fried/fatty foods, soda pop or fruit/flavored drinks	Detroit, Michigan	Participants in the intervention group had a mean A1C value of 8.6% at baseline, which improved to a value of 7.8% at 6 months, for an adjusted change of −0.8% points (p < .01). There was no change in the mean A1C among the control group (8.5%). Intervention participants also had significantly greater improvements in self-reported diabetes understanding compared with the control group.	Rigor: High Relevance: Low
Vincent (2009)	To report the results of a culturally tailored diabetes intervention for Mexican American adults on physical activity and to report the results of a focus group with intervention participants	N = 17 (with T2DM) Quantitative Qualitative Pretest/posttest control group design with two groups Facilitated in Spanish and English Latino participants, Mexican American subgroup 71% female participants >75% of participants reported an annual income of $20,000 or less urban location individual focused	8 weekly 2 h group sessions with cooking demonstrations and group support sessions Low-fat modifications of traditional foods; Use of traditional home remedies; Exercise (walking/dancing); Support person; Bilingual facilitators; Promotora; Community-based Healthy eating; Low-fat foods	Community health center in Tucson, Arizona	Results suggest a positive effect of the intervention on physical activity level, weight, and sense of control over diabetes self-management. Focus group results indicate that participants were satisfied with the culturally tailored intervention and that they and their families benefited from the intervention and 80% of participants lost weight.	Rigor: High Relevance: High

Note: BMI = body mass index; T2DM = type 2 diabetes mellitus.

Data Abstraction

Articles were then organized and compiled into a bibliography and database manager. Data from articles were extracted and prepared for data display and comparison. The data were entered into a matrix, organized, and analyzed for patterns, themes, and relationships, based on aim, design, and results (Whittemore & Knafl, 2005) (Table 1). The matrix provided a method for ordering, coding, categorizing, and summarizing the findings of the articles (Cooper, 1998). Articles with similar findings and themes were grouped together. Constant comparison was utilized to ensure that articles showed distinct relationships to the themes.

To score the quality of the articles, articles were evaluated based on methodological/theoretical rigor and data relevance with a possible “high” or “low” determination on a 2-point Likert scale (high = 2 or low = 1) (Whittemore & Knafl, 2005). A high rigor and relevance score had a greater contribution to the analytical process and required a clear description and appropriate use of the methodology, valid tools, and transparency regarding study limitations and potential threats to validity (Whittemore & Knafl, 2005) (Table 1).

Results

Development and implementation of culturally tailored interventions require specific planning prior to implementation, as well as measurement of the impact of the intervention, to determine the cultural impact, benefit, and outcome (Brown & Hanis, 2014; Carrasquillo et al., 2017; Hammons et al., 2019; Kerber et al., 2014). Studies were conducted across the United States, ranging from Washington to Florida, with the majority implemented in urban areas in California (4), Texas (3), and Arizona (2) (Table 1) with two studies including African American participants. Study designs mainly consisted of randomized controlled trials (7) and focus groups (6) conducted in English and Spanish. Additionally, the majority of studies focused on individual-level change and included primarily female participants. This may be due to cultural beliefs about nutrition or traditional gender roles. However, this also reveals a need for additional research on gender diversity and inclusion.

Theme 1: Participant Interest

When implementing culturally tailored interventions, two studies emphasized the importance of participant interest and feasible interventions with attainable outcomes to facilitate enrollment/retention (Peña-Purcell et al., 2018; Vincent et al., 2014). Participants’ interest levels should be assessed prior to an intervention, as well as their ability to participate (e.g., transportation, financial/time commitments, family/social responsibilities, support systems, and health literacy levels). This type of needs assessment can take place through focus groups, questionnaires, or informal conversations. Individuals may also need assistance with finances if participating in a dietary intervention, and childcare and/or transportation, depending on various commitments. Facilitators should make accommodations and efforts to remove potential barriers when planning interventions and develop community partnerships prior to the implementation of studies (Peña-Purcell et al., 2018; Vincent et al., 2014).

Theme 2: Feasibility of Intervention

Individuals may often verbalize that they wish to participate in diet/nutrition interventions. However, they may feel hesitant to make a change, if they feel that the change may potentially impact their family/social interactions in a negative way (e.g., meal planning for holidays/events) (Pilcher, 2015). Two studies reported that in Hispanic/Latino culture, participants may find it beneficial to include family members/support persons in education sessions/appointments to promote accountability and facilitate ongoing participation (Brown et al., 2015; Sorkin et al., 2014). Barriers to self-management and other cultural challenges (e.g., food preparation for self/others) should also be taken into consideration (Sorkin et al., 2014).

Regarding food preparation, previous studies in Latin America have shown that long-held cultural traditions of eating whole plant foods can potentially be an attractive target for high-impact interventions (Singh et al., 2019). In addition, many ancestral foods were actually plant-based and beef was only introduced to the Americas during colonization (Medina-Cadena, 2017).

Regarding time commitment and location, participants may express that due to time constraints, it is most effective for them to participate in interventions provided at community locations they already frequent on a regular basis (e.g., work, church) (Brown et al., 2015). Researchers reported interventions with timelines ranging from three weeks to more than a year, with one study analyzing results of a 20-year program (Brown & Hanis, 2014). However, regardless of length of intervention, participant burden should be taken into consideration.

Theme 3: Development and Implementation of Intervention

The third theme focused on the development and implementation of culturally tailored diet/nutrition interventions that included components such as the use of Spanish-speaking health care workers and improving health literacy, staff with a shared cultural identity, and how interventions were carried out to ensure sustainability. In two studies, researchers described essential design components that included the development and implementation of culturally tailored interventions which have the potential to make or break a study. Researchers confirmed that while participants may be eager and enthusiastic, as often as possible, education should be provided in the primary language and at a health literacy level that is appropriate to help promote understanding (Kerber et al., 2014). If education cannot be provided in a language that is understood, an interpreter must be made available.

In addition to primary language, cultural traditions surrounding identity and food should also be discussed to facilitate engagement and to remove/alleviate any potential barriers to achieve successful outcomes. According to Coffman et al. (2013), “Learning is best applied to daily life when it mimics life as it normally occurs” (p. 71). To assist participants with lifestyle changes, family and social network support may be utilized through small group gatherings and meals (Coffman et al., 2013).

Theme 4: Impact of Intervention

To validate the impact of culturally tailored interventions, nine studies reported changes in a variety of ways, including weight loss, serum lab values, diet quality, and food efficacy. While WFPB diets were not always specifically mentioned, studies specified increasing consumption of fruits/vegetables, as well as low-sodium, low-fat, and whole grains in interventions. Improvements were documented in record logs noting any changes in glycosylated hemoglobin tests (A1C), weight loss through body mass index (BMI), and other lab values, often compared to a control group. An article by Brown and Hanis (2014), provided an overview of a 20-year research program aimed at testing diabetes self-management education interventions culturally tailored for Mexican Americans residing in an impoverished rural community on the Texas–Mexico border.

A qualitative study by Alcazar et al. (2017), explored the adoption of healthy eating strategies in low-income Spanish-speaking families by distributing produce through a school-based program. Themes during the produce distribution period included cost savings, an increase in access and variety of fresh produce, as well as opportunities for healthy eating. However, once the distribution period ended, participants reported increased costs and loss of produce variety.

Successful results were measured through A1C ranging from a 1.4% to 1.7% overall decrease (Brown & Hanis, 2014). Mean baseline A1C levels were 12% and ranged from 6% to 18%, but individuals who attended at least half of the intervention sessions achieved a 6% point reduction (Brown & Hanis, 2014). Lessons learned included the impact of culture and the importance of family involvement. Cultural aspects included topics such as fatalism, folk remedies, language, religion, gender/family roles, social support, personal relationships, and also had an impact on recruitment/retention. Another study also utilizing a culturally tailored approach measured participants’ baseline mean A1C value at 8.6% at baseline, which improved after 6 months to 7.8% (p < .01) (Spencer et al., 2011).

Some studies used bilingual and bicultural community health workers in various capacities ranging from education to home visits and telephone calls to group activities (Carrasquillo et al., 2017; Ko et al., 2016). Results ranged from lowering A1C levels (52-week intervention) by 0.51% to providing food baskets (an 8-week intervention) with ingredients used in cooking demonstrations to encourage consumption of fruits/vegetables in Latino adults with financial constraints (Ko et al., 2016). The results from the food baskets showed a statistically significant change in knowledge (p < .01), food efficacy, and vegetable consumption (3.1 ± 2.0 vs. 3.9 ± 2.1; p < .05).

A study by Hammons et al. (2019) focused on culturally tailored nutrition education by focusing on the whole family and traditions and practices related to diet quality, family time, and physical activity in Hispanic mother–child dyads. Education sessions were two hours long, for six weeks, with a total of three hours dedicated to nutrition education. Participants received instruction on incorporating higher nutritional value foods and decreasing foods with lower nutritional value. Although this study was not directly focused on diabetes, the study was included as it described at-risk individuals using a culturally tailored intervention involving nutrition. The results indicate a significant change in diet quality categorization after participation in the workshops (p < .001, effect size 0.39). Workshop topics for changes in diet quality included activities, discussion, and hands-on demonstrations related to portion sizes and food labels, fruits/vegetables, whole grains/legumes, salt/sugar, fat, and protein. Participants were advised to start with small dietary changes and to eat foods with higher nutritional value while using traditional foods (e.g., beans as a plant-based source of protein/fiber) to strengthen family and cultural connections.

In a study by Vincent (2009), the use of a culturally tailored self-management approach with focus groups and physical activity resulted in a mean weight loss of 5 pounds at 4 weeks post-intervention. Through these combinations of culturally tailored interventions and lifestyle modifications (e.g., learning how to build social/familial support and use of culturally specific foods to improve diet quality), participants were able to make measurable improvements in their health.

A study by Hu et al. (2016) tested the efficacy of a family-based, culturally tailored intervention using bilingual and bicultural registered nurses with team members for Hispanic individuals with T2DM and their family members. The intervention group received eight weeks of diabetes education presented in Spanish with data collection occurring at baseline, after intervention, and at 1- and 6-month follow-ups for the patients and their families. While the intervention appeared effective over time, the results did appear to be sustained at the 6-month follow-up (Hu et al., 2016). There were changes over time, with the most significant change occurring in A1C (p < .001) after adjustment for repeated measures and propensity score weighting with results based on mixed-effect models. Cultural tailoring in this study included use of a family-focused intervention in facilitating stress management, problem-solving, and confidence in diabetes self-management (Hu et al., 2016).

A study conducted by Ramal et al. (2018), was the only study that specifically mentioned the use of a diet obtained from mostly plant-based sources. In both the control and experimental groups, mean A1C levels decreased from baseline to six months (μ₁ = 9.57, μ₂ = 9.49; experimental, μ1 = 8.53, μ2 = 7.31). The experimental group also was found to have a statistically significant reduction in mean A1C levels (p = .002) when compared to the control group.

However, not all results were statistically significant. In a pilot study by Coffman et al. (2013), Latina women with T2DM and low health literacy levels took part in a self-management education class and focus groups to discuss diabetes concepts related to nutrition and physical activity. Participants kept nutrition logs and had access to pedometers. No statistical significance was found between the health literacy level and completion of the nutrition log (r_s = .11; p = .58). The participants reported that the pedometers and logs helped to increase physical activity and improve the consumption of vegetables. Regarding cultural tailoring, the class materials and booklets were designed for individuals that speak Spanish and have low literacy levels, as well as having a research assistant who had experience working with a Latino population and was fluent in Spanish and English.

Discussion

As evidenced by the amount of research (n = 15) conducted from January 2009 to January 2020, there is an interest and need for culturally tailored nutrition interventions to prevent and reduce T2DM risk in Hispanic/Latino adults. Cultural tailoring was described as occurring through curriculum with culturally relevant themes and exercise, ethnic recipes, and language of delivery. Additional topics included stress management, religion, gender and family roles, and findings emphasized the value of bilingual and bicultural health care workers. Outcomes revealed an increased familiarity of fruits/vegetables and facilitation of family and community support.

Six of the studies resulted in significant reductions in weight, waist circumference, BMI, diet quality and self-efficacy, and A1C values, suggesting that culturally tailored nutrition interventions may be effective in reducing diabetes risk indicators. Some reported limitations included length/frequency of the interventions, inclusion of uncontrolled trials, generalizability, and sample sizes.

Conclusion and Clinical Implications

By utilizing culturally tailored methods (e.g., through curriculum, language, themes, food preparation, and eating), nurses and interdisciplinary teams can work together to design, implement, and evaluate innovative patient education while facilitating collaboration and open communication with Hispanic/Latino individuals and communities. In the study by Hu et al. (2016), using bilingual and bicultural registered nurses in their intervention, sustainable results were observed after six months. Nurses are in a strategic position to educate and assist in health promotion and disease prevention among Hispanic/Latino adults and their communities. Nurses compose 30% of the health care workforce and spend the most face-to-face time with patients; therefore, nurses are integral and should be prepared to advocate and support patients in the prevention of chronic diseases through health promotion, including nutrition (U.S. Bureau of Labor Statistics, 2020; Williams et al., 2018).

While policy changes, including those related to environmental and structural changes, are often beneficial for health outcomes, more research is needed in this area. Current studies show that individuals oftentimes experience greater success with individual and community-based or group health interventions than with policy change (Hillier-Brown et al., 2014). Therefore, research must be patient- and community-centered while focusing on sustainable health promotion, disease prevention, and self-management of chronic conditions. Through understanding of the sociocultural dimensions that influence decision-making processes and behavioral changes, nurses and health care providers can utilize culturally tailored nutrition interventions for equity, health promotion, and disease prevention.

Footnotes

Acknowledgments

The author would like to thank Dr. Kalpana Poudel-Tandukar and Dr. Rachel (Rae) Walker for their support during this review.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Linda M. Koh

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Culturally Tailoring Plant-Based Nutrition Interventions for Hispanic/Latino Adults at Risk for or With Type 2 Diabetes: An Integrative Review

Abstract

Keywords

Introduction

Background

Hispanic/Latino Individuals and Diabetes

Hispanic/Latino Individuals and Nutrition

Knowledge Gaps

Aim

Methods

Data Sources and Search Criteria

Search Strategy

Data Abstraction

Results

Theme 1: Participant Interest

Theme 2: Feasibility of Intervention

Theme 3: Development and Implementation of Intervention

Theme 4: Impact of Intervention

Discussion

Conclusion and Clinical Implications

Footnotes

Acknowledgments

Declaration of Conflicting Interests

Funding

ORCID iD

References