The Latin American Diet Pyramid: Serving the Latino Population?

Transcription

1 Elena Blebea 12/22/09 HSOC Senior Thesis The Latin American Diet Pyramid: Serving the Latino Population? Abstract: Poor nutrition is a prominent health issue in the United States and has significantly contributed to the rising obesity epidemic. Various studies have shown that the prevalence of obesity is higher among Latinos as compared to non-latino Whites due to multiple factors such as low socioeconomic status and cultural differences in food beliefs and behavior. In 1996, the Oldways Preservation Trust created the Latin American Diet Pyramid, a food pyramid incorporating traditional Latino foods as well as a physical activity component, in an attempt to address these influential factors and thus improve Latino nutrition. This study proposes to evaluate the effectiveness of the pyramid as a nutritional tool and a dietary guideline for Latinos in the US. The study takes place in South Philadelphia and consists of focus groups, interviews, and a local grocery store NEMS-based survey. My hypothesis that the Latin American Diet pyramid is ineffective because it does not fully account for the socioeconomic and cultural structures in the US Latino population was only partially upheld. There were actually few socioeconomic barriers inhibiting the effectiveness of the Pyramid. However, there were some cultural and educational barriers which could perhaps best be addressed through revisions of the Pyramid, a nutrition class based on the Pyramid, and the establishment of market vendors such as the Italian Market in Latino communities. Introduction In April 2005, at the Latin American Diet Summit in Mexico City, Mission Foods announced a surprise donation of $100,000 to Oldways Preservation Trust for the foundation of the Latino Nutrition Coalition (LNC). 1 The much-needed coalition was promptly established that summer in order to realize the Summit goals of improving and maintaining the health of Latinos through traditional foods and active lifestyles. 2 The LNC began its work with the following mission statement: to provide the Latino community, and those that serve them, with easy-to-understand nutrition, cooking, shopping, and health information. 3 That a coalition such as the LNC was much-needed was not in question. Poor nutrition is a major health concern in the United States and has significantly contributed to a marked increase in obesity rates. This is especially alarming considering that obesity increases risk for hyptertension, dyslipidemia, type-2 diabetes, low glucose tolerance, and heart disease. 4 Various 1

2 studies have shown that the prevalence of obesity is higher among Latinos as compared to non- Hispanic Whites. 5 For example, the prevalence of obesity among Latino 6-11-year-olds is 39.3% as compared to 26.2% among their non-hispanic White counterparts. 6 This higher level of obesity has led to significant health outcome disparities with Latinos now almost twice as likely to develop diabetes as non-hispanic Whites of the same age. 7 Factors that influence this health disparity include acculturation, 8 the language barrier, 9 low socioeconomic status, 10 and cultural differences in food beliefs and behavior. 11 These Latino-specific factors confirm findings that Latino nutrition education cannot merely consist of translated materials originally developed for non-hispanic Whites. 12 The need for health literature designed particularly for Latinos only began to be recognized around 1990 and there is still a dearth of such material. Thus, although the Latino growth rate is over three times that of the total US population and Latinos are known to experience this health disparity, there is currently no standard tested nutritional guideline which can adequately address the needs of this growing population. 13 The LNC recognized this health situation and decided that, in order to successfully improve Latino health outcomes through easily understandable and practical nutrition information, it would utilize the Latin American Diet Pyramid. The Oldways Preservation Trust created this pyramid in 1996 in order to provide a healthy dietary recommendation and educational tool for Latinos which focuses specifically on traditional Latino food. 14 It has become the cornerstone of the LNC and been used as a basis for many LNC health initiatives. The pyramid has also received national attention and been incorporated in programs launched by prominent organizations such as the Mayo Clinic and the Harvard School of Public Health. 15 However, although its proposed diet is in accordance with current nutritional recommendations, the actual impact of the pyramid on the US Latino population has never been evaluated. 16 Thus, 2

3 I propose to analyze the effectiveness of the Latin American Diet Pyramid as an educational nutritional tool and a dietary guideline capable of promoting behavioral change in the US Latino population. This research will help to determine whether and how organizations such as the LNC should continue to promote the pyramid. On a larger scale, this research will provide insight into successful methods for addressing the obesity health disparity in the Latino population. As a double major in Health & Societies and Hispanic Studies, I am well-suited to conduct research on the Latin American Diet Pyramid and have experience and knowledge regarding health, nutrition, and Latino culture. Not only do I have access to the literary resources of my two major departments, but I also have the opportunity to work with Penn experts such as the following: Dr. Frances K. Barg at the Department of Family Practice and Community Medicine; Dr. Janet Chrzan, a nutritionist at the Department of Anthropology; Dr. Shiriki Kumanyika, a health disparities expert at the Department of Biostatistics and Epidemiology; Dr. Amy Hillier at the Department of Urban Studies; Dr. Seema Sonnad of the Department of Surgery at the Hospital of the University of Pennsylvania; and Dr. Steven Larson, one of the directors of Puentes de Salud, a free clinic for Latino immigrants in South Philadelphia and a doctor at the Department of Emergency Medicine. I have been working with Dr. Larson and volunteering at Puentes de Salud for the past two years. Thus, I am familiar with a Latino community in the US and have contacts in the area. I also have access to an unpublished nutritional survey of the South Philadelphia Latino population conducted in the summer of 2008 by Marc Rabner, a Puentes volunteer and a medical student at the University of Pennsylvania. I am fluent in Spanish and English and thus able to conduct interviews and focus groups in the preferred language of the research participants. State of Studies 3

4 The general scholarly literature regarding Latino nutritional health in the US has thus far focused on the aspects of the cultural and socioeconomic environment of Latinos which might cause health disparities and magnify obesity risk factors. The research primarily examines factors such as acculturation, legal status, insurance, the language barrier, lower socioeconomic status, a difference in food beliefs and behavior, and the Spanish-language media. Oldways attempted to account for many of these factors while constructing the Latin American Diet Pyramid in the tradition of the USDA food guides. However, the effectiveness of the pyramid remains unknown and must still be evaluated. A number of studies have examined the effects of acculturation, which is defined as those phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original culture patterns of either or both groups. 17 It is unclear what effect US acculturation has on Latino dietary practices as various studies have found differing results. For example, Katarina M. Sussner and others conducted a study which found that a high level of acculturation in the US promotes obesity through a reduction of fruit and vegetable intake, a tendency of over-consumption of certain unhealthy foods, and decreased breastfeeding duration. 18 However, H. Balcazar found that groups with a low level of acculturation actually had a higher level of obesity. 19 The Viva la Familia Study, on the other hand, reported that acculturation did not, in fact, have any impact on weight gain in second-generation Latino children. 20 The obesity disparity among Latinos may also be due to a lack of or reduced access to medical care. The legal status of Latinos in the US and an inability to secure health insurance are two factors that can significantly influence the decision to seek needed health care. Illegal immigrants and their children born outside of the US are not eligible for state or federally 4

5 sponsored health insurance. Latinos are the most likely to be uninsured of all racial or ethnic groups. They comprise nearly 25% of the nation s uninsured people 21 as compared to African Americans, who represent 17% of the US uninsured. 22 It is important to note that these statistics are derived by reviewing only the legal population and thus the number of uninsured Latinos is actually much higher. 23 The lack of insurance and fear of deportation has contributed to decreased preventative care, a lack of regular care, and access to lower-quality care. 24 In fact, the Center for Disease Control found that Latinos are three times as likely as non-hispanic Whites to lack a regular health care provider. 25 The lack of a regular health care provider prevents access to nutritional education and probably decreases the likelihood of obesity detection and intervention. The language barrier has also been cited by many studies as a contributing factor to Latino nutrition disparities. In 1994, The American Public Health Association acknowledged that, because of the dearth of bilingual health practitioners and Spanish or multilingual health messages, the inability to speak English greatly undermines the ability of those of other cultures to receive health information, communicate with health providers, and identify available health services in their community for themselves and their children. This is a major barrier to the use of health care services by Latinos. 26 However, since the time of that report, bilingual services have become more widely available. Although the language barrier and different cultural concepts are still an issue in providing health care and health messages, they do not appear to be the central barrier to Latino access to care. 27 A study by the Pew Hispanic Center in Washington could help to explain why the language barrier can be overcome. The study found that although only 23% of the first- generation immigrants from Spanish-speaking countries said that they speak English very well, 88% of the members of the second generation described themselves as strong English speakers. 28 These 5

6 children have the capacity to act as translators for the first generation, although in a hospital setting this is technically prohibited. In addition, the language barrier may be less of an issue since the Office of Minority Health implemented the National Standards on Culturally and Linguistically Appropriate Services (CLAS) in March of 2001 which dictates that healthcare organizations must offer and provide language assistance at no cost to the patient. 29 Much of the literature has focused on the low socioeconomic status (SES) of the Latino population, which contributes to poor nutrition through producing food insecurity and reducing the availability of quality food. Food insecurity is a condition in which people lack sustainable physical or economic access to enough safe, nutritious, and socially acceptable food for a healthy and productive life. 30 Relative to non-latino Whites, Latinos in the United States have a lower SES profile. 31 Low SES increases the likelihood of food insecurity. For example, in three low income immigrant Latino Chicago communities, thirty percent of residents reported household food insufficiency caused by a lack of money or Food Stamps. 32 Not only are low SES people compromised in their purchasing power, but they may also be unable to find quality foods in their neighborhood. Many low SES neighborhoods are food deserts, areas in which there is little or no access to foods needed to maintain a healthy diet. For example, minority and lowincome communities have fewer than average supermarkets and convenience stores that stock fresh, high-quality, affordable foods such as whole grains or low-fat dairy products and lean meats. 33 One study found that areas with predominantly Latino communities had 38% less fresh fruit and vegetable retailers than areas with smaller Latino populations. 34 Philadelphia in particular has the second lowest amount of supermarkets per capita of major US cities. 35 Supermarkets not only increase access to food, but they also have been shown to improve diet 6

7 because each additional supermarket in a community increases fruit and vegetable intake by thirty-two percent. 36 Rather than supermarkets, there is a high concentration of fast food restaurants in many low-income neighborhoods. Although it is unclear whether a high density of fast food restaurants is an environmental risk factor for obesity, it has clearly been shown that eating fast food is associated with a higher BMI, reduced vegetable intake, reduced exercise, and a high fat diet. 37 Furthermore, income level affects fast food intake, probably because fast food is cheaper than food sold at non-fast food restaurants or even grocery stores. For example, in a California study of adolescents, approximately 47% of low-income teens reported eating fast food the previous day as compared to 37% of teens who were more affluent. 38 Latino children may have a high frequency of fast food dining. For example, in a 2008 study of Latino mothers and their children living in San Francisco, nearly two-thirds of the children ate fast food every week. 39 The bodega, a small food variety store, is another prominent provider of food in lowincome neighborhoods and has been linked to obesity. A study of the Latino population in Bushwick, Brooklyn revealed that Latino families often bought basic food necessities at local bodegas. However, the bodegas consisted of fewer choices, lower-quality food, and limited fruits and vegetables. Families who shopped there also tend to purchase high-fat, high-carbohydrate, processed foods such as ham, egg, and cheese sandwiches, chips, and soda. 40 A separate study in an inner-city Latino community reported that although low-fat milk was sold in two-thirds of the bodegas, in some of the stores it was more expensive than whole milk. 41 Another potential contributing factor to the obesity disparity is that perceptions about the traditional Latino ideal body weight is heavier than that of non-hispanic Whites. For example, one study of Latina mothers showed that most believed that a heavier infant was a healthier 7

8 infant. 42 An ethnographic study of a Puerto Rican community in Philadelphia showed that there are positive associations with obesity as well as a lack of social stigma regarding overweight people. 43 The Tarahumara of Northern Mexico traditionally believe that large, fat thighs are an essential component of beauty. In fact, an attractive woman is often called a beautiful thigh. 44 Although traditional cultural beliefs favor a heavier body image as compared to non-latino Whites, as the level of acculturation increases, these beliefs may conform more to the American norm which prizes thin body types. 45 This can be seen in a study which showed that secondgeneration Latina women feel more stress regarding weight than their first generation peers and tend to have a thinner ideal body image. 46 Cultural food behaviors may also lead to the obesity disparity among Latinos. In a 1995 study, it was shown that Mexican-American mothers regulated their child s food intake more than Anglo mothers did. This increased involvement in their child s diet was associated with a higher skin-fold ratio, indicating a higher level of obesity, perhaps because their children were then unable to regulate their own diets. 47 Latino parents were also more indulgent than African- American parents, meaning that they were more likely to grant most of their children s food requests. This indulgence is associated with higher Body Mass Index measurements, possibly because children do not learn how to carefully choose healthy foods or are given more unhealthy foods and/or calories than children of less indulgent parents. 48 The Spanish-language media can contribute to obesity and poor nutritional habits through advertisements. Latino children spend significantly more time watching TV and movies and playing video games than do White children. 49 During after-school hours on Spanish-language television, 31% of food/drink commercials advertised fast food, and 27% advertised drinks, of which 54% were sugared. Only 16% of the food/drink commercials contained health-related 8

9 messages. 50 These advertisements can affect purchase selection, especially because consumers in low-income households are more likely to heavily consider television commercials when shopping. 51 Research has only recently begun to focus on designing effective methods to improve Latino nutrition through accounting for at least some of the aforementioned factors of acculturation, legal status, insurance, the language barrier, a lower SES, heavier ideal body image, food behavior, and the Spanish-language media. Oldways and its Scientific Committee attempted to consider all of the above when creating the Latin American Diet Pyramid food guide. Food guides have an extensive history as a critical component of US nutritional policy. The essential objective of food guides is to translate dietary standards and recommendations into simple nutrition education tools that are useful for consumers. 52 Arguably, the most wellknown food guides in America have been published by the United States Department of Agriculture (USDA), which was established in 1862 with the mission to acquire and diffuse among the people of the United States useful information on human nutrition as well as to oversee and promote US agriculture. Unfortunately, these two components of the mission statement have the potential for dissonance if the USDA promotes an American food product which may be unhealthy when consumed in large quantities. 53 Thus, from the inception of food guides, nutrition experts have maintained skepticism regarding the political influences which may affect the recommended diet. The first food guide, entitled Food for Young Children, was published in 1916 by the USDA. 54 During the Great Depression, the USDA published the first buying guides, which specified how many servings of each food should be consumed per week and how to select foods economically. 55 The USDA created additional food guides during World 9

10 War II such as the Basic Seven, 56 describing the seven basic food groups, and later the Basic Four, a revised version of the Basic Seven. Finally, in 1992, the USDA released the first Food Guide Pyramid. Since its creation, the USDA Food Guide Pyramid has become an American dietary icon. The pyramid was meant to function as an easily comprehensible pictorial representation of the Dietary Guidelines for Americans, which are reviewed and updated every five years by national nutrition experts. 57 In testing multiple potential graphic representations such as bowls, picnic designs, and pie charts, consumer research showed that pyramid shape was the most effective in communicating the primary dietary messages. 58 The pyramid originally included six food categories with the bread, cereal, rice and pasta group as the base with a recommended 6-11 servings, and fats, oils, and sweets as the top with a caution to use sparingly. 59 Among the many initial goals of the pyramid were the following: a focus on overall health rather than diets to prevent and/or treat specific diseases; a basis in recent authoritative dietary standards and food consumption data; and usefulness to consumers. 60 It was also intended to be most useful when used as a complement to population-wide nutrition education campaigns or individualized nutrition counseling rather than as a stand-alone teaching device. 61 Although the pyramid was revised in 2005 to become the MyPyramid.gov pyramid, which maintains the six basic categories albeit 10

11 with different formatting, it still reflects the key concepts of variety, moderation, and proportionality. 62 The exact impact and effectiveness of the Food Guide Pyramid and subsequent MyPyramid.gov have been somewhat unclear. One of the well-cited positive aspects of the pyramid is its widespread recognition. In the 1997 American Dietetic Association Nutrition Trends Survey, two thirds of consumer respondents recognized the pyramid. 63 In a more recent 2000 Gallup survey for the Wheat Foods Council, 75% of consumers stated that they were either somewhat or very familiar with the pyramid. 64 Although many Americans have been exposed to the Pyramid, there have been few studies to evaluate how increased familiarity with the Pyramid actually affects diet. The majority of Americans do not adhere to the recommended diet. In the Healthy Eating Index, only 16% of the population ate a good diet, whereas the diets of 74% needed improvement. 65 Food group Recommended range of servings Average number of servings consumed per day, 2-day average US Department of Agriculture Food Surveys Research Group. Available at: odsurvey/fsrgfaq.html#pyramid. Grains 6 to Vegetables 3 to Fruits 2 to Dairy 2 to Meat (oz) 5 to A potential factor contributing to this lack of adherence could be that the pyramid has often been regarded as a stand-alone nutrition education document, contrary to the original conceptions of the USDA. Another potential factor could be that the pyramid was designed for adults with at least a high school education, whose eating patterns were typical of the general US population, and for whom food cost was not an overwhelming concern. 66 Thus, many nutrition experts felt 11

12 that the pyramid would not be nearly as relevant, and thus effective, for minority groups with different eating patterns. For example, Liz Mintz, the director of the Latino Nutrition Coalition, noted the inadequacy of USDA Food Pyramid for Latinos and stated, Many times, Latin American people see the [USDA] pyramid and they say, What do I do with this? 67 Mintz s informal analysis was confirmed in a study conducted by the School of Public Health of the University of California at Berkeley which found that the USDA Mypyramid.gov has no culturally tailored messages that would make the pyramid easily comprehensible and usable for minorities such as Latinos. 68 At the 1996 Latin American Diet Summit in El Paso, Texas, the lack of relevance to Latin American nutrition in the USDA Food Guide Pyramid design was of great concern. 69 The conference was part of a multiyear conference series, "Public Health Implications of Traditional Diets," organized by the Harvard School of Public Health and sponsored by Oldways Preservation Trust. The Oldways Preservation Trust was founded by K. Dun Gifford in 1990 as a non-profit food issue think tank based in Boston. For the summit, Oldways formed a Scientific Committee comprised of nutritionists, scientists, and food experts. At the time, Latino health was already a pressing issue as the US Latino population was rapidly expanding. According to the Census of 1996, Latinos, along with Asians, were expected to represent more than half of US population growth every year for the subsequent 50 years and were projected to become the largest minority of color by Nutrition for the general US population was a growing issue due to the rising incidence of obesity; however, the obesity disparity in the Latino population was particularly alarming. This disparity, which was clearly caused by Latino-specific factors 12

13 such as low socioeconomic status and different food beliefs and practices, illustrated the need for culturally relevant nutrition education materials. Also, nutrition experts at the summit believed that a major factor influencing the disparity was that Latinos were replacing traditional healthy foods with unhealthier, processed foods popular in the US. 71 The Oldways Scientific Committee decided to address the need for culturally appropriate nutrition materials for Latinos as well as the need to return to traditional healthy diet patterns by creating the Latin American Diet Pyramid. 72 The Latin American Diet Pyramid represents a compilation of the USDA food guide tradition, Oldways tradition, and Latino nutrition research. The Latin American Diet Pyramid was formatted in the pyramid shape established by the USDA Food Guide Pyramid. The process of constructing the Pyramid was based on the procedure which Oldways used when developing Original Latin American Diet Pyraid LatinAmericanDietPyramid.htm the Mediterranean Diet Pyramid in This process consisted of having certain members of the Oldways Scientific Committee evaluate data on food consumption in Latin American countries as well as Pan American Health Organization (PAHO) health profiles of Latin American countries to formulate a healthy diet pyramid. Although a list the members of the original Oldways Scientific Committee has not been published, through interviews with members of the Committee which revised the Pyramid in 2005, it seems that the original committee consisted of nutrition experts and academics such as Hannia Campos, Dr. Hector Bourges, and K. Dun Gifford. 74 According to K. 13

14 Dun Gifford, the president and founder of Oldways, Committee members compared available quality food consumption statistics with the PAHO country health profiles to develop a profile of people, what they eat, and how it relates to public health statistics. 75 They then worked with chefs and used the diets which seemed to promote the healthiest populations to form the Latin American Diet Pyramid and provide relative serving size proportions and a general sense of serving frequency. 76 The Scientific Committee was also sure to maintain a focus on traditional foods. According to the Latino Nutrition Coalition, the pyramid s use of traditional Latino foods was based upon two historical periods in Latin American history which are associated with good health. The first is the period of the Aztecs, Mayas, and Incas. The second begins with the arrival of Columbus and continues to the present. 77 According to K. Dun Gifford, the Pyramid was originally meant to be used by public health agencies, physicians, dietitians, and families. 78 Since 1996, Oldways and its Scientific committee have added a few minimal revisions to the pyramid such as the following: changing the cartoon format to one consisting of food photographs; altering the beverage recommendations from stating alcohol in moderation and six glasses of water a day to stay hydrated, drink a variety of beverages; and adding specific portion amounts such as 5-7 portions per day. 79 The creation of the Latin American Diet Pyramid has many positive attributes. The Pyramid ostensibly has filled the gap for a culturally tailored dietary guideline for Latinos by attractively demonstrating how popular traditional Latino foods can be healthfully consumed. It also is a visual guide following the tradition of food pyramids so allegedly many people in the US have already had exposure to that type of nutrition information. The Pyramid is also research-based and was created by experts from a variety of professions including Latino chefs and nutritionists. 14

15 Although the creation process of the Pyramid has several positive aspects, it also has some negative facets. From the information provided on the Oldways and Latino Nutrition Coalition websites as well as interviews with available members of the Oldways Scientific Committee, 1 it seems that the research to construct the pyramid may have been poorly conducted. First, relating health and food consumption patterns does not control for potentially significant confounding variables such as country GDP, locally grown foods, and socioeconomic disparities within the country. Thus, it is impossible to exactly define the relationship between Revised Latin American Diet Pyramid -LatinAmericanDietPyramid.htm health profiles and consumption patterns. Second, data were only used from countries that were considered to have quality data. None of the sources explained how quality was defined or which specific countries were examined. It is possible that the Committee only utilized data from a couple of countries and thus the Pyramid is not actually representative of Latin American diets. For example, many traditional and frequently-consumed Honduran foods such as passion fruit and zapote are not included. As Simopoulos and Painter have stated, to be effective, food guides must incorporate the unique dietary components of specific populations and perhaps this Pyramid does not actually look at the unique components of all of the populations which it claims to review. 80 Third, it is unclear how many people were actually involved in developing the Pyramid. The Oldways website claims that Oldways and the Scientific Committee developed the Pyramid, however Oldways is a small organization only 1 Six out of the nine members were interviewed. Three of them (Hector Bourges and Miriam and Adolfo Chavez) are deceased, according to K. Dun Gifford 15

16 consisting of five core people. 81 Furthermore, of the nine people on the Committee, six were interviewed and only three (Hannia Campos, K. Dun Gifford, and John Foreyt) confirmed that they were actually involved in creating the Pyramid. Those three people mentioned differing timelines for creating the Pyramid. K. Dun Gifford stated that the Pyramid creation process took two or more years, 82 Ms. Campos stated that the Pyramid took about six months 83 to create, and Mr. John Foreyt said that the creation of the Pyramid occurred only during the Latin American Diet Summit which lasted for a few days. This could indicate that a few people were much more involved in the creation process than others so the process was less of a collaboration and thus potentially less valid. Finally, there has been absolutely no follow-up research on the Latin American Diet Pyramid and only one review in 2005 to see if revisions were needed. 84 Another negative aspect of the Pyramid is that it could include some Western notions which may render it ineffective for the Latino community. It was created based on the USDA Food Guide Pyramid. The USDA pyramid form has been rejected in a few Latin American Countries such as Mexico, which uses a plate form that was thought to be more comprehensible. 85 Also, the Pyramid itself has included a picture of a milk carton which says Milk instead of leche, clearly not adapted to Spanish-speakers. The Latin American Diet Pyramid was created following a long tradition of food guides in the US at a time when Latino health was a growing concern. Although the Pyramid has several positive attributes, it also has some negative characteristics. Since its creation, the Latin American Diet Pyramid has been cited in articles in national media outlets, such as MSNBC 86 and USAToday, 87 and utilized in multiple nutritional campaigns for Latinos. However it is unclear whether the pyramid actually does overcome many of the structural socioeconomic and cultural barriers which contribute to the Latino obesity disparity. Because it has never been 16

17 critically evaluated, its effectiveness is unknown and it is unclear how the Latino population interprets and uses the Pyramid. As Ms. Hannia Campos stated, What would be interesting would be to see what people actually say about the pyramid itself. Usually research and scientists are far away because we try to teach people something, but they see something totally different. 88 This thesis is exactly the research which Hannia Campos has suggested. In this study, I evaluated the impact of the Latin American Diet Pyramid on Latinos in the US both as an educational nutritional tool and a dietary guideline which can inspire behavioral change. The research was conducted with Latino adults living in South Philadelphia. Adults were the target population because the first and arguably more widely used Latin American Diet Pyramid was created specifically for adults and a Latino Children s Diet Pyramid was only constructed in South Philadelphia was chosen for its large Latino population and my connections to the community. The area of South Philadelphia is defined as the section bounded by South Street to the north, the Delaware River to the east and south, and the Schuylkill River to the west. 90 The effectiveness of the pyramid will be defined by evaluating both educative and behavioral influence through assessing the following criteria: knowledge of the existence of the pyramid, ability to access the pyramid, ability to understand the message of the pyramid, ability to use the pyramid as a dietary guideline, and the potential to inspire a healthy diet change. The ability to use the pyramid as a dietary guideline includes the capacity to purchase and prepare the recommended food. Thus, my research question is: Is the Latin American Diet Pyramid effective? I hypothesize that the Latin American Diet Pyramid will prove ineffective as a nutritional tool and dietary guideline for Latinos in the US as it does not fully account for the socioeconomic and cultural structures in Latino communities such as the inability to purchase the 17

18 food due to low income, food deserts, and the variety of dietary practices throughout Latin America. The research that I use to test my hypothesis is comprised of pilot data using focus groups, face-to-face interviews, and grocery store surveys based on the Nutrition Environment Measures Surveys (NEMS) created by Dr. Karen Glanz. Methodology Pilot Data I used a focus group to develop and refine individual survey questions. The focus group research subjects were recruited from an English as a Second Language (ESL) Course taught by Ms. Victoria Behrend, a graduate student at the University of Pennsylvania. The class was chosen because class participants were adult residents of South Philadelphia who self-identified as Latino. The focus group was held after the ESL class at approximately 11 AM on May 6, 2009 at the Annunciation B.V.M Church, the site of the ESL class, in South Philadelphia. The group consisted of six adult participants, three women and three men. I conducted the group in Spanish because the participants were all native Spanish-speakers who would probably feel most comfortable and able to express their sentiments in their native language. Jonathan Rivera, a bilingual senior at the University of Pennsylvania and a volunteer at Puentes de Salud, assisted me by taking notes during the session. The meeting was audio recorded to ensure accuracy of data collection. Questions for the focus group were designed to determine which factors might influence the effectiveness of the pyramid. After signing an informed consent form approved by the University of Pennsylvania Internal Review Board [Appendix A], the focus group members completed a short form regarding the following socio-demographic parameters: age, selfidentification of race, residential zip code, educational level, marital status, number of children, 18

19 date of immigration to US, weight, height, family health issues with obesity, and country of origin [Appendix B]. I requested this information in order to determine eligibility for the study, obtain socio-demographic information considered to be standard for Latino obesity studies, and evaluate which factors might affect the usefulness of the pyramid. Following these forms, questions were posed to the focus group [Appendix C]. These questions were informed by feedback from the following experts from the University of Pennsylvania: Frances K. Barg (Department of Family Practice and Community Medicine), Amy Hillier (City and Regional Planning School of Design), Shiriki Kumanyika (Department of Biostatistics and Epidemiology), Janet Chrzan (Department of Anthropology), Steven Larson (Department of Emergency Medicine), and Seema Sonnad (Department of Surgery). The questions also integrated information from literature searches, thus enhancing content validity. Jean Knight, a Hispanic Studies professor at the University of Pennsylvania, ensured that the questions were equivalent in English and Spanish. The Institutional Review Board of the University of Pennsylvania also reviewed them to verify accurate translation. At the completion of the meeting, I gave each participant a free copy of Camino Mágico, a Latino Nutrition Coalition bilingual supermarket shopping guide translated into both English and Spanish which gives nutrition advice based on the Latin American Diet Pyramid. The focus groups also included light snacks and beverages using the foods in the Latin American Diet Pyramid. These snacks followed the focus group session so as not to influence answers regarding the preparation of food. Both Camino Mágico and the refreshments were funded by the Louis H. Castor Undergraduate Research Award. The nutrition literature 19

20 and food were meant to act as an incentive which would encourage focus group attendance without exerting undue influence. Although the participants were already acquainted with each other due to the ESL class, I made every effort to ensure confidentiality outside of the session. Every participant signed a confidentiality agreement and I explained that nothing discussed should leave the room. The data have been kept in a locked drawer and during analysis names were coded using pseudonyms and no identifiers were used. Jonathan Rivera also signed a statement agreeing to protect the security and confidentiality of identifiable information. After the study is completed, all identifying data will be permanently erased. Face-to-Face Interviews The second part of the study consisted of face-to-face interviews in order to ask more formalized quantifiable questions suggested by the focus group results. A face-to-face interview was chosen instead of a survey because of the low literacy rate among Latinos in the US. 91 Interview subjects (n=64) were recruited from June 4, 2009 to October 1, 2009 from multiple sites and events in order to ensure adequate representation. These sites included the following places: Puentes de Salud waiting room, Juntos meetings, the Latina Womens Health Services waiting room, the Mexican Independence Day Fair, the South Philadelphia WIC office waiting room, and all Mexican shops on 9 th street between South and Wharton Street in South Philadelphia. Upon going to these venues, I invited people to complete the brief minute interview. Each person signed an IRB-approved consent form [Appendix D]. All interviews except one were conducted in Spanish because that was the preferred language of participants. The structured interview consisted of a series of questions [Appendix E] separately approved by the 20