Journal of Community Health Nursing, 31: 225–237, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2014.926674

Lifestyle Intervention for Filipino Americans at Risk for Diabetes Jillian Inouye, PhD, FAAN Schools of Nursing and Allied Health Sciences, University of Nevada, Las Vegas, Las Vegas, Nevada

Christine Matsuura Kahi Mohala Behavioral Health, Ewa Beach, Hawaii

Dongmei Li Department of Public Health Sciences, University of Hawaii, Honolulu, Hawaii

Rosa Castro John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii

Anne Leake Queens Medical Center, Honolulu, Hawaii

The aims of this study were to determine recruitment and retention feasibility, changes in self-efficacy for diet and exercise, and weight and fasting insulin level change after a lifestyle intervention in a community park. A randomized wait-list control design was used to recruit 50 Filipino American participants into a flexible eight-week curriculum. The retention rate was 88%. A weight loss of 1.52 kg (p < .05) and a waist reduction of 5.46 cm (p < .05) were found in the intervention group. Significant predictors for weight loss were gender and marital status. The intervention showed promise for this community program.

BACKGROUND Type-2 diabetes (T2D) is a major cause of morbidity and mortality in the United States with a majority of new cases occurring in minority populations (Centers for Disease Control and Prevention, 2011; Craig & Huang, 2009). According to the 2012 US Census Bureau Report, Asian Americans are the fastest growing ethnic group in the United States; Filipinos are currently the third largest Asian American group immigrating into the United States (US Census Address correspondence to Jillian Inouye, PhD, FAAN, Professor and Associate Dean for Research, The Tony and Renee Marlon Angel Fellowship, University of Nevada, Las Vegas, Schools of Nursing and Allied Health Sciences, 4505 S. Maryland Parkway, Box 453018, Las Vegas, NV 89154-3018. E-mail: [email protected]

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Bureau, 2010). Of the total immigrant population in Hawaii in 2010, 43.7% were born in the Philippines. Filipinos comprise the second largest racial group in Hawaii, having increased by 24.1% between 2000 and 2010 (US Census Bureau, 2011). In a large survey study of middle-aged Filipino women in San Diego, 33% were found to have asymptomatic diabetes unrelated to obesity (Araneta, Wingard, & Barrett-Connor, 2002). T2D has become especially prevalent among Filipinos in Hawaii, affecting over 10.1% of the population (Hawaii Health Data Warehouse, 2011). This rate is second only to the Native Hawaiians, with a rate of 11.4% (Hawaii Health Data Warehouse, 2011). A multiethnic epidemiological study in North Kohala, Hawaii found that Filipinos had the highest rates of metabolic syndrome, often a precursor to diabetes (Grandinetti, Chang, Theriault, & Mor, 2005). Nationally, Asians and Pacific Islanders made up 4.4% of the 3,234 participants, and treatment effects did not differ significantly by race or ethnic group (Knowler et al., 2002). Filipinos are currently the largest immigrant group in Hawaii, and Filipino Americans (FA) are the third largest Asian American group in the United States (US Census Bureau, 2011). Hawaii’s population is 25% (347,040) Filipino, the highest percentage of all the states in the United States (US Census Bureau, 2011). On Oahu, the target island for this project, the Filipino population is 234,894 or 24% of the island population (Hawaii Department of Economic Business Development & Tourism [DEBDT], 2010). No published studies have targeted FAs for an intervention to prevent diabetes, although studies with other Asian populations exist (Knowler et al., 2002; Kosaka, Noda, & Kuzuya, 2005; Pan et al., 1997; Weber, Oza-Frank, Staimez, Ali, & Venkat Narayan, 2012). Recruitment and retention of participants in lifestyle interventions is challenging (Leake, Bermudo, Jacob, Jacob, & Inouye, 2012; Reddy et al., 2011; UyBico, Pavel, & Gross, 2007). However, lifestyle interventions have demonstrated efficacy in diabetes prevention. Although the programs adapted for Asian populations differ slightly, they share common components: a low-fat, reduced calorie diet and an increase in leisure time, physical activity, behavior change counseling, and weight reduction. Additionally, the structured intervention curriculum, utilizing risk identification and communication, and providing incentives to motivate participants to change lifestyle behaviors were a consistent factor in these programs (Weber et al., 2012). The efficacy of lifestyle changes to prevent diabetes has been demonstrated in both national and international studies (Knowler et al., 2002; Pan et al., 1997; Tuomilehto et al., 2001), but no interventions for diabetes prevention have been culturally tailored for FAs. The multisite Diabetes Prevention Programs (DPP) included Hawaii as a study site and aimed to determine if weight loss through dietary and physical activity or drug treatment prevented or delayed the onset of T2D. Findings from this study revealed that lifestyle intervention of the DPP was highly effective in all ethnic subgroups to restore normal post-load glucose values. They also found that losing weight through diet and exercise delayed or avoided the development of T2D with participants reducing their risk by 58% (US Department of Health and Human Services, 2013). The DPP showed that 7% weight loss was efficacious for preventing diabetes in high risk groups with no differences in weight loss noted between white and minority participants (Hamman et al., 2006). The DPP had 16 sessions and used individual sessions between health professionals and participants, an approach that may be too costly and too long for community-based organizations. The Filipina Women’s Health Study was conducted to measure the rates of diabetes, heart disease, hypertension, and osteoporosis among 454 female Filipinas, ages 50 and older, in San Diego County (Araneta et al., 2002). One in three Filipino women had diabetes, compared to one

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in 11 Caucasian women. Of those Filipinas with diabetes, 90% were not obese and 60% did not know they had diabetes. Filipinos in Hawaii have a prevalence of diabetes of 10%, surpassed only by native Hawaiians at 11.4% (Hawaii Health Data Warehouse, 2011). A survey study of a multiethnic population in North Kohala, on the island of Hawaii showed that the Filipinos also had the highest rate of metabolic syndrome that occurred at lower body mass index (BMI) compared to other Asians and Pacific Islanders ethnic groups (Grandinetti et al., 2005). FAs develop T2D more often than is expected based on BMI (Araneta & Barren-Connor, 2005). In that study, Filipinos had the highest adjusted odds for prevalent metabolic syndrome among all non-Caucasian ethnic groups (Japanese, Filipino, Hawaiian/part-Hawaiian, Other/mixed non-Hawaiian) when compared to Caucasians (prevalence OR = 4.2; 95% CI = 2.4-7.3). Insulin resistance is one of the five diagnostic criteria for metabolic syndrome and can herald the development of T2D. Health is Wealth was a cultural belief of the sakadas (original Filipino immigrants who came to Hawaii beginning in 1886 as plantation workers; Leake et al., 2012). The Philippine Nurses Association (PNA) of Hawaii, the community partner for this study, chose this name to bridge the cultural values of the importance of good health, the value of working hard, and the dreams that the sakadas followed to America for a better life for their families. Characteristics of Filipinos in Hawaii currently present potential barriers to lifestyle interventions. The Hawaii Department of Health’s Healthy People 2010 Report showed that 13.7% of Filipinos hold more than one job, more than double the national average of 5.4%, and higher than the state average of 12.6% (DEBDT, 2010). This finding implies that Filipinos have little leisure time and emphasizes the need for more flexibility with both time and location of a lifestyle intervention to enhance access. During the presentations to the Filipino community in Hawaii on findings from the 2001 Behavioral Risk Factor Surveillance Survey, the participants raised concerns that Filipinos had the lowest percentage of adults who participate in moderate physical activity. Concerns included a lack of sensitivity to socio-economic class in the design of physical activity survey questions, which currently focus on middle-class recreational activities and exclude heavy physical labor required on the job. In summary, the Filipino community in Hawaii is at high risk for diabetes, and there is evidence that lifestyle interventions are efficacious, but translational research with cultural tailoring of interventions that use a family approach is needed to reduce the burden of disease for this population. In 2003, Leake conducted a focused ethnography on self-management by uninsured Filipino immigrants with T2D. In that study, worry was the most frequently mentioned emotion by 10 of 11 study participants and was categorized as a negative emotion (Leake, 2003). Four cultural themes emerged from this study related to the pervasiveness of worry by these patients with T2D: (a) extended-family finances, (a) how to seek medical advice, (c) the central importance of the family, and (c) the cultural significance of decreasing the role of white rice in the diet. One of the cultural themes derived from that study was called “worry is a Filipino pastime.” “I am thinking of my family” and the impact on the family from lost income due to disability were both a cause of worry and a source of motivation to engage in self-care. As a follow up, another study, Kalayaan Para Sa Diabetes (Freedom with Diabetes), key Filipino health professionals on Oahu were interviewed about how to approach the Filipino community to conduct research in the area of diabetes (Leake, 2005). That study led to a partnership between the PNA of Hawaii and the principal investigator to conduct a community-based participatory research study called PNA Bayanihan Para Sa Diabetes (Working Together with Diabetes). Ten community presentations about the impact of diabetes on the Filipino community

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were made, and the audiences selected preventing diabetes in adults and preventing obesity in children as priorities for future research (Leake & Jacob, 2007). This positioned the research team well to conduct the proposed study, because the principal investigator and the Filipino community on Oahu developed a successful partnership over 3 years with preliminary studies. The PNA of Hawaii has been an active research partner in conducting participatory research with the Filipino community to identify diabetes prevention in adults as their research priority. Finally, a review of the effectiveness of 28 lifestyle interventions based on the DPP in the United States concluded that there was an average 4% weight loss in participants (Ali, EchouffoTcheugui, & Williamson, 2012). Recruitment for the DPP did target minorities and 45% of the 3,048 participants were Asians (Fujimoto, 2000). Their study also concluded that costs associated with diabetes prevention can be lowered without sacrificing effectiveness, using non-medical personnel, and motivating higher attendance at program sessions. However, to date, no research findings on diabetes prevention intervention studies tailored to Filipino cultural themes have been found. This study was designed to fill this gap. Research Questions and Hypothesis The three major aims of the study were to (a) develop an innovative culturally tailored lifestyle intervention for FAs to reduce the risk of developing diabetes, (b) test the feasibility of this lifestyle intervention which incorporates flexible scheduling of the curriculum on weekends to accommodate working parents, and (c) assess the efficacy of this lifestyle intervention. The research questions were: Would increasing the accessibility and cultural competence for a lifestyle intervention to prevent diabetes (a) increase rates of completion of the intervention and (b) improve outcomes such as fasting insulin, weight loss, waist-to-hip ratios, and self-efficacy for diet and exercise (efficacy)? It was anticipated that a culturally tailored intervention focused on family and community support would facilitate positive behavior change with Filipino adults at risk for diabetes. Conceptual Framework Social learning theory (Bandura, 1977) was used to guide the design and delivery of our pilot study utilizing a randomized, controlled-trial design with a wait-listed control group. The conceptual framework for the intervention was the social learning theory that states that people are more likely to change their behavior if they are confident they can make the change (i.e., selfefficacy). This was accomplished by having participants set behavioral goals at the end of each session and discussed progress toward goals at the beginning of each following session. The facilitator taught a problem-solving approach so participants could help each other with ideas for reducing barriers to accomplishing their goals. Self-efficacy was later measured to see if any changes occurred due to the intervention.

METHODS A community-based participatory research approach was used for this pilot study. The PNA of Hawaii, as research partners, guided the implementation of the project and participated in the

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dissemination of results to both the Filipino community and the scientific community. Three PNA Board members served as the advisory committee during the curriculum design, recruitment, and evaluation. After the curriculum was culturally tailored, a focus group of participants from the target population reviewed the curriculum as part of a no-cost extension of a preliminary study, PNA Bayanihan Para Sa Diabetes. Revisions to the curriculum materials suggested by the focus group were made before the intervention began. The Site and Participants The intervention was held in a park on Sunday afternoons, with most participants recruited from two large Catholic churches not far from the study site, frequently visited by Filipino families (Leake et al., 2012). Participants were counted if they attended at least 75% of the intervention sessions, such as at least six of eight units in the curriculum. Inclusion criteria included being Filipino aged 30 or older, with a risk score of greater than nine on the American Diabetes Association “Are you at risk for diabetes?” screening questionnaire. Because of the Filipino community’s interest in preventing childhood obesity (Leake, 2003), recruitment efforts focused on parents with children still living at home. Exclusion criteria included having a diagnosis of diabetes, uncompensated cardiac disease, respiratory disease, or musculoskeletal disease that would prevent exercise. The Intervention During the first 6 months of the study, community presentations and diabetes screenings were held within Filipino community groups in collaboration with the PNA. The survey from the American Diabetes Association “Are you at risk for diabetes?” was used to assess risk. Study participants were recruited from the participants at diabetes screenings and informed consents were obtained. Participants were required to complete their eight sessions during a 6-month period. The sessions were offered on multiple dates, so participants were able to schedule their sessions at convenient times. They could finish the intervention in as short a period of 6 weeks or up to 6 months. A total of 40 subjects were recruited and then randomly assigned to either the control group or the intervention group. The control group received the intervention 6 months after the experimental group. A dropout rate of 50% was expected based on experience in lifestyle intervention studies for obesity. Innovative scheduling of sessions was anticipated to facilitate attendance and retention. Design The eight adapted sessions included two on diet, two on exercise, two on self-management, and two on stress management. Health is Wealth used a randomized, controlled trial with a wait-listed control group. All participants (n = 40) received the intervention with n = 22 subjects randomized to the intervention group for first 6 months and n = 18 randomized to a wait-listed control group. After 6 months, all the subjects in the control group received the intervention for another six months (Figure 1). Attendance and missed-visit forms recorded participation rates. Participant satisfaction surveys were also distributed at the conclusion of the eight sessions. A phone survey

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FIGURE 1 Design of the Study.

or return visit with incentive was conducted for measurement and evaluation for noncompleters. The sample included a large number of first-generation immigrants, an underserved population. The facilitator of the intervention was fluent in English and two Filipino dialects. Eight sessions from the DPP interventions were culturally tailored to include diet and exercise options more commonly used by Filipinos. The DPP was an individual intervention, but Health is Wealth was family- and community-oriented and presented in small groups. With the intervention conducted in small groups, the elements of social learning, such as role modeling, vicarious learning, verbal persuasion, and graduated mastery experiences, were used to increase self-efficacy for lifestyle behavior change. The innovative scheduling of intervention sessions included sessions held on Saturdays, with participants offered four options of when to attend each session to optimize retention. The information presented in each session was stand-alone to allow participants maximum flexibility to attend all eight sessions without having to attend them in a particular order. The leader of the small groups was a Filipino health care worker with training and experience facilitating self-management groups. Family members were invited to the small group sessions as well. A research assistant assisted the facilitator with measurement and taking attendance. Measures The intervention was intended to increase self-efficacy for lifestyle improvement in the areas of diet and exercise for the prevention of T2D. The variables related to outcomes were physical functioning, biometrics, and psychosocial relationships. These variables were based on the social cognitive theory model. Measurements were conducted at baseline and 6 months for the experimental group and baseline, 6 months, and 12 months for the control group (see Figure 1). Biophysical measures included height, weight, BMI, waist and hip circumference, waist-to-hip ratio, blood pressure, and pulse. The biometric measures were collected with the Tanita Electronic Scale Model BWB-800A, a wall-mounted stadiometer SECA Model 240, and donated Asencia Breeze glucometers. Fasting insulin levels was analyzed at a commercial lab using an Access Ultrasensitive Insulin Assay Kit (Becton, Dickinson, and Company, Franklin Lakes, NJ). Increased scores on the following measures served as preliminary outcomes of efficacy of the intervention: improved biometric profile, weight/height ratio, BMI, waist-to-hip ratio, fasting blood glucose, and fasting insulin. Measures included the scale/stadiometer, BMI calculator, tape measure, glucometer, Access Ultrasensitive

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insulin assay, waist-to-hip ratio for metabolic syndrome with sensitivity of 0.83 and specificity of 0.78 (Laaksonen et al., 2002), and fasting insulin for Polycystic Ovary Syndrome with sensitivity of 0.95 and specificity of 0.78 (Legro, Finegood, & Dunaif, 1998). Anticipated outcomes included decreased (a) or maintained weight, (b) BMI, (c) waist-to-hip ratio, (d) fasting blood glucose, and (e) fasting insulin. Psychosocial measures included the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36), World Health Organization Quality of Life-BREF (WHO-QOL BREF; six environment-related items only), and depression (CES-D) and self-efficacy for self-care and exercise scales. The psychosocial measures included (a) five items from the Self-Efficacy for Managing Chronic Disease 6-Item Scale; (b) the SF-36 to measure quality of life and the CES-D depression screen; (c) the Exercise Regularly Scale to measure self-efficacy for exercise; and (d) six items from WHO-QOL BREF related to the domain of environment, which included a measure of having enough money to meet one’s needs and opportunities for leisure activities, both of which are anticipated barriers to a healthy lifestyle. To determine an increased self-efficacy for exercise, three items of the self-efficacy for exercise, Exercise Regularly Scale by Lorig et al. (1996) were utilized. Internal consistency was 0.83 with test–retest reliability at 0.86. To determine increased self-efficacy for self-management tasks, item #5 from the six-item self-efficacy for managing chronic disease scale by Lorig, Sobel, Ritter, Laurent, and Hobbs (2001) was utilized and had an internal consistency of 0.91. This question asks, “How confident are you that you can do the different tasks and activities needed to manage your health condition so as to reduce you need to see a doctor?” Improved scores on perception of economic stress and opportunities for leisure activities based on six items from domain on environment (Quality of Life survey and the WHO QOL-BREF survey; WHO QOLBREF, 1996) were also observed. Improved scores were also observed with reduced distress in population at risk for chronic disease and improved depression scale measure (CES-D; Radloff, 1977). Internal consistency for CES-D in general population was 0.85, with test–retest reliability at four weeks of 0.67. To measure environmental factors, financial resources, physical safety, and security, opportunities for recreation and the physical environment data were collected. The primary outcome variables included weight loss and self-efficacy for diet and exercise. The secondary outcomes were fasting insulin level and other biometrics measures. Analyses Frequency distributions and summary statistics were used to summarize the demographic characteristics of the participants and baseline measurements. Chi-square tests/Fisher’s exact tests and two-sample t-tests were used to compare the differences in demographic and baseline measurements between participants who dropped out from the study and non-dropouts. The intervention effects were examined through linear mixed effects model with correlations across repeated measurements within the same subject taken into account. This analysis was designed to show change across the post-test measurements while controlling for the probability of a Type-I error across multiple comparisons. Descriptive statistics and linear contrasts comparing changes between baseline and 6 months for the experimental and control groups were used to analyze efficacy of the intervention. SAS 9.3 (SAS Institute, Cary, NC) was used for all the data analysis and the significance level was set at p = .05.

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RESULTS Demographics There were three subjects from the intervention group (13.6%) and two subjects from the control group (11.1%) that dropped out during the first 6 months of the study. Fisher’s exact test showed no significant difference between the percentages of drop-outs between the intervention group and the control group during the first six months of the study period (p = 1.000). The participants were overweight at baseline with average fasting blood glucose 95 mg/dL. One-third of participants spoke only a Filipino dialect at home and 22% were potentially depressed. The experimental group lost an average of 3.3 pounds (1.5 kg), an amount that was statistically significant compared to the control group. Waist circumference and BMI reductions were also significant (p < .05). None of the other biometric or psychosocial outcomes reached significance. Aim 1: To Develop an Innovative Culturally Tailored Lifestyle Intervention for FAs to Reduce the Risk of Developing Diabetes To develop an innovative culturally tailored lifestyle intervention for FAs to reduce the risk of developing diabetes, feedback about printed materials and different features of the intervention were collected. Focus groups with Filipino parents with children at home were conducted, as well as a review of the curriculum by the PNA Advisory group. A semistructured interview guide was developed and included questions such as “What do you do to keep healthy?” and “What gets in the way of regular exercise?” The results of these focus groups aided in revisions of the DPP intervention for this study. Aim 2: Test the Feasibility of This Lifestyle Intervention Which Incorporates Flexible Scheduling To test the feasibility of the new interventions, we aimed at an 80% participation rate for all sessions. Five out of 40 participants dropped out during the study period, which gave us a retention rate of 88%. The dropouts tended to be heavier than the nondropouts. They were also more likely to be male and never married or separated. Age, educational level, and primary language spoken at home did not make a difference in the likelihood of dropping out of the study. Other than weight (p < 0.01), waist size (p < 0.01), and waist-to-hip ratio (p < .001), there were no other significant findings between dropouts and completers in the biometric measures. For the psychosocial measures, dropouts had significantly lower scores for self-rated physical health and functioning than the non-dropouts (p < 0.05). Aim 3: Assess the Efficacy of This Lifestyle Intervention The sample had a high degree of self-efficacy for exercise and healthy lifestyle at baseline. The average CES-D score of 9.4 (SD = 8.4) was below the cut off score of 16 that indicates possible depression, and is in keeping with the landmark study that showed 21% of community-dwelling FAs were depressed. Quality of life at baseline was also averaged using norm-based scoring for

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the SF-36 with the M = 50, SD = 10. These values at baseline would make it difficult to show an improvement. This eight-group session community-based pilot study of a lifestyle intervention for FAs was successful in reducing risk for developing diabetes by 24%, but not to the level of the 58% risk reduction achieved by the DPP sessions, which ran longer. Preliminary data showed that, compared to a wait-listed control group, participants lost an average of 3.3 pounds (p < .05), thus reducing their risk for developing T2D by 24%, because 1 kg of weight loss reduces risk by 16% (Hamman et al., 2006). Although change in BMI was not significantly different between intervention and control group during the first 6 months, the estimated mean change in BMI did show a positive trend associated with the intervention. The intervention group had their BMI lowered by 0.57 during the 6-month period; the control group had their mean BMI remain almost at the same level (increased 0.01). With a larger sample size in future studies, the intervention may show significant effects on reducing BMI. Meanwhile, Asian Americans may need to achieve a lower BMI of < 23 to prevent diabetes and studies powered to achieve this amount of weight loss have been conducted in several Asian countries. Change in other biometrics and psychosocial measures showed no statistically significant differences. The baseline level for self-efficacy was high and did not increase postintervention. To achieve a BMI target of < 23, to be considered normal weight by Asian BMI standards, the experimental group would have had to lose 7.76 kg or 12.56% of body weight. Pre- and Post-test Differences From Baseline to 6 Months, Experimental Versus Control Group The intervention group achieved a weight loss of 1.52 kg (p < .05) and a waist reduction of 5.46 cm (p < .05), as compared to the DPP, which found that for every 1 kg of weight loss, participants reduced their risk of developing diabetes by 16%. FAs in the intervention group reduced their risk for diabetes by 24%. All other outcome measurements, such as glucose, insulin, blood pressure, pulse, waist-to-hip ratio, BMI, depression, physical and mental self-efficacy, quality of life, physical activity, and self-management, were not significantly different between intervention and control group (Table 1). A linear mixed-effects model was used to determine significant demographic predictors for weight besides intervention. The significant predictors of weight loss were gender with men losing more weight than women (p < .05) and marital status with currently married or never married having more weight loss than widow/widower (p < .05; Table 2). Age, years in school, and language had no significant effects on weight.

DISCUSSION The goal was to develop an accessible and culturally tailored lifestyle intervention, with preliminary data on efficacy, to decrease the prevalence of T2D in Filipino communities. This goal is not only important for reducing the burden of T2D and its complications for FAs, but to determine if the culturally appropriate procedures developed can also be applied to other ethnic minority and underserved immigrant populations. By meeting the objectives of the project, new knowledge

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TABLE 1 Pre- and Post-test Means for Control vs. Experimental with P-values from Baseline to Six Months Intervention Group (N = 22) Pre-test

Control Group (N = 18)

Post-test

Pre-test

Post-test

Variables

Mean

SE

Mean

SE

Mean

SE

Mean

SE

p-Value

Glucose Insulin Weight SBP DBP Pulse Waist Waist–hip ratio BMI CES_D SF_PCS SF_MCS WHO_QOL Physical activity Self-management

100.25 7.32 61.76 130.24 73.06 71.14 89.27 0.91 26.24 11.42 46.90 52.46 3.77 8.03 7.59

2.45 0.94 2.41 3.19 1.86 2.01 2.13 0.02 1.00 2.28 1.78 1.49 0.15 0.34 0.34

102.05 8.31 60.24 128.62 71.72 69.08 83.81 0.87 25.67 12.21 50.51 52.41 3.89 8.67 8.26

2.67 1.00 2.42 3.40 1.99 2.14 2.22 0.02 1.00 2.34 1.91 1.60 0.15 0.36 0.36

93.75 7.13 69.39 140.48 76.99 72.67 97.46 0.92 29.49 11.96 46.72 55.00 3.89 7.80 7.89

2.74 1.04 2.64 3.55 2.04 2.22 2.33 0.02 1.03 2.50 1.97 1.65 0.15 0.37 0.38

96.32 8.31 69.34 128.76 73.85 72.03 94.65 0.90 29.50 13.52 48.02 52.87 4.05 8.32 8.53

2.79 1.05 2.65 3.71 2.18 2.34 2.43 0.02 1.03 2.66 2.08 1.75 0.17 0.39 0.40

0.0815 0.9438 0.0255 0.1958 0.1798 0.3878 0.0023 0.3059 0.0599 0.6633 0.2255 0.4109 0.3346 0.4756 0.5151

Note. BMI = body mass index; SBP = systolic blood pressure; DBP = diastolic blood pressure; CES_D = Center for Epidemiologic Studies Depression Scale; SF_PCS = Short Form Physical Component Scale; SF_MCS = Short-Form Mental Component Scale; WHO_QOL = World Health Organization Quality of Life.

TABLE 2 Linear Mixed Effects Model to Determine Significant Demographic Predictors for Weight Solution for Fixed Effects Effect Treatment Experimental group Control group Time Baseline Six months Sex Male Female Marital status Never married Currently married Living with domestic partner Divorced or separated Widow/widower

Estimate

Standard Error

t-Value

p-Value

−9.2077 0

3.5931

−2.56

0.0155 0.0155

0.7922 0

0.4408

1.80

0.0815 0.0815

18.0139 0

4.2662

4.22

0.0002 0.0002

19.1090 7.4902 23.2198 −0.8722 0

8.3206 4.3954 10.7856 6.1479

2.30 1.70 2.15 −0.14

0.0321 0.0284 0.0984 0.0392 0.8881

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about this proposed intervention may guide the development of future programs in partnership with the Filipino community in Hawaii. Lack of time is often a barrier to participation in lifestyle interventions and maintaining behavior change (Leake et al., 2012). Health is Wealth (Kalusugan ay Kayamanan) was a pilot study (n = 40) testing flexible scheduling for eight stand-alone classes for community dwelling FAs at high risk for diabetes. The project achieved attendance of 88% of participants attending all eight sessions, with 93% of participants highly satisfied overall. This study also gathered preliminary data on clinical outcome measures with weight loss and improved self-efficacy for lifestyle improvements as primary outcomes. There was no difference in dropout rate based on language spoken at home, and language spoken at home was not a predictor of weight loss. The language ability of the facilitator allowed all participants to feel understood and to gain clarity about the content of the curriculum. To achieve a higher level of weight loss, the dose of the intervention would need to be increased similar to the DPP study. Yet, more than eight sessions would not be feasible or affordable for community-based classes. Other adaptations of the DPP have kept the features of tracking exercise and dietary intake through food logs and logs of exercise measured in minutes or steps taken if walking. Health is Wealth provided tracking tools for exercise, but not for dietary intake, and provided a scale at the study site, but being weighed at every session was not a requirement. Health is Wealth showed promise for preventing diabetes through weight loss. Intensifying the intervention to require weigh-ins and tracking of food intake and physical activity could have produced more weight loss. Results from linear mixed effects model shows weight was significantly different between men and women, and was affected by marital status. Stratifying subjects according to their gender and marital status in study design will help increase the power of future weight loss intervention studies. Further analysis of this preliminary data may provide a focus for improving the intervention. Analysis of individual items in the psychosocial scales for all 35 of the participants completing the intervention may reveal barriers to a healthy lifestyle that are not apparent from the data analysis comparing the experimental and control groups. This study did find acceptance and satisfaction of a program that was selected and provided to the participants in their own community. Although abbreviated in length compared to other recognized programs, it provided promising results in weight loss for this particular ethnic group. Future programs and research could utilize this method of intervention in a community setting acceptable to participants. REFERENCES Ali, M. K., Echouffo-Tcheugui, J., & Williamson, D. F. (2012). How effective were lifestyle interventions in real-world settings that were modeled on the diabetes prevention program? Health Affairs, 31, 67–75. doi:10.1377/hlthaff.2011.1009 American Diabetes Association. (2014). Are you at risk for type 2 diabetes. Retrieved from http://www.diabetes.org/areyou-at-risk/diabetes-risk-test/ Araneta, M. R. G., & Barren-Connor, E. (2005). Ethnic differences in visceral adipose tissue and type 2 diabetes: Filipino, African-American, and White women. Obesity Research, 13, 1458–1465. Araneta, M. R. G., Wingard, D. L., & Barrett-Connor, E. (2002). Type 2 diabetes and metabolic syndrome in FilipinaAmerican women: A high-risk nonobese population. Diabetes Care, 25, 494–499. doi:10.2337/diacare.25.3.494 Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191–215.

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