Creative Education
2011. Vol.2, No.4, 370-374
Copyright © 2011 SciRes. DOI:10.4236/ce.2011.24052
Outcome Measures of a Family-Based Education Approach with
Mexican Immigrants in the Yakima Valley
Virginia A. Bennett, Carissa Sundsmo-Switzer
Department of Nutrition, Exercise & Health Sciences, Central Washington University, Washington, USA.
Received July 26th, 2011; revised August 30th, 2011; accepted September 8th, 2011.
With the continued incidence of obesity and health related issues in the United States and especially in the His-
panic population, it is important to provide useful healthy lifestyle education to this population. One of the bar-
riers to providing this information is the lack of culture sensitivity in the content and presentation of current pro-
grams. In this pilot study, pre and post tests were used to measure the effectiveness of Salsa, Sabor, y Salud, a
culturally sensitive program designed for Latinos. Outcome measures included dietary changes, weight, body
mass index, waist circumference, blood pressure, heart rate, reported physical activity, and healthy lifestyle
score. Diet was evaluated by 24-hour diet recall for both adults and children. Difference in outcome measures
was assessed using a dependent t test. Significant decreases in weight, waist circumference, diastolic blood
pressure, kilocalories, and grams of carbohydrates were observed. Adults reported an increase in total minutes of
physical activity and the importance of living a healthy lifestyle. This culturally sensitive education program,
Salsa, Sabor, y Salud, has a positive effect on health related outcome measures.
Keywords: Cultural Sensitivity, Mexican Immigrants, Salsa Sabor y Salud
With the continued increase of overweight and obesity in the
United States and especially in the Hispanic population (Ogden,
Carrol, Curtin, McDowell, Tabak, & Flegal, 2006; Flegal, Ogden,
& Carroll, 2004), it is important to provide useful healthy life-
style education. One of the barriers to providing this informa-
tion is the lack of culture sensitivity in the content and presen-
tation of current programs. The Salsa, Sabor, y Salud program
has broken the barrier and offers a culturally sensitive program
to the Hispanic population on healthy lifestyle choices. How-
ever, at this time the only evaluation of the program that has
been completed is a participant self assessment and satisfaction
sur vey . Although knowledge is an important component to ma k-
ing healthy lifestyle changes, it does not always result in par-
ticipant compliance. More objective data are necessary to
measure the outcomes of an educational program. The purpose
of this pilot study was to gather and analysis objective data.
Implications of Ethnicity
According to the 2010 Behavioral Risk Factor Surveillance
System, 36.3% of all adults are overweight and 27.60% are
obese in the United States (CDC, 2010). When ethnicity is fac-
tored in, a disproportionate number are either Hispanic or
non-Hispanic blacks. In 2007, Wang and Beydoun reported a
higher prevalence of overweight and obesity in the adult His-
panic population when compared to the adult non-Hispanic
white population, 63.6% and 54.8% respectively. (Wang &
Beydoun, 2007). The higher percent of Hispanics with un-
healthy weight is further complicated by the increased number
of Hispanics without health insurance (Doty, 2003). Even with
the extensive research and knowledge of the nutritional and
physical activity issues necessary to maintain a healthy life
style, there continues to be the challenge of providing effective
health education and incorporating it into culturally sensitive
programs. Several successful culturally sensitive education
programs that target Hispanic minorities focus on diabetes
(Mauldon, Melkus, & Cagganello, 2006; Brown, Kouzehananie,
Garcia, & Hanis, 2002; Gilmer, Philis-Tsimikas, & Walker,
2005). However, with the rise of obesity and related diseases in
our nation, health care has increased its focus on preventive
medicine. Kraft in partnership with the National Latino Chil-
dren’s Institute has developed Salsa, Sabor y Salud (SSS), a
healthy lifestyle program that incorporates Latino traditions to
educate families with children under the age of 12 (Barrera, et
al., 2002). Two evaluation studies have been conducted to
measure participants’ knowledge, attitudes and behaviors re-
garding a healthy lifestyle. Both of these evaluations had posi-
tive results ( Center for Prevention Research and Development,
2005; Huang, et al., 2008). To date, however there have been
no studies that have measured objective outcomes of this pro-
Program Design
The SSS program was created through the collaboration of
the National Latino Children’s Institute and Kraft Foods. The
program was designed to teach healthy lifestyle choices utiliz-
ing the traditions of Latino family gatherings. The curriculum
provides 12 hours of instructional and activity time that can
easily be adjusted to meet the needs of the organization or
group providing the classes. Each session has a theme that
educates families on a component of nutrition and physical
activity. Themes include: 1) family reunions; 2) ideal pair
(beans and rice); 3) mid-day breaks and snacks; 4) seeds from
the Americas; 5) the harvest; 6) salsa y sabor; 7) at the park and,
8) the celebration. All classes include both healthy eating edu-
cation and a physical activity component. During each session
the educational component of the class is broken into three age
groups; adults, 8 - 12 year olds and 3 - 7 year olds. The theme
being addressed is the same for each group, but provided at the
appropriate learning level for each age group. Following the
educational component, families come together in one room to
share information and participate in a physical activity or ‘play
time’. All materials for the program are provided in both Eng-
lish and Spanish to meet the needs of the particular group being
instructed. There is also an emphasis on ethnic pride and heri-
tage that is woven through-out the sessions. Developers of the
SSS program speculate that this program design is better suited
for a family-based culture.
Methodol ogi cal Design/Data An al ysis of Partici pants
Study Population
Participants were previously enrolled with La Casa Hogar, a
local community organization dedicated to providing re-
sources to Mexican immigrant women and children, in Ya-
kima, Washington. This population served as a sample of
convenience for this pilot study. During quarterly registra-
tion for classes at La Casa Hogar, participants were pro-
vided flyers with information about SSS. Those who were
interested in taking the class were enrolled.
Sixteen adult female participants enrolled for the spring
quarter class and seven adult female participants enrolled in
the summer quarter class. Of these, twelve were included in
the study. Participants who had missing data or dropped out
of the class were not included in the study.
For this study, only adult data were used. Children partici-
pated in the classes but data are not included in this paper.
Study Design
The Central Washington University Institutional Research
Board approved the study protocol and all participants were
provided written informed consent. All explanations and
materials were provided in both Spanish and English. If an
individual refused to take part in the study, they were still
allowed to participate in the SSS progra m.
Classes were taught in Spanish by bilingual and bicultural
faculty of La Casa Hogar who were trained to teach the
class from one of the principal researchers who attended a
national training conference for the SSS program. At every
class, two Registered Dietitians and two bilingual under-
graduate Nutrition and Dietetic students from Central
Washington University were in attendance to answer any
questions that were related to nutrition and activity and
were outside of the scope of the instructor. Subjects acted as
their own control with pre and post measurements taken for
each participant. All data were collected prior to the first
class and one week following the last class.
Outcome Measures
Pre and post testing was used to assess changes in nutrition
and physical activity as a result of the SSS program using the
following tools.
Anthropometric. Height was recorded to the nearest quarter
of an inch. Weight was measured using a balance scale (Conti-
nental Scale Corp Health o Meter Model Number 400 G2L).
Waist circumference was measured using a Dean flexible non-
stretch retractable measuring tape. Body Mass Index (BMI) was
calculated as body weight in kg/ height in m2.
Blood Pressure. Systolic and diastolic blood pressure was
mea su re d with an automatic digital blood p ressure monitor (O m-
ron Model: HEM-725C). Instructions provided by the manufac-
ture of the blood pressure monitor were followed.
Nutritional Assessment. Diet was assessed using 24-hour
dietary recall recorded by trained bi-lingual Nutrition and Die-
tetic University students. Three dimensional food models were
used to demonstrate and determine serving sizes. Information
of all foods and beverages consumed during the 24 hours pro-
ceeding the day of the interview from midnight to midnight
were recorded.
Nutrient Estimation. Mean values for macronutrients and
servings from each food group were assessed using Food Proc-
essor for Windows (Version 7.9, 2002, ESHA Research, Salem,
OR). Percent kilocalories from the macronutrients were calcu-
Healthy Lifestyle Knowledge. A pre-and post-test derived
from the National Latino Children’s Institute was used to assess
knowledge, beliefs, and attitudes of nutrition and physical ac-
tivity (Barrera, et al., 2002). All questions were answered using
a 5-point Likert scale; 1 meaning strongly disagree through 5
meaning strongly agree.
All participants that were included in the sample had to com-
plete both the pre measurements and post measurements.
Statistical Analysis
Data were analyzed using SPSS 16.0 for Windows (version
16.0, SPSS Inc., Chicago, IL). Mean weight, BMI, systolic
blood pressure, diastolic blood pressure, resting heart rate,
macronutrients, percent kilocalories from macronutrients, and
servings of each food group were compared with dependent t
test. Statistical significance was set at P < 0.05.
Anthropometric Data. Table 1 shows the mean pre and post
anthropometric measures. Mean weight decreased by 1.27 kg
(P = 0.005) and mean waist circumference decreased by 3.23
cm (P = 0.004). A decreasing trend in BMI was also observed
(P = 0.053). One participant’s waist circumference was not
included in the analysis because of missing data.
Physical Activity, Blood Pressure, and Heart Rate. Diastolic
Table 1.
Baseline and post-intervention anthropometric measures.
Variable n Baseline Post-intervention P value
Weight (kg) 12 72.81 ± 4.04 71.72 ± 4.04 .005*
Body mass indexª 12 30.25 ± 1.49 29.75 ± 1.48 .053
Waist circumference (cm) 11 91.49 ± 3.63 88.26 ± 3.45 .004*
Systolic blood pressure 12 115.33 ± 4.63 100.08 ± 9.62 .110
Diastolic blood pressure 12 72.25 ± 3.12 65.58 ± 2.74 .008*
aCalculated as kg/m2; *P < 0.05.
blood pressure decreased significantly (P = 0.008). Positive but
insignificant changes were also observed in a decrease in sys-
tolic blood pressure. Although participants increased the num-
ber of minutes spent doing physical activity by 43 minutes per
week, the increase was not found to be significant, nor were
there any changes in resting heart rate.
Macronutrients. Kilocalories and grams of carbohydrates
consumed were significantly lower after SSS (P = 0.012, and
0.019, respectively). There was a decreasing trend in the con-
sumption of grams of fat and saturate d fat (P = 0.053 and 0.060,
Servings per Food Group. There was a significant decrease in
the number of servings consumed from grains and milk (P =
0.035 and 0.045, respectively). The mean servings of fruits and
vegetables consumed increased while consumption of fats and
sugars decreased. However, these changes were not significant.
Servings per Food Group. There was a significant decrease in
the number of servings consumed from grains.
Healthy Lifestyle Knowledge. Using a 5-point Likert scale,
participants reported an increase in making it a point to eat
more healthy foods (P = 0.026). Participants’ belief that eating
and physical activity habits have a huge impact on the health of
their body also increased, with 100% of participants rating this
statement as a 5 on the post test Likert scale (P = 0.039).
Implications of the Study
For a group of minorities with a high prevalence rate of dia-
betes and a high rate of being uninsured, it is especially impor-
tant to provide culturally sensitive lifestyle education as a
means of prevention. Approximately 40% of Hispanics are
uninsured, compared to 25% of African Americans and 14% of
non-Hispanic whites (Doty, 2003). Hispanics have a lifetime
risk of 45.4% for males and 52.5% for females of developing
diabetes (Venkat Narayan, Boyle, Thompson, Sorensen, &
Wiliamson, 2003). Hispanics are also less likely to seek medi-
cal care or follow medical instructions due to not fully under-
standing their doctors (Doty, 2003). This communication bar-
rier may be due to Spanish-English translation, understanding
written information, or cultural barriers between patients and
medical staff (Doty, 2003). For this reason, culturally sensitive
education programs are extremely important in this minority
group. Other culturally sensitive education programs that target
Hispanic populations have focused on improving diabetes con-
trol and have been successful in decreasing fasting blood glu-
cose, hemoglobin A1C, and cholesterol levels (Mauldon,
Melkus, & Cagganello, 2006; Brown, Kouzehananie, Garcia, &
Hanis, 2002; Gilmer, Philis-Tsimikas, & Walker, 2005). This
study evaluated SSS, a culturally sensitive education program
designed to prevent adverse health outcomes, using both objec-
tive and subjective tools.
The rate of obese adult participants in this study exceeded the
rates for Hispanics from the 2008 Behavioral Risk Factor Sur-
veillance System in Washington State (CDC, 2010). Fifty per-
cent of adult participants were obese and 33% were overweight
at the beginning of the class. Adult participants’ mean BMI
decreased from obese to overweight status. A BMI greater than
30 is one measure of obesity which is related to many adverse
health conditions including gallbladder disease, high blood pre-
ssure, high cholesterol, asthma, arthritis and diabetes (Mokad,
et al., 2003; Must, Spadano, Coakley, Field, Colditz, & Dietz,
1999). Although not within the recommended BMI of 19.9 -
24.9, the participants decrease in BMI indicates improvement in
the weight status.
BMI alone is not always an indicator of health risks if an in-
dividual has a higher percent of lean body mass. However,
when a BMI exceeds 30 and a waist circumference exceeds 40
inches for males and 35 inches for females, there is a strong
correlation of high percent of body fat. Abdominal fat is an
indicator of central obesity and is associated with mortality
related to excess body fat (Biggard, et al., 2005). In the current
study, 45% of subjects had a waist circumference greater than
35 inches, decreasing to only 36% after SSS. These results
coupled with the significant decrease in weight are particularly
impressive as the program’s intention was not weight loss but
to focus on a healthy lifestyle.
Blood pressure and heart rate were within normal limits prior
to the study and therefore little change was expected. Although
blood pressure and heart rate did decrease after the program,
only diastolic blood pressure was significantly lower. SSS en-
courages physical activity by involving the entire family with
physical activities such as walking, playing with a parachute,
making an obstacle course, etc. Although these activities in-
volve getting up and moving, they may not be as high of an
intensity as running or riding a bike and therefore may not re-
sult in as drastic a change in blood pressure and heart rate as
other more intense physical activities.
The Latina participants in a prior study stated that it would
be easier for them to increase their physical activity if a facility
provided child care for them and if there was a class for them to
gain more knowledge regarding physical activity (Wilbur,
Chandler, Dancy, & Lee, 2003). SSS provided education re-
garding physical activity to participants and child care was
provided during this time. The fact that the physical activities
used in this program were able to be completed while indoors
or outdoors at La Casa Hogar, demonstrated that a gym is not
needed in order to be physically active. It also allowed for
women to learn and apply physical activities that involved their
children and could be used as exercise for themselves. When
compared to Caucasian populations, Mexican American women
have higher levels of physical inactivity (Crespo, Smit, Ander-
son, Carter-Pokras, & Ainsworth, 2000; Crespo, Keteyian,
Heath, & Sempos, 1996; Slatttery, et al., 2006). However, only
20% of Mexican American women meet the recommend 30
minutes of exercise 3 or more times per week (Mier, Ory,
Dongling, Wang, & Furdine, 2007). Participants in the current
study averaged 26 minutes 3 times per a week prior to the in-
tervention. Average minutes spent doing physical activity in-
creased to 35 minutes 3.75 days a week, which meets recom-
mendations for weekly physical activity.
Studies of diets among Hispanic populations have shown that
average caloric intake varies between 1600 and 2400 kilo-
calories (Bermudez, Falcon, & Tucker, 2000; Loria, et al., 1995;
Guendelman & Abrams, 1995; CDC, 2010). The participants in
this study had lower total caloric consumption when compared
to other studies. Average caloric intake decreased over the
course of the program as well as total grams from all macronu-
Percentage of kilocalories from carbohydrates and protein
increased. Percentage kilocalories from saturated fat decreased,
to less than 7% of kilocalories, which meets the recommenda-
tions of the American Heart Association (AHA) (Guendelman
& Abrams, 1995). The women in this study were first genera-
tion immigrants. Studies of acculturation effect on dietary con-
sumption have shown that less acculturated minorities have
healthier eating habits than more acculturated (Guendelman &
Abrams, 1995; Neuhouser, Thompson, Coronado, & Solomon,
2004). Previous studies on Mexican American women born in
Mexico found a lower percentage of kilocalories from fat and
saturated fat when compared to U.S. born Mexican Americans,
but still exceeded the AHA recommendations (Dixon, Sund-
quist, & Winkleby, 2000; Loria, et al., 1995; Lichtenstein, et al.,
2006). It is important to maintain or improve dietary habits of
first generati on immigrants before di ets become westernize d. In
this study improvement of dietary habits was accomplished
with the use of a culturally sensitive education pr ogra m.
When servings of food groups were examined, a decrease in
both dairy products and grains was observed. Upon review of
the diet recalls, it was noted that the number of corn tortillas
consumed decreased as well as the serving size of milk. The
SSS class emphasizes portion control and balance in meals
using a plate model. Although the plate model used in the class
encourages milk to be consumed with meals, the participants in
this study elected to decrease their serving size. This was un-
expected and will be addressed in future education sessions
provided by these researchers. Corn tortillas are a popular
source of calcium among Hispanic groups (Block, Norris,
Mandel, & DiSogra, 1995). Although the decreased consump-
tion of corn tortillas is a positive result for portion control at
meals, corn tortillas and milk are among the top five sources of
calcium for Hispanics (Block, Norris, Mandel, & DiSogra,
1995). If Hispanics are to decrease the number of corn tortillas
they consume daily, it is important that they replace the lost
source of calcium with another source to ensure the recom-
mended daily allowance of calci um is met.
A positive result in the increase of fruits and vegetables was
observed. Total fruit and vegetable consumption met the rec-
ommended 5 servings a day after the SSS class. A previous
study found that Mexican Americans in the Yakima Valley of
Washington state, where this current study also took place,
consumed an average of 4.96 servings of fruits and vegetables
per day (Neuhouser, Thompson, Coronado, & Solomon, 2004).
In comparison, the participants in this study consumed fewer
servings of fruit and vegetables prior to the class but increased
to 6.26 servings per day after SSS.
Following SSS, participants better recognized the importance
of eating healthy foods and being physically active, as meas-
ured by the Healthy Lifestyle test. This may indicate that a
healthy lifestyles class that is culturally sensitive has a positive
effect on participant’s cognitive thinking regarding living a
healthy lifestyle.
The current pilot study demonstrated that Mexican immi-
grants who participated in the class had positive outcomes of
improved healthy lifestyle choices based on both objective and
subjective testing methods. There are some limitations in the
current study which include a small sample size, the possibility
of the 24-hour diet recall being biased, and the classes not being
offered throughout the year. The current study was held during
the spring and summer months, allowing for more fruits and
vegetables to be available at lower cost and more chances of
nice weather for participants to play outside. Although the class
does address physical activities that can be conducted indoors,
it is recommended by the researchers that the class be repeated
during the fall and winter to observe if seasonality has an effect
on the outcome.
The increasing obesity rates and lower insurance rates of the
Hispanic population make this an area of immediate concern
for health educators. Therefore, it is important that programs
designed to meet their cultural needs are made available. This
study evaluated one such program and found it to have a posi-
tive effect on objective outcome measures associated with
health parameters.
The authors would like to thank the staff and director of La
Casa Hogar in Yakima, Washington for providing their time
and facility for this project.
Barrera, R., Garza, J., Guido, C., Leija, M., Lester, M., Lobo, B., et al.
(2002). Salsa, Sabor y Salud: A healthy lifestyles program for young
Latinos. Facilitators Guide Los Ninos Y Los Chicos. San Antonio:
National Latino Children’s Institute, in collaboration with Kraft Foods
Bermudez, O., Falcon, L., & Tucker, K. (2000). Intake and food
sources of macronutrients among older Hispanic adults: Association
with ethnicity, acculturation, and length of residence in the United
States. Journal of the American Dieteti c Association, 100, 665-673.
Biggard, J., Frederiksen, K., Tjonnelan, A., Thomsen, B., Overvad, K.,
Heitmann, B., et al. (2005). Waist circumference and body composi-
tion in relation to all cause mortality in middle aged men and women.
International Journal of Obesity, 29, 778-784.
Block, G., Norris, J., Mandel, R., & DiSogra, C. (1995). Sources of
energy and six nutrients in diets of low-income Hispanic-American
women and their children: Quantitative data from NHANES, 1982-
1984. Journal of the American Dietetic Association, 95, 195-208.
Brown, S., Kouzekanani, K., Garcia, A., & Hanis, C. (2002). Culturally
competent diabetes self-management education for Mexican Ameri-
cans. Diabetes Care, 25, 259-268. doi:10.2337/diacare.25.2.259
Centers for Disease Control (2010). Behavioral risk factor surveillance
system: Prevalence and trends d a t a 2010.
Center for Prevention Research and Development (2005). An executive
summary of the evaluation of the Salsa, Sabor y Salud program.
Chicago: Kraft’s Foods.
Crespo, C., Keteyian , S., Heath, G ., & Se mpos, C. (19 96). Leisure-ti me
physical activity among US adults. Archives of Internal Medicine,
156, 93-98. doi:10.1001/archinte.156.1.93
Crespo, C., Smit, E., Anderson, R., Carter-Pokras, O., & Ainsworth, B.
(2000). Race/ethnicity, social class and their relation to physical in-
activity during leisure time: Results from the third national health
and nutrition examination survey, 1988-1994. American Journal of
Preventive Medicine, 18, 46-53.
Dixon, L., Sundquist, J., & Winkleby, M. (2000). Differences in energy,
nutrient, and food intakes in a US sample of Mexican-American
women and men: Findings from 3rd NHANES. American Journal of
Epidemiology, 152, 548-557. doi:10.1093/aje/152.6.548
Doty, M. (2003). Hispanic patients double burden: Lack of health
insurance and limited English. The Common Wealth Fund.
Flegal, K., Ogden, C., & Carroll, M. (2004). Prevalence and trends in
overweight in Mexican-American adults and children. Nutrition Re-
views, 62, S144-148.
Gilmer, T., Philis-Tsimikas, A., & Walker, C. (2005). Outcomes of
project dulce: A culturally specific diabetes management program.
Annals of Pharmacotherapy , 39, 817-822. doi:10.1345/aph.1E583
Guendelman, S., & Abrams, B. (1995). Dietary intake among Mexi-
can-American women: Generational differences and a comparison
with white non-Hispanic women. American Journal of Public Health,
85, 20-25. doi:10.2105/AJPH.85.1.20
Huang, D., La To rre, D., Oh, C., Ha rven, A., Hub er, L., Leon, S., et al .
(2008). An executive summary of the Afterschool Experience in Salsa,
Sabor Y Salud evaluation 2007-2008. Los Angeles: CRESST/Uni-
versity of CA.
Lichtenstein, A., Appel, L., Brands, M., Carnethon, M., Daniels, S.,
Franch, H., et al. (2006). Diet and lifestyle recommendation revision
2006: A scientific statement from the American Heart Association
nutrition committee. Journal of the American Heart Association, 114,
Loria, C., Bush, T., Carroll, M., Looker, A., McDowell, M., Johnson,
C., et al. (1995). Macronutrient intakes among adult Hispanics: A
comparison of Mexican Americans, Cuban Americans, and Mainland
Puerto Ricans. American Journal of Public H ea l th , 85, 684-689.
Mauldon, M., Melkus, G., & Cagganello, M. (2006). Tomando control:
A culturally appropriate diabetes education program for Spanish-
speaking individuals with type 2 diabetes mellitus-Evaluation of a
pilot project. The Diabetes Educator, 32, 751-760.
Mier, N., Ory, M., Dongling, Z., Wang, S., & Furdine, J. (2007). Levels
and correlates of exercise in border Mexican American population.
American Journal of Health Behavior, 31, 159-169.
Mokad, A., Ford, E., Bowman, B., Dietz, W., Vinicor, F., Bales, V., et
al. (2003). Prevalence of obesity, diabetes, and obesity-related health
risk factors, 2001. Journal of the American Medical Association, 289,
76-79. doi:10.1001/jama.289.1.76
Must, A., Spadano, J., Coakley, E., Field, A., Colditz, G., & Dietz, H.
(1999). The disease burden associated with overweight and obesity.
Journal of the American Me d i cal Association, 282, 1523-1529.
Neuhouser, M., Thompson, B., Coronado, G., & Solomon, C. (2004).
Higher fat intake and lower fruit and vegetable intakes are associated
with greater acculturation among Mexicans living in Washington
State. Journal of the Ameri ca n Di e t et i c Association, 104, 51-57.
Ogden, C., Carrol, M., Curtin, L., McDowell, M., Tabak, C., & Flegal,
K. (2006). Prevalence of overweight and obesity in the United States,
1999-2004. Journal of the American Medical Association, 295, 1549-
1555. doi:10.1001/jama.295.13.1549
Slatttery, M., Sweeney, C., Edwards, S., Herrick, J., Murtaugh, M.,
Baumgartner, K., et al. (2006). Physical activity patterns and obesity
in Hispanic and non-Hispanic white women. Medicine & Science in
Sports & Exercise, 33-41.
Venkat Narayan, K., Boyle, J., Thompson, T., Sorensen, S., & Wiliam-
son, D. (2003). Lifetime risk for diabetes mellitus in the United
States. Journal of the American Medical Association, 290, 1884-
1890. doi:10.1001/jama.290.14.1884
Wang, Y., & Beydoun, M. (2007). The obesity epidemic in the United
States—Gender, age, socioeconomic, racial/ethnic, and geographic
characteristics: A systematic review. Epidemiologic Reviews, 29, 6-
28. doi:10.1093/epirev/mxm007
Wilbur, J., Chandler, P., Dancy, B., & Lee, H. (2003). Correlates of
physical activity in urban Midwestern Latinas. American Journal of
Preventive Medicine, 25, 69-76.