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http://tde.sagepub.com/content/36/5/784 The online version of this article can be found at:

DOI: 10.1177/0145721710377360

2010 36: 784 originally published online 22 July 2010The Diabetes Educator Oratowski-Coleman and Athena Philis-Tsimikas

Karen J. Coleman, Leticia L. Ocana, Chris Walker, Rachel A. Araujo, Veronica Gutierrez, Maggie Shordon, Jesica Low-Income School: Horton Hawks Stay Healthy (HHSH)

Outcomes From a Culturally Tailored Diabetes Prevention Program in Hispanic Families From a

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- Jul 22, 2010 OnlineFirst Version of Record

- Sep 27, 2010Version of Record >>

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Karen J. Coleman, PhD

Leticia L. Ocana, MPH

Chris Walker, MPH

Rachel A. Araujo

Veronica Gutierrez, MPH

Maggie Shordon, MPH

Jesica Oratowski-Coleman, MPH

Athena Philis-Tsimikas, MD

From the Scripps Whittier Diabetes Institute, La Jolla, California (Ms Ocana, Ms Walker, Ms Araujo, Dr Philis-Tsimikas);

Southern California Permanente Medical Group, Research and Evaluation, Pasadena, California (Dr Coleman, Ms Shordon);

Benton-Franklin Health District, Kennewick, Washington (Ms Gutierrez); and the Department of Family and Preventive Medicine, University of

California at San Diego, La Jolla (Ms Oratowski-Coleman).

Correspondence to Karen J. Coleman, PhD, Department of Research and Evaluation, Southern California

Permanente Medical Group, 100 S Los Robles, 2nd Floor, Pasadena, CA 91101 (email: Karen.J.Coleman@kp.org).

Acknowledgment: Funding for this study was received from The California Endowment, the Legler Benbough Foundation, and the

Alliance Health Care Foundation.

DOI: 10.1177/0145721710377360

© 2010 The Author(s)

Outcomes From a Culturally Tailored Diabetes Prevention Program in Hispanic Families From a Low-Income School

Horton Hawks Stay Healthy (HHSH)

Purpose

The purpose of this study was to test the effectiveness of a minimal, tailored diabetes prevention program for families that could be delivered in elementary school settings.

Methods

Families were eligible for the program if they had at least one child aged 8 to 12 years old attending the elementary school who was at high risk of developing type 2 diabe- tes mellitus. Families attended ten 90-minute sessions with exercise, cooking demonstrations, and healthy life- style lessons. Height, weight, and self-reported behavior were assessed in parents and height and weight in chil- dren before and after classes.

Results

A total of 82 parents (2% men, 98% women) and 62 chil- dren (47% boys and 53% girls) enrolled in the program across 3 replications. Parents had an average weight loss from baseline to the end of the program of 1.5 lb (P = .05). There was a large increase in the number of parents who self-reported engaging in leisure-time physical activ- ity as a result of participating in the program (14% vs 64%; P < .01). There were no changes in children’s body mass index percentile or z score as a result of the program.

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Conclusions

Delivering a diabetes prevention program in an elemen- tary school setting was effective for increasing diabetes- related knowledge, chronic disease awareness, and self-reported healthy behavior in low-income Spanish- speaking families.

I n the past 30 years, the prevalence of overweight and obesity has increased sharply for both US adults and children. During 2003 to 2004, 33% of adults, 17% of youth aged 12 to 19 years, and 15% of children aged 6 to 11 years old were

obese.1,2 Overweight and obesity in the United States occur at higher rates in ethnic minority and low-income populations.3 In addition, low-income children are at excess risk of obesity regardless of ethnicity, although ethnic differences in pediatric obesity still appear at lower income levels.2 In the past 15 years, the number of Americans with diagnosed diabetes has more than dou- bled, reaching 14.6 million in 2005.4 One of every 3 children born in 2000 is expected to develop diabetes during his or her lifetime.4 In adults, type 2 diabetes mel- litus (T2DM) is more common among African Americans and Hispanics/Latinos than among non-Hispanic whites.4

T2DM, which was previously diagnosed only in adults, has recently emerged as a health concern for chil- dren and adolescents. Although there is some debate about the true prevalence of childhood/adolescent T2DM, recent findings from the SEARCH for diabetes in youth study estimated that less than 1% of diabetes cases in Hispanic/Latino youth younger than 10 years had T2DM. However, there was a steady increase in the percentage of cases: to 14.5% in Hispanic/Latino youth aged 10 to 14 years old and to 28.7% in youth aged 15 to 19 years old.5 Children from minority populations—American Indians, African Americans, Asian/Pacific Islanders, and Hispanics/Latinos—all had a higher prevalence of T2DM than did non-Hispanic white youth.6

Schools are an ideal setting for promoting, engaging, and modeling lifelong healthy eating and physical activ- ity behaviors that could lead to the prevention of obesity and T2DM in children and their families.7 There is no other setting where a large number of children are pres- ent approximately 6 to 8 hours a day, regularly consum- ing meals, where parents are encouraged to be involved

and resources such as a school nurse and health and physical education programs are already in place.8

The school setting is also a place where obesity and diabetes prevention programs can be delivered at little or no cost to families who might not otherwise have this opportunity. Several school-based interventions have been designed for preventing and treating childhood obe- sity.9,10 What is clear from the literature is that successful school-based obesity interventions are not “one size fits all” programs. They may need to be tailored to specific ages and/or cultural groups, intervene in a variety of school settings (ie, physical education and school meals), require family and community involvement, integrate with classroom programs, and/or require policy and envi- ronmental changes. Above all, school-based obesity interventions need to be flexible and innovative to create and sustain a school environment that encourages health- ful choices, nutrition education, physical activity, and a reduction in sedentary behaviors.11-13

Because there is some evidence that low-income Spanish-speaking communities respond more positively to messages about diabetes prevention as compared with those focusing on obesity prevention,14 prevention of child obesity in schools serving Spanish-speaking fami- lies may have a greater impact if programs focus on diabetes prevention. There have been very few diabetes prevention programs in school settings, targeting low- income minority communities at greatest risk for diabe- tes. Those that have been published have been multilevel interventions targeting families, classroom curricula, food service, and after-school settings.15-18 For those pro- grams with health outcomes, results were positive, with reductions in diabetes-related outcomes such as blood glucose levels and increases in self-reported health behaviors such as physical activity.15,17,18

These programs were costly, labor intensive, and required a high degree of cooperation from school admin- istrators and teachers to implement. It would be difficult for schools to adopt these programs on their own with limited resources and within the current focus on perfor- mance-based standards. There have not been published studies evaluating a basic diabetes prevention effort that could be taught by one person; introduce the basic knowledge of diabetes, healthy behaviors, and nutrition in a group setting; and be easily implemented in school settings with a minimal burden on school staff. This study was designed to test the effectiveness of a minimal, tailored diabetes prevention program for families with

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children at risk of developing T2DM that could be deliv- ered in elementary school settings in the context of English as a second language (ESL) and parent develop- ment classes. It was hypothesized that this approach would lead to significant increases in parent diabetes knowledge and self-reported health behaviors.

Methods

Eligibility

Families were eligible for Horton Hawks Stay Healthy (HHSH) if they had at least one child aged 8 to 12 years old attending the elementary school who was at high risk of developing T2DM. High risk was defined as being of Hispanic or African American ethnicity/race, having family members with T2DM, and/or the child being at or above the 85th percentile body mass index (BMI) for his or her gender and age.

Recruitment

Initial recruitment efforts included sending informa- tion about the program home with eligible children. Families were recruited by distributing materials at Back to School and Walk Your Child to School events, staff meetings, and school open houses. The program was also promoted with an interactive bilingual-bicultural presen- tation delivered at health-screening and diabetes educa- tion events, and staff and parent meetings. Table-top displays were created for parents when they dropped their children off at school. Parents were also recruited through word of mouth through the school nurse and the Parent Academic Liaison instructor who conducted English as a Second Language (ESL) classes during and after school.

Enrollment

All interested parents were invited to attend several orientation meetings where the program was explained and the eligibility criteria were clearly stated. Parents who were interested signed up at the orientation, and their eligibility was verified when they were called to schedule the first class. Child weight status was not con- firmed until the first day of class; however, to enroll, the families had to meet one of the other eligibility criteria first. Although both African American and Hispanic par- ents showed interest in the program, all families eventu- ally enrolled in the program were Hispanic and preferred

to speak Spanish; thus, the classes were delivered in Spanish. A total of 82 parents (2% men and 98% women) and 62 children (47% boys and 53% girls) enrolled in the program. At the time of recruitment, 293 children were eligible to participate (program reach = 21%). Approval for this study was granted by the Institutional Review Board for Human Subjects at Scripps Mercy Hospital.

Curriculum Development and Description

Overview. The HHSH curriculum was modified from a long-standing diabetes management program19 and was based on theoretical models of behavior change adapted for diabetes prevention as suggested by Burnet and col- leagues.20 A set of classes was composed of 10 sessions. Classes began with 30 minutes of physical activity with parents and children and then continued for 1 hour in different groups: children aged 0 to 5 years, children aged 6 to 13 years, and the parents. Classes ended with a 30-minute session with both parents and children to dis- cuss topics learned and to make plans for the coming sessions. The central theme throughout the curriculum was a healthy lifestyle with a focus on prevention of T2DM.

Physical activity. The physical activity for the class was designed to be something that the parents could eas- ily replicate in the home setting. For example, instead of using equipment such as hula hoops and jump ropes, common household items were used such as pots, pans, sheets, balls, and boxes. The goal of every physical activ- ity session was to promote interaction, build communica- tion skills, and increase cooperation between the parents and their children.

Food preparation. Snacks were provided for every session and included cheese sticks, yogurt, granola bars, fruit chews, and fruit. In addition, 2 food demonstrations were provided to parents to show how a healthy meal could be prepared in 10 to 20 minutes. Recipes were obtained from Cocinando Saludable21 and a grocery store cookbook.22 Efforts were made to ensure that all recipes reflected the culture in which they would be prepared. Recipes are available upon request. During the cooking demonstrations, the benefits of healthy foods were dis- cussed as well as the accessibility and affordability of the ingredients.

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Adult lectures. The adult class lectures were interac- tive and crafted to engage the participants. The lectures brought to light barriers that the participants faced in making healthy lifestyle changes and gave them an oppor- tunity to ask questions and learn how to overcome chal- lenges. The lectures encouraged participants to build on their current knowledge and life experiences. Incentives were also used to keep participants engaged. These included insulated lunch bags, hats, hand lotion, sun- screen, and toys that promoted movement. Parents earned the incentives by participating in class, regular atten- dance, and bringing a healthy snack to class.

Child lectures. The child class lectures were a combi- nation of educational materials and activities appropriate for each age group (0-5 years and 6-13 years). Class top- ics were similar for adults and children; however, they were modified for the children. For example, when the parents were learning about the symptoms of T2DM, the children aged 0 to 5 years were learning basic feelings such as “feeling well” and “not feeling well” with happy and unhappy faces. When the parents were learning about portion sizes, their 0- to 5-year-old children were learning about big fruit versus little fruit and why the little fruit was better. The 6- to 13-year-old groups were given a simplified version of the parent lecture with more physical activity to keep them moving and engaged.

Measurements

BMI. BMI (kg/m2) was assessed by measuring weight in kilograms with a digital scale and height in centime- ters with a tape measure for all children and parents who consented to be measured. Both measures were assessed without shoes and heavy clothing. Measures were taken at the beginning and end of the 10-week intervention.

Parent self-reported health behavior and program knowledge. The survey used for parent health behavior was based on validated sources such as the International Physical Activity Questionnaire,23 the Behavioral Risk Factor Surveillance Survey,24 and the San Diego Health and Exercise Survey.25 These questions were chosen because they have been extensively evaluated and validated and have been used with a number of Spanish- speaking adult populations. Questions about the parents’ perceptions of their child’s behavior were from a survey developed by the first author for use with parents of pediatric endocrine patients. This survey has not been

validated but was chosen for inclusion to determine if parents’ perception of their child’s risk for disease and health habits changed as a result of the program. The knowledge survey for the parents was developed specifi- cally for the curriculum. It was developed using the basic principles of survey design with respect to number of items, avoiding double-barreled questions, and design for low-literacy groups (third-grade reading level).26

In the first round of classes, many of the parents/ guardians and younger children (8-10 years old) could not complete the self-report instrument on their own, and thus it had to be completed as a one-on-one interview. This was extremely labor intensive, and the researchers could not continue to collect information with this method for the second and third round of classes. Thus, self-reported behavior was collected only for the first round of classes in both adults and children.

Structured interviews with parents. Using the meth- ods of qualitative interviewing and program process evaluation,27 the researchers identified and contacted 14 women to interview, approximately 4 to 5 in each round of classes. A total of 11 interviews were conducted, 8 with women who regularly attended the classes (at least 50%) and 3 with women who dropped out of the program (attended at least 1 class but less than 50%) for a 78.5% response rate. A copy of the transcripts is available upon request. Interviews took between 25 and 40 minutes.

Analyses

In addition to descriptive statistics, differences between baseline and end-of-program data were ana- lyzed using paired-sample t tests for continuous variables and McNemar tests for categorical variables. Interviews were summarized into general themes independently by 2 people, and discrepancies were discussed and resolved before a final summary was prepared following the meth- ods of qualitative data analyses.27

Results

Participants

Participant characteristics and health outcomes are shown in Table 1. There were a total of 62 children (47% boys, 53% girls), and 82 parents (2% men, 98% women) across 3 replications. Parents were 37.5 ± 8.6 years old and had a BMI of 30.84 ± 5.44 kg/m2 (36% overweight

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and 52% obese). Children were 7.5 ± 3.1 years old and had an average 1.15 ± 1.02 BMI z score (17% overweight and 29% obese). Health outcome data are shown in Table 1 for parents and children.

Preprogram and postprogram height and weight data were available for 38 of the 82 parents (46%) and 44 of the 62 children (71%) who started the classes. There were no significant differences in baseline age, height, weight, BMI, or knowledge between these 38 parents and the remaining parents for whom the researchers did not have both time points. There was also no difference between the 44 children and the ones without both time points in BMI and BMI z score. Thirty-eight families completed at least 5 of 10 classes. Parents attended an average of 4 ± 3 classes and had a significant increase in knowledge regarding healthy lifestyles and diabetes pre- vention, t(24) = 2.95, P = .007.

Body Weight and BMI

Parents had an average weight loss from baseline to the end of the program of 1.5 lbs, t(37) = 1.99, P = .05. Although the weight change was small, 61% of parents lost some weight (range, 1-10 lbs), and 7 parents (18%) moved to a lower obesity category as a result of the pro- gram. This is evident in the decrease of parents in the obese BMI category at baseline (51%) as compared with

the end of the program (45%). There was no significant change in BMI for either parents or children, percentile BMI, or BMI z score for the children from the baseline assessment to the end of program assessment (10 weeks).

Self-reported Behavior

Parent self-report is shown in Table 2. There were prequestionnaires and postquestionnaires for 24 parents/ guardians in the first round of classes (59%). Parents were much more likely to believe that their child’s weight led to serious chronic illnesses after participating in the program (17% vs 33%; χ2(1) = 17.33, P < .001). There was a large increase in the number of parents who self-reported engaging in leisure-time physical activity as a result of participating in the program (14% vs 64%; χ2(1) = 8.50, P < .01), and parents also self-reported eat- ing more servings of vegetables after participating in the program (7% vs 42%; χ2(1) = 8.00 P < .01).

Parent/Guardian Interviews

Parents/guardians who regularly attended classes. The women who attended most classes made several changes because of the diabetes prevention classes. Women discussed going out for walks with their families after dinner as well as using olive oil for cooking. They were not buying as much junk food as before the classes, were reducing their portion sizes, and were letting their children play outside more often. Many mentioned buy- ing and drinking water instead of sodas. Women said that they had a greater understanding that they were in control of what foods they gave their children and were empow- ered to change their family’s health by the information they received from the class. Families were trying to eliminate fried foods and keep the house stocked with healthy foods.

All of the women interviewed said that they had learned a great deal in the classes. They no longer feared diabetes and felt much more empowered to help their family and friends cope with this disease. They under- stood that regular checkups with their physician were very important for the prevention of disease and that visits to the physician did not only have to be when there was a crisis or when someone had an illness. They espe- cially enjoyed the hands-on cooking demonstrations and the social support from other women who shared their stories of trying to change their family’s health habits. They also said that the program reminder phone calls

Table 1

Parent and Child Health Outcomes

Baseline Postprogram (10 Weeks)

Parents Diabetes knowledge 12 ± 8 13 ± 9

Body weight, kg 74.3 ± 10.8 73.6 ± 10.6

Body mass index, kg/m2 30.6 ± 5.1 30.3 ± 5.6

Overweight, % 37 39

Obese, % 51 45

Children

BMI, kg/m2 20.5 ± 5.4 20.3 ± 5.4

BMI z score 1.16 ± 1.04 1.17 ± 0.90

Obese (>95th %BMI), % 33 31

Abbreviation: BMI, body mass index.

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were very helpful and encouraged them to attend classes. Overall, the women were extremely content with the information they learned during the classes and felt empowered to talk about diabetes, nutrition, and exercise with their families and communities. Women enjoyed receiving diplomas for completing the class, and their children also felt special when they received their own certificates.

The mothers discussed their children’s positive expe- riences in the classes and how the children took a proac- tive role in reminding their moms about correct portion sizes and limiting sugary juices and junk food. Younger children learned the colors of the fruits and vegetables and were able to identify a much wider variety of fruits and vegetables to eat. Older children were making their

own healthy lunches and reduced their own portion sizes. One participant said that her son said, “These foods are not healthy for me to eat,” when she was preparing a meal for her extended family.

Women discussed many barriers to changing their lifestyles; however, the most difficult changes concerned those that involved their husbands and extended families. Many women said it was hard to change the habits of their own parents (ie, grandparents) despite the fact that their parents had many health problems directly related to lifestyle (eg, diabetes). Despite these reports, one par- ticipant talked about how her daughter was trying to teach her grandparents about what she had learned in the classes during family dinners. The most difficult behav- ior to change was limiting the portions during meals. One

Table 2

Parent Self-reported Outcomes

Baseline, % End of Program (10 Weeks), %

Parent behavior Watch at least 2 h of television per weekday 50 39

Watch at least 2 h of television per weekend day 50 57

Eat at least 3 servings of fruit per day (yes) 21 27

Eat at least 3 servings of vegetables per day (yes) 7 42a

Participate in leisure-time physical activity (yes) 14 64a

Parent’s belief that their child’s

weight leads to disease (% yes)

Heart attack 0 36

Type 2 diabetes 7 43

High blood pressure 50 43

Cancer 0 14

Insomnia 14 14

Liver disease 0 21

Asthma 14 36

Overall 17 33a

Parent report of child behavior

Physical activity after school 21 57

One or more soda bottles/cans/glasses per day 36 28

2 h or more of television per weekday 36 35

2 h or more of television per weekend day 57 64

aSignificantly different from baseline, P < .01.

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mother mentioned her child was upset with her because she no longer bought any junk food.

Parents/guardians who did not regularly attend classes. Women were asked to describe what the program could have done to encourage their attendance. Many of the women said that there were many life circumstances that hindered their ability to attend the classes and that the program would not have been able to help with these issues. For example, one woman became ill during the classes and another woman said it was hard for her to come to the classes because she was supposed to cook for her husband during class time. The women said that they would like more cooking demonstrations and that this would have been a very strong motivator to attend.

Despite their poor attendance, these women men- tioned many of the same changes in behavior as a result of the program as were voiced by women who attended most classes. For example, women said they were cook- ing with more vegetables, eating less meat and fat, drink- ing water, exercising, and eating more natural foods without sugar. They understood that their children needed to be exercising and playing outside as well as eating nutritious snacks. The mothers mentioned that the hardest things to change were taking away junk food, not drink- ing soda, and getting their children to eat vegetables.

Discussion

It was found that delivering a diabetes prevention pro- gram in an elementary school setting was effective for increasing diabetes-related knowledge, chronic disease awareness, and self-reported healthy behavior in low- income Spanish-speaking families. Although changes were small, this work is the first to show significant reductions in parent/guardian body weight as a result of a school-based program focused on healthy lifestyles. This may have been due to the large changes seen in self- reported physical activity (28% vs 64%) and consump- tion of vegetables (7% vs 42%). Survey changes were also supported by interviews with participants across all rounds of classes about the changes they made as a result of the program.

These changes are comparable to those reported for other diabetes prevention efforts in schools15-18; however, these more comprehensive studies saw additional posi- tive changes in other health outcomes such as aerobic fitness, body fat, and fasting glucose.15-18 The total cost

per class for the HHSH program without evaluation, including health educator time, child care, food, and pro- gram materials was $415. For 10 weeks, this was a total cost of $4150, amounting to $51 per family for the pro- gram. Although other school-based diabetes prevention programs have not published cost information, the HHSH program was much less than the cost of treating a patient with T2DM for a lifetime.28

There were a number of limitations to the study, most importantly the reach of the intervention and the attrition rates. Despite vigorous efforts at recruitment, only 82 parents and 62 children participated in classes through- out the 3 years of the project. This represents only 21% of the eligible children at the school (ages 8-12 years and parents who were Spanish speakers). In addition, classes lasted 10 weeks and could accommodate only 20 to 30 parents, also limiting the number of parents and children who could participate. To reach the widest audience pos- sible, the diabetes prevention classes should not be the only source of information at the school regarding this topic. If large numbers of families are to be reached, these classes need to be accompanied by schoolwide health promotion efforts. By targeting the entire school setting, programs such as Bienestar were able to reach 74% of the children.18

Many efforts were also made to retain the parents and their children in the classes once they had enrolled. Participants immediately received a raffle ticket giving them a chance to win a prize if they attended the first day of class. At each class, participants were provided with a healthy snack, water, and various incentives. To keep the family’s interest, immediate, inexpensive incentives were given during each class as well as more expensive, long- term incentives given after participants had attended most of the classes in a series. Besides incentives, participant retention efforts included follow up and class reminder phone calls. Even with these intensive efforts to motivate participants to attend classes, the average attendance was only 57%. Attendance was hampered by a number of fac- tors, including sick family members, having to prepare meals for husbands during class time, lack of transporta- tion, time needed to prepare children for the next day of school, time for work, and many other personal issues.

It was also a challenge to evaluate the behavioral changes of families who participated in the HHSH program. Self-reported measures were completed for only 59% of the families enrolled in the program. Because the program was only 10 weeks long, more than

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1 class period could not be taken for administering ques- tionnaires. Consent and assent for the children also had to be completed. This consent process took at least 1 hour. The questionnaires took 90 minutes to complete. Many of the women also had difficulty completing ques- tionnaires on their own, and information had to be col- lected by one-on-one interviews. The NEEMA program17 reported that after 7 weeks, they were able to obtain com- plete measures for only 58 of 269 enrolled (22% reten- tion), while Beinestar18 was able to measure 87% after 1 school year.

Implications

When promoting diabetes prevention practices in low-income Spanish-speaking families, agencies and researchers should address the barriers to behavior change they often face. These include extended family members not supporting changes in nutrition and physi- cal activity practices, spousal demands, and permissive parenting practices (ie, using junk food and videos as incentives for their overweight and obese children to behave). Health professionals and researchers need to recognize that many of these families may have needs such as employment, health care access, and transporta- tion that must be addressed before they can participate fully in programs to change lifestyle behaviors. Finally, findings from the Kahnawake Schools Diabetes Prevention Project,15 one of the longest running diabetes prevention programs in schools, clearly emphasized the importance of using community-based participatory research methods to ensure long-term success of these kinds of programs for underserved communities.

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15. Paradis G, Levesque L, Macaulay AC, et al. Impact of a diabetes prevention program on body size, physical activity, and diet among Kanien’kehá:ka (Mohawk) children 6 to 11 years old: 8-year results from the Kahnawake Schools Diabetes Prevention Project. Pediatrics. 2005;115:333-339.

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17. Shaw-Perry M, Horner C, Trevino RP, Sosa ET, Hernandez I, Bhardwaj A. NEEMA: a school-based diabetes risk prevention program designed for African-American children. J Nat Med Assoc. 2007;99:368-375.

18. Trevino RP, Yin Z, Hernandez A, Hale DE, Garcia OA, Mobley C. Impact of Bienestar school-based diabetes mellitus prevention program on fasting capillary glucose levels: a randomized trial. Arch Pediatr Adolesc Med. 2004;158:911-917.

19. Gilmer TP, Phillis-Tsimikas A, Walker C. Outcomes of Project Dulce: a culturally specific diabetes management program. Ann Pharmacother. 2005;39:817-822.

20. Burnet D, Plaut A, Courtney R, Chin MH. A practical model for preventing type 2 diabetes in minority youth. Diabetes Educ. 2002;28:779-795.

21. San Diego Nutrition Network. Cocinando Saludable. http://www. sdnnonline.org/tools_cooking_healthy.htm. Accessed March 1, 2004.

22. Kraft Foods. Albertsons cookbook. http://www.kraftfoods.com/ esi.net/albertsons/library.aspx?shortname=default&d=. Accessed March 1, 2004.

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23. International Physical Activity Questionnaire (IPAQ). http:// www.ipaq.ki.se. Accessed January 11, 2005.

24. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey. http://www.cdc.gov/brfss/about.htm. Accessed January 11, 2005.

25. Sallis JF. San Diego Health and Exercise Survey. http://www .drjamessallis.sdsu.edu/measures.html. Accessed January 11, 2005.

26. Fowler FJ. Improving Survey Questions: Design and Evaluation. London, UK: Sage; 1995.

27. Charmaz K. Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. London, UK: Sage; 2006.

28. Eggleston KN, Shah ND, Smith SA, et al. The net value of health care for patients with type 2 diabetes, 1997 to 2005. Ann Intern Med. 2009;151:386-393.

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