Challenges encountered in the implementation of a diet and exercise intervention for low-income Hispanic older adults with diabetes

The purpose of this study was to present the challenges faced when implementing a diet and exercise intervention for low-income older Hispanics with type 2 diabetes with an observational study of recruitment, attendance, and characteristics of Hispanic adults with type 2 diabetes in a community congregate meal site pre and post administration of a diet and exercise intervention. T his report evaluates retentions and diabetes self-management beliefs Hispanic adults ≥60 years with type 2 diabetes (n=17) at baseline, and completion of the six-month intervention in terms of the Health Belief Model. There was limited interest in controlling diabetes with diet and exercise. Major barriers included lack of perceived vulnerability to diabetes complications and a belief that medication alone is sufficient to stabilize blood glucose. Environmental barriers included lack of transportation, access to exercise groups, access grocery stores, and limited ability to pay for healthy foods. A lesson learned from this intervention was that the diet and exercise intervention given was insufficient as a cue to action for this population interventions to engage low-income, older Hispanics with diabetes in diet and exercise need to consider strategies to overcome barriers such as health beliefs, transportation issues, lack of access to nutritious food and group exercise classes. methodology, S.C. M.H.; software, J.A.V.; validation, T.G. F.G.H formal analysis, J.A.V.; investigation data J.A.V., T.G., S.C., M.H.; writing—original


Introduction
Type 2 diabetes is a major health concern in the U.S. affecting 9.3% of the general population, only when medical complications occur [8]. Diabetes education programs are less likely to be offered and more likely to be discontinued in economically disadvantaged communities due to lack of referrals and reimbursement [8]. In addition, socioeconomic deprivation is associated with decreased physical activity and increased sedentary behavior in older adults [9].
Potentially preventable hospital admissions in Florida have increased 21% from 2014-2015 to 2016-2017 and diabetes ranked eight among the conditions leading to admission at 5.5% for 2016-2017 [10]. Hispanics have over twice the percent of undiagnosed cases (4.5% versus 2.0%) [11].
Hispanics also experience higher rates of diabetes complications than non-Hispanic Whites and 1.4 times the death rate from diabetes compared to non-Hispanic Whites [11,12].
Interactive diet and exercise interventions in older, low-income Hispanics with type 2 diabetes have not been reported. Hu, Wallace, McCoy and Amirehsaniv [13] conducted a familybased diabetes intervention for Hispanic adults, however the average age was 41 years and their lesson content and approach differed greatly from this current study. Health literacy and health beliefs are barriers for diet and exercise interventions in Hispanics [14]. The purpose of the current study was to test a culturally appropriate diet and exercise intervention for Hispanics 60 years old or older with type 2 diabetes (T2DM). This report presents the challenges encountered in implementing a diet and exercise intervention in terms of the relationships among participants' characteristics, retention, participation, and diabetes self-management beliefs.

Study design:
This report evaluates the 'diet and exercise arm' from recruitment, baseline, and completion of the intervention at six-months of a larger study. The study was approved by the institutional review board and all participants read and signed an informed consent form in Spanish.

Setting:
A senior center and congregate meal site serving low-income, primarily Hispanic adults ages 60 and older in the in the southeastern United States.

Participants:
The participants were older Hispanics with T2DM.  (Figure 1). Diabetes education, diet and exercise fit into "cues to action". The intervention goal was to alter the participants' perceptions and increase in the likelihood of improving diet and increasing exercise. The anticipated Mechanism of Action of the diet and exercise interventions include improved diet quality and lipid profile [18], increased protein, vitamin D and calcium intake, increased antioxidants from fruits and vegetables, reduced hemoglobin A1C, improve physiological function, increased energy for physical activity, increased muscle mass, and reduce falls and hospitalizations.  Various methods of instruction were applied during the six months. First, power point presentations were used with discussions for the first three months. The final intervention delivered from three to six months was done with individual assessment in a small group setting of 24-hour recalls and worksheets to teach carbohydrate counting and collaborative modifications for the participants' meal options. Discussion of hyperglycemia and scheduling of meals and exercise were integrated into the format as per the needs of the participants. The food quality change was measured using a Food Frequency Questionnaire and validated in Hispanic populations. The goals were to increase the participants' self-efficacy (belief and self-confidence) that they could follow the diabetes diet. Aside from the 30 minutes of exercise twice a week on site, the participants were encouraged to do the exercises by themselves on days the group sessions were not offered and provided with exercise log sheets.

Data Analysis:
Attendance was calculated as percent of participation for the total number of available sessions ( Table 1). Demographics and biomarkers were presented as means and standard deviations for continuous variables such as age, years with diabetes, hemoglobin A1c (A1C), and blood pressure. Demographics for categorical variables (sex, education, marital status, and method of controlling diabetes were calculated and presented as frequency and percent ( Table 2). The scale for diabetes self-management was the total of Likert scores coded for the higher numbers to reflect better diabetes self-management. In addition, a sub-scale for diabetes self-efficacy was created.
Pearson's correlations were used to show the association of perceived diabetes self-management and diabetes self-efficacy with attendance (Table 3).

Recruitment results:
There were approximately 40 members of the senior center that were known to have diabetes. Out of the potential participants, 23 showed an initial interest in the study; six did not pass the screening (one failed the cognitive test and five were not willing to come in for the assessment) leaving N=17 participants.

Program participation:
During the recruitment phase, those who were interested were provided additional information regarding the study. Approximately half of eligible members stated that they did not believe they needed diet and exercise to manage their diabetes because they could regulate their blood glucose using medication. Others expressed enthusiasm for the educational sessions that would be offered or the A1C screening at each evaluation session from baseline to 3, 6, and 9 months. Most of the people who approached the recruitment team mentioned how they were pre-diabetic and were very interested in learning, but unfortunately fell into our exclusion criteria and could not participate.
During the intervention, the average class size was four participants. Individual attention for diet and exercise was given. The diet recalls and individual counseling resulted in only one participant modifying their diet. The exercise logs showed there was little change in their exercise routine from the beginning to the end of the program. Participants' attendance is shown in Table 1. *site closures and holidays accounted for less sessions than anticipated.
There were four no shows. For the first three months, three participants had greater than 80% attendance. The overall attendance for the six-month intervention shows only two participants with 70% or greater attendance. Two participants fell during the study period : one male fell as a result of vertigo, and a female was without her walker and fell due to loss of balance outside her home.
Preprints (www.preprints.org) | NOT PEER-REVIEWED | Posted: 4 August 2020 doi:10.20944/preprints202008.0076.v1 The participants' demographics and biomarkers are shown in  beliefs -in particular, that medication can take the place of healthy eating to regulate blood glucose.
Barriers to exercise included mobility issues, vertigo, pain, and fear of falling. Table 3. There were no relationships among attendance and the participants' perception of their diabetes self-management beliefs, motivation, and practices. The association of diabetes education on perceived vulnerability to diabetes complications could not be assessed due to low attendance and retention. Health beliefs for diabetes self-management are presented in Table 4. A significant percent of the population reported that they would have to change too many habits to follow their diet, become more active, and to take their medications.

Discussion
Application of the Health Belief Model to this study suggests that the participants may not perceive the severity of their condition and their susceptibility to declining health and loss of physical function. The belief that medication alone was enough to successfully manage their diabetes was widespread among the eligible members and limited their interest and willingness to join and complete the study. Approximately half of the eligible members explained that they can manage their diabetes with medication, and they did not need to change their diet or increase exercise. Attrition was 88% as compared to 24% attrition reported in an exercise intervention for a cohort of older adults (primarily White non-Hispanic) [28]. Attrition may be attributed to diabetes health beliefs. Since the majority of participants stated that they would have to change too many habits to follow the diabetes diet (58.8%) and one-third indicated that they would have to change too many habits to become more active (35.3%). Attrition has been related to low-self efficacy for several intervention studies in older adults [28,29].
Several barriers to achieving diet: stress, lack of willpower, and the food home environment and exercise: time, fatigue, and lack of motivation in a middle-aged group of low-income Hispanics This study has several limitations. The participant's stage of change for motivation and confidence to improve their diet and activity level was not measured. Participants who dropped the study were not available to discuss their reasons for not continuing. The barrier of access to healthy food was not addressed in the initial diet lessons. An initial meeting before the intervention inquiring as to what the participants wanted to learn could have been one approach to increase cues to action and minimize perceived barriers. Participants were asked at the second lesson what they wanted from the diet intervention and their responses were 'what should we eat?' and where can we buy healthy food on a budget?' We developed and integrated these lessons (process evaluation) into the ongoing lessons instead of addressing them immediately. The initial lessons were presentations with questions and answers rather than dynamic interactive discussions on dietary recall and suggested modifications. Whittemore et al. [39] reported that lack of access to healthy foods was a major barrier for Mexican with type 2 diabetes. The strength of this study was initiating diet and exercise education and presenting the challenges presented for a hard-to-reach population. In fact, there was only one other study similar to this current study highlighting the need for refinements in the delivery and design of interventions for low-income, older Hispanics with type 2 diabetes. .

Conclusions
The diet and exercise intervention given was insufficient as a cue to action for this population.
Methods to engage low-income, older Hispanics with T2DM in diet and exercise interventions need to consider strategies to overcome barriers for engagement such as health beliefs, transportation, and access. Pre-intervention engagement to discuss barriers is recommended. Another approach would be to have an open presentation discussion the long-term consequences of diet and exercise on glucose regulation and diabetes outcomes. Since physicians prescribe medication, having endocrinologists address this community in conjunction with diabetes educators may dispel these beliefs.