Assessment of Mexican American Adults in Maricopa County, AZ

Vivianne Swart
November 16th, 2015

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In Maricopa County, 1 in 4 adults are obese, and 3 in 4 adults dont eat their 5 a day fruits and
vegetables1. According to the 2014 census data, those who identify as Hispanic make up about
30% of the population2. Subsequently, they are a crucial minority group to pay attention to in
this location, especially since Hispanics have a higher obesity percentage overall as compared to
the white population, 34.1% versus 20.3% respectively3. The rationale for a dietary assessment
comes from the fact that Hispanics have disproportionately more diet-related health problems;
this includes obesity, which is 32% higher among Hispanic women than non-Hispanic white
women, and diabetes, with 41% greater age-adjusted years of potential life lost than among the
non-Hispanic white population4. In terms of receiving food assistance, either food stamps or a
food benefit card, Hispanics had a four times higher percentage than non-Hispanic whites28%
as compared to 7.7%3. Less than 1 in 5 Hispanic adults report getting their 5 a day fruit and
vegetables3. The Hispanic population could be considered an at-risk population by these
standardsbut Maricopa County uses Hispanic as an umbrella term. About 86% of this Hispanic
population is made up of those who identify as Mexican Americans2; however, very little has
been studied specifically about Mexican Americans in this location. Additionally, although the
link between dietary intake and disease has been heavily studied, little has been explored in this
specific minority group separate from the overall Hispanic population. My primary goal is to
focus attention on Mexican American adults and recommend two nutritional assessment tools to
help the Maricopa County Department of Public Health (MCDPH) better understand this
predominant population in the community, and create an effective intervention utilizing this data.
Investigating the intake of fruit and vegetable consumption in Mexican Americans is significant
for a variety of reasons. One comprehensive review conducted in Europe found that associations
between the intake of vegetables and fruit and the risk of several chronic diseases demonstrate
that a high daily intake of these foods promotes health. Consequently, the review goes on to say
that a campaign to increase fruits and vegetable consumption would be justified5. Although this
review was conducted in Europe, the incidences of chronic diseases are incredibly high in the
United States, justifying these sorts of campaigns in this country. Obesity is considered a chronic
disease as of 2008, and Maricopa County residents of all races and ethnicities consider it to be
the second most important health problem in the communitythe most important being diabetes,
to which obesity has been linked6. Through gathering specific fruit and vegetable consumption
among Mexican Americans, a targeted intervention can be made and evaluated. Furthermore, a
systematic review found that an increase in fruit and vegetable consumption after an intervention
is possible in population subgroups7. Another review found that more than three-quarters of the
studies they looked at (17 of the 22 reporting results for fruit and vegetable intake) reported
significant increases in fruit and vegetable intake after interventions8.
The second assessment in this community will be measurements of hip circumference and height
in order to assess adiposity utilizing a new technique that was validated in Mexican Americans:
the Body Adiposity Index. Additionally, waist circumference will also be measured, because a
study conducted over a seven-year period found that it was the best predictor of Noninsulin
Dependent Diabetes Mellitus (NIDDM) in Mexican Americans as compared to BMI, waist/hip
ratio and other anthropometric measurements9. With this surveillance data being available in this
minority group, effectiveness of an intervention can be adequately measured by conducting both
these assessments again. To incentivize participation in these assessments, the MCDPH can
disseminate to the public their conclusion that in 2020, if obesity continues to rise, Maricopa

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County adults will spend $910MM more on health care6. As seen in Figure 1, the Hispanic
population has the highest obesity rate, making an intervention with this target community all the
more worthwhile.

Figure 1. Maricopa County Community Health Assessment Public Health Strategic Priorities 20126

In order to form a more targeted approach for Mexican Americans, a food frequency
questionnaire (FFQ) screener about fruits and vegetables would be advantageous. Although there
are a few Food Frequency Questionnaires validated for this population, they are often full
nutrient assessments10. A study published by the Center for Disease control looked at the
development and reliability of brief dietary tools for Hispanics, also referred to as screeners.
Although this tool initially seems to target all Hispanics, the authors state in the introduction that
they specifically studied Mexican Americans due to the lack of appropriate dietary assessments
for minorities11.
To develop this fruit and vegetable consumption screener, the researchers looked at the most
commonly eaten foods off a list created using NHANESIII, with national data on the Mexican
American population. In order to continue development of the screener, there were three phases
including interviews and small group discussions, field tests, and a reliability study. The first
phase, interviews and small group discussions, was conducted in either English or Spanish,
depending on what the participants preferred, and collected information regarding ease of selfadministration and suitability of food phrasing. The bilingual approach used here was especially
poignant85% of participants chose the Spanish FFQ. This phase yielded only minor
modifications such as clarity of wording or formatting changes; the original list was found to
adequately represent the main sources of fruits and vegetables consumed in the study population.
The second phase of this study included field tests as an informal observation of the screener in
real world situations. The FFQ was immediately scored, and participants were given time to
provide feedback about ease of use and satisfaction with the questionnaire11.

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The final fruit and vegetable screener had 7 items, including fruit juice, other fruit, green salad,
tomatoes or salsa, potatoes, soups or stews with vegetables, and any other vegetables. There were
six responses categories for the screener, ranging from less than once per week to two or more
times per day. The simplicity of the FFQ was important because about 42% of the study
population had an 8th grade education level or less. To expand upon the CDC published study,
almost half of Spanish speakers in Maricopa County identify that they speak English less than
very well, indicating that the availability of either a Spanish food FFQ or an interviewer assisted
FFQ would be necessary to lower participant burden2. If there is a substantial budget then
interviewer assisted might be the way to go; another study reinforced this stating, better
information about dietary behavior may be obtained by interview than by self-administration11.
For the reliability study, there were 93 people recruited from three community-based
organizations: an organization providing referral services, adult education classes, and two health
clinicsone urban and one semirural. They completed the brief questionnaire twice, 4 weeks
apart. Men comprised 42% of the sample, and 91% of participants had been born in Mexico.
Results were originally examined utilizing two different scoring systems, either simple or times
per week. Since the reliability correlations didnt show any significant differences between using
the simple and times-per-week scoring systems, the results for the reliability analysis were based
on the simple scoring system. Each food in the screener was given a score from 0 to 5 across the
six categories and then the scores were summed for all the 7 fruit and vegetable screener foods.
The simple scoring system was a continuous variable and the reliability correlation was r = 0.64
for the fruit and vegetable screener11.
For fruits and vegetables, the simple scores were broken down as follows:

18 5 per day, Excellent

1617 4 per day, Good
1315 3 per day, Fair
<13 2 per day, Poor

For the reliability analysis, the researchers assessed the agreement between the two
administrations using Pearson correlation coefficients. Both scores were approximately normally
distributed and were not transformed. To estimate the meaning of the simple score in relation to
recommended levels of intake, the researchers also conducted a regression analysis of the
relationship between the simple score and estimated times per day. Speaking to the validity of
the study, the researchers report that their correlation coefficient is similar to the r = 0.62 found
in separate study for the 17-item dietary component of the Behavioral Risk Factor Surveillance
System conducted among white, African American, and Hispanic respondents12. Another study
reported reliability correlations of r = 0.55 and higher13. In conclusion, this brief FFQ regarding
fruit and vegetable consumption would be an ideal screener to use in Maricopa County to assess
the average consumption among Mexican Americans.

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In recent years, a new anthropomorphic measurement has been validated in the Mexican
American population called the Body Adiposity Index (BAI). The inspiration for this new tool
was the limitation of BMI in its accuracy. The BAI is for use in adults in some ethnic groups to
estimate body fat percentage for both men and women14.
BAI = ((hip circumference)/((height)1.5)18))
The study that identified the index was done with 1,733 Mexican Americans, who had both
parents and at least 3 grandparents who were Mexican or of Mexican descent. These subjects
were either diagnosed with gestational diabetes mellitus (GDM) within the previous 5 years, or
had normal glucose levels during pregnancy the previous 5 years. Non-GDM subjects were
recruited if they had a 2-hour, 50g glucose screening result that was less than 130 mg/dl during
their most recent pregnancy, had no family history of diabetes, and had normal glucose
tolerance. The non-GDM participants were then frequency-matched to GDM participants by age,
BMI, and similar characteristics14.
The goal when creating this index was to find a specific characteristic or combination of
characteristicssuch as age, height, waist circumference, weight, BMI, or hip circumference
which would most strongly correlate with the DEXA-measured adiposity, considered the gold
standard for validation in this study. Correlations ranged from a high of 0.602 for hip
circumference to a low value of 0.158 for age. The researchers took the reasonable approach
applying those values with the strongest correlation with percent adiposity: hip circumference (R
= 0.602, P < 0.001) and height (R = 0.524, P < 0.001). As such, the researchers expected that
the suggested surrogate index would be associated in some way with the ratio of hip
circumference to height, since correlation was positive for the first and negative for the second
value. Independence also had to be taken under consideration, because little absolute correlation
between the two chosen variables would mean that the overall index would garner significant
information from each characteristic. Consequently, there was no significant correlation found
between hip circumference and height (R = 0.005, P = Not Significant), suggesting that they
each contribute independent information to the percent adiposity prediction14.
To examine the generalizability of the BAI, the researchers applied it to a separate crosssectional study, the Triglyceride and Cardiovascular Risk in African-Americans (TARA),
conducted at the National Institutes of Health. The TARA study subjects were all African
Americans. The index emerging from the prior study conducted with Mexican Americans
(BetaGene) was examined in the TARA study to determine if it more accurately reflected
adiposity than the BMI itself. The study populations are compared side by side in Figure 2 on the
following page14.

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Figure 2. A Better Index of Body Adiposity14.

As can be seen in Figure 3 below, the BAI predicts the percent adiposity best when measuring a
true percent adiposity above twenty percent. At a measured percent adiposity of 2025%, BAI is
2627% in the BetaGene and TARA populations. The ability of the BAI to predict percent
adiposity is accurate up to and including true percent adiposity greater than fifty percent.

Figure 3. A Better Index of Body Adiposity14.

Although there arent many studies currently using this index, there also arent many studies
looking specifically at Mexican Americans. This method would be an inexpensive, innovative
way to measure adiposity in this population unique from BMI. As previously mentioned, waist
circumference will also be measured because a study conducted over a seven-year period found
that it was the best predictor of Noninsulin Dependent Diabetes Mellitus (NIDDM) in Mexican
Americans as compared to BMI, waist/hip ratio and other anthropometric measurements9, and it

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can use the same tape measure employed in the index. These measurements would also be useful
since there is already BMI information available for Hispanics, and some studies have shown
that depending on the level of overweight or obesity, it can matter more about the distribution of
fat rather than the quantity, which BMI cannot quantify15.
The combination of a specific FFQ screener regarding fruit and vegetable intake and
anthropometric measurements would create a substantial screenshot of the Mexican American
population in Maricopa County. Information gathered by this assessment would contribute to
future community needs assessments or interventions. To expand further upon this data, the
MCDPH could look at barriers to access, whether it is a socioeconomic status issue, an available
issue, or something more. Additionally, studying children and adolescents would enhance the
quantity and quality of information started by this assessment. Whatever future direction
MCDPH decides to take, monitoring and improving fruit and vegetable consumption and the
obesity rate would decrease the chronic disease burden in adult Mexican Americans in Maricopa
County.

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