Welcome to LifeWalk’s Doctor’s Corner

LifeWalk is a commercially marketed weight loss and healthy lifestyles system. It is designed to serve people from all backgrounds but focuses particular attention on the specific needs and circumstances of US Latinos. Using research-supported methods, LifeWalk integrates culturally attuned nutrition, physical activity, stress coping, and lifestyle change methods into one comprehensive system. Designed to meet the American Cancer Society’s Guidelines on Nutrition and Physical Activity for Cancer Prevention as well as American Diabetes Association recommendations, LifeWalk seeks to reduce health risks associated with sedentary lifestyles, poor nutrition, and obesity.

Epidemiology and Risk Factors

Sedentary lifestyle, poor nutrition, and resulting obesity pose interlinked and mounting risks for several chronic illnesses in the US. These include metabolic irregularities, heart disease, some types of cancer, and other problems. The American Cancer Society, for example, identifies poor nutrition and little physical activity as a risk factor for carcinomas including stomach, pancreatic, colorectal, kidney, and endometrial cancer.1 Persons who are obese also face major risk of developing glycemic irregularities such as metabolic syndrome and type 2 diabetes. Impaired glucose tolerance, in turn, increases risk for pancreatic cancer. Additionally, about 80% of deaths among persons with diabetes are caused by cardiovascular disease.2 In short, substantial evidence links multiple problems to obesity.3

At the same time, US obesity rates have seen dramatic increases in recent years.4 The consequences are far-reaching. Obesity and related chronic diseases account for major financial and personal costs. National diabetes health care expenditures were, for example, estimated at $98 billion in 1997 alone.5 Personal consequences from chronic illnesses include heart attacks, blindness, amputations, renal failure, and premature death. Many of these consequences are connected. For example, roughly 80% of deaths among persons with diabetes are caused by cardiovascular disease.6 Reducing the prevalence of obesity among adults is thus one of the US Department of Health and Human Services’ major current objectives.7

In this context, Latinos face particular nutrition and physical activity-based difficulties. They, for example, experience notably high rates for stomach cancer. Specifically, stomach cancer rates are 30-90 percent higher in males, and 50% higher in women than those found in the broader population. Overall, stomach cancer is a major worldwide problem, and ranks second only to lung cancer in the global cancer burden. A 2004 report by Redes En Acción the NCI-funded national Latino cancer network listed “status and communication of cancer risk” as the third-highest cancer issue of relevance to Latinos.8

Cancer is, however, not the only problem. The type 2 diabetes rate among US Latinos is more than twice that of non-Latino Whites, rising, and occurring at an increasingly younger age.6 In San Diego County, 30,407 (30% of confirmed adult cases) were Latino.9 Nationally, type 2 diabetes is the fourth leading cause of death in Latino women and the sixth leading cause of mortality in Latino men. In addition, many long-term complications such as end-stage renal disease, diabetic retinopathy, and cardiovascular disease are more prevalent in Latinos than non-Latino whites.10-13 Latinos also tend to be younger at diagnosis, have a lower prevalence of diabetes control,14 and undergo more diabetes related amputations than their non-Latino white counterparts.15 Links between pancreatic cancer and impaired glucose tolerance (e.g., such as metabolic syndrome and type 2 diabetes) raise further concerns. An additional problem is that hyperglycemia can promote cardiovascular disease years before type 2 diabetes becomes clinically evident.16

It is increasingly recognized that comprehensive prevention and early intervention efforts must not only focus on diabetes per se, but on a broader spectrum of linked conditions. Type 2 diabetes, for example, is just one of a cluster of inter-related metabolic irregularities that have insulin resistance as a primary characteristic. Such irregularities, for example, include metabolic syndrome, a condition that places individuals at substantial risk of coronary artery disease, type 2 diabetes, stroke, and other illnesses.2,5 Specifically, persons with metabolic syndrome face three times the risk of coronary artery disease and stroke compared to persons with normal glucose tolerance.5 While there is no automatic one-to-one relationship, metabolic syndrome is also frequently a precursor to, or co-exists with, type 2 diabetes.

Preventative attention must also be paid to “pre-diabetes” [formerly known as Impaired Glucose Tolerance or Impaired Fasting Glucose (IGT/IFG)]. According to the American Diabetes Association,17 persons with pre-diabetes are likely to develop type 2 diabetes and may already be experiencing related adverse health effects. In addition, they are at higher risk of cardiovascular problems. Specifically, people with pre-diabetes have a 1.5-fold risk of cardiovascular disease compared to people with normal blood glucose, and have a 2- to 4-fold increased risk of cardiovascular disease. An estimated 47 million persons in the US have metabolic syndrome.18 As with type 2 diabetes, Latinos, especially women, have particularly high and increasing prevalence rates for pre diabetes and metabolic syndrome.19

The rise in metabolic syndrome and type 2 diabetes has been attributed, in large part, to the accompanying epidemic of obesity,20 particularly abdominal obesity.21 As with cardiovascular disease and other health problems, a low-fat diet and physical activity are thus key to multiple aspects of chronic disease prevention. 22 While this formula sounds simple, its implementation is often complicated by a host of social trends and personal behaviors. Among these, sedentary lifestyles, individual and familial eating habits, and psychosocial stressors can interact to hinder improvements.

In this context, psychological factors are increasingly understood as key to chronic disease prevention and control efforts.23,24 Psychological difficulties such as depression, anxiety, and poor self-image, are frequently associated with overeating,25 weight gain, and lack of physical activity, especially if they are exacerbated by environmental stressors.26 Psychological stress has further been associated with physical risk factors for metabolic syndrome and type 2 diabetes. Specifically, Black27 describes chronic and repeated acute stress as activating acute phase responses and chronic inflammatory processes. These factors are, in turn, linked with the development of insulin resistance, metabolic syndrome, and type 2 diabetes. In summary, psychological stress has multiple negative consequences on physical and behavioral dimensions. It can 1) increase physiological risks, 2) stimulate overeating behaviors, and 3) impede positive lifestyle changes. On the other hand, personal confidence that stressors can be managed and behavioral goals are reachable increase the probability that positive changes occur.

Understanding the psychosocial connections to weight gain is thus essential. As demonstrated by a recent Framingham study, obesity is often correlated with specific family and friendship groups.28 In short, we most often tend to overeat for social reasons, not because we are “too hungry.” Appetite suppressants and other quick-fix approaches are unlikely to address this scenario. Instead, we must change social habits and emotional connections to eating. While family tends to be universally important, kinship groups are particularly extended and influential in traditional Latino culture.29

Among Latinos, behavioral risk factors are similar to, but sometimes more pronounced than those found in the general population. Limited physical activity, for example, is a problem among most US groups. But self-reported inactivity rates have been documented at 38.5% for Latino men and 42.7% for Latino women, well above those in the broader population.30 Estimates using Body Mass Index (BMI) criteria further indicate that 39% of Mexican American women and 30 % of men are overweight.31

Taken in combination, the factors described above highlight our need to provide substantive obesity prevention and intervention efforts to Latino.

Interventions: What Does & Does Not Work

It is important to note that chronic illnesses can be prevented, or at least substantially delayed through lifestyle changes alone. The Diabetes Prevention Program Research Group,32 lifestyle interventions, for example, found that weight control, increased physical activity, and reduced dietary fat / calorie intake prevented type 2 diabetes onset among non-diabetic persons with impaired glucose tolerance. This result was consistent across racial and ethnic groups including Latinos. Furthermore, the study’s lifestyle protocol was superior to a pharmacological intervention (metformin) in that it displayed significantly greater preventative value and involved fewer adverse effects. The preventative value of lifestyle changes has also been evident in other diabetes studies.33,34

That physical activity and proper diet are essential to disease prevention is hardly news. But most attempts to encourage such actions have had limited success. Recent summaries of the literature point out that simply following calorie restricting diets has very poor long-term outcomes,35 while programs that integrate nutrition, physical activity and psychosocial support are more effective.36 In short, diets do not help people maintain weight loss over the long run, but a comprehensive, systemic approach can develop habits leading to long-term improvements.37

Several factors account for these outcomes. In general, health education programs targeting dietary intake and physical activity through 1) classes limited to covering basic disease risk information 2) traditional physical exercise (PE) projects have done little to promote long-term changes. This is probably because activities need to be intrinsically interesting and satisfying to foster long-term change. Put simply, scaring people with potential future health problems may motivate temporary, but not more permanent exercise and diet changes. Our clinical patients often make barriers to diet change clear. They describe "healthy" food as tasting terrible. Family members are also unlikely to accept such a diet or prepare "special" diets for one or two individuals, especially since additional grocery costs are often involved. Similarly, gym-based exercises were seen as expensive, uncomfortable, and boring. Such approaches are thus difficult to maintain in every-day life.

Attention to the needs of specific high-risk culturally distinct groups is rare. While some effective Latino-focused care for those who already have chronic diseases exist,38 preventative efforts have had less success.

Social and cultural factors play an additional role among Latinos. Health educators' personal reactions based on conscious and unconscious stereotypes are, for example, likely to hamper interactions with members of culturally distinct groups.39,40 Incongruent expectations between participant and health educator foster misunderstandings, mistrust, and lack of follow-through.41 In short, limited cultural competence hampers risk prevention efforts.41,42 Current cultural competence efforts tend to focus on translating materials into Spanish and marketing health education efforts through Community Health Workers (promotoras). While both strategies are important, cultural competence must progress to the next level. This includes identifying opportunities to tap into culture-based strengths. For example, Shapiro and Gong43 found that 56% of Latinos served by one East Los Angeles health center used nopales (cooked prickly pair cactus) as a hypoglycemic agent. Research shows that nopales do, in fact, help lower blood glucose.44 Encouraging dose-effective nopales use could thus likely enhance dietary outcomes for some Latinos. But health educators under-utilize such approaches because of limited knowledge about, or acceptance of, traditional diets.45,46 In addition, our experience suggests that a practical, hands-on, approach to nutrition (e.g. demonstrating that "healthy" food can taste good to individuals and their family members) and health information is likely to be effective.

Another strategy is to harness social support and personal resources that foster lifestyle change. Teaching culturally and linguistically congruent approaches that address areas such as stress management, dealing with family life, and other emerging developmental processes have the opportunity to reinforce and facilitate diet and exercise interventions. For example, positive family functioning has been related to disease management, including diet and exercise among Latinos.47

Ultimately success depends on the belief such success is possible. Focused effort to increase personal resources can thus facilitate positive interactions between health education (e.g., diet) and efforts to increase physical activity. For example, it can increase stress coping abilities that, in turn, raise confidence, and increase physical activity. Physical activity, in turn is well known to further reduce stress.48 Thus various components complement and facilitate each other to form one positive whole. LifeWalk integrates the key elements discussed above into such a comprehensive system that supports participants as they make long-term lifestyle changes.

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