Nutrition knowledge, attitudes, and behaviors among Latinos in the USA: Influence of language

This article was downloaded by: [University of South Florida]On: 07 May 2015, At: 09:27Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number:1072954 Registered office: Mortimer House, 37-41 Mortimer Street,London W1T 3JH, UK

Ecology of Food andNutritionPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/gefn20

Nutrition knowledge,attitudes, and behaviorsamong Latinos in the USA:Influence of languageRafael Pérez‐Escamilla a , David Himmelgreenb c , Harby Bonello d , Anir González d ,Lauren Haldeman e , Ivette Méndez d & SofiaSegura‐Millán d

a Associate Professor & Extension NutritionSpecialist, Department of Nutritional Sciences ,University of Connecticut , Storrs, Conn.,06269–4017 Phone: (860) 486–5073 Fax: (860)486–5073 E-mail:b Visiting Assistant Professor, Department ofApplied Anthropology , University of SouthFloridac Associate Director for Research , HispanicHealth Councild Hispanic Health Council Inc. , Hartford, Conn.e Doctoral student at the Departmentof Nutritional Sciences , University ofConnecticut , Storrs, Conn.Published online: 31 Aug 2010.

To cite this article: Rafael Pérez‐Escamilla , David Himmelgreen , HarbyBonello , Anir González , Lauren Haldeman , Ivette Méndez & Sofia Segura‐Millán(2001) Nutrition knowledge, attitudes, and behaviors among Latinos in theUSA: Influence of language, Ecology of Food and Nutrition, 40:4, 321-345, DOI:10.1080/03670244.2001.9991657

http://www.tandfonline.com/loi/gefn20

http://www.tandfonline.com/action/showCitFormats?doi=10.1080/03670244.2001.9991657

To link to this article: http://dx.doi.org/10.1080/03670244.2001.9991657

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of allthe information (the “Content”) contained in the publications on ourplatform. However, Taylor & Francis, our agents, and our licensorsmake no representations or warranties whatsoever as to the accuracy,completeness, or suitability for any purpose of the Content. Anyopinions and views expressed in this publication are the opinionsand views of the authors, and are not the views of or endorsed byTaylor & Francis. The accuracy of the Content should not be reliedupon and should be independently verified with primary sources ofinformation. Taylor and Francis shall not be liable for any losses, actions,claims, proceedings, demands, costs, expenses, damages, and otherliabilities whatsoever or howsoever caused arising directly or indirectlyin connection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private studypurposes. Any substantial or systematic reproduction, redistribution,reselling, loan, sub-licensing, systematic supply, or distribution in anyform to anyone is expressly forbidden. Terms & Conditions of accessand use can be found at http://www.tandfonline.com/page/terms-and-conditions

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

http://dx.doi.org/10.1080/03670244.2001.9991657

http://www.tandfonline.com/page/terms-and-conditions

http://www.tandfonline.com/page/terms-and-conditions

Ecology of Food and Nutrition, Vol. 40(4), pp. 321-345 © 2001 OPA (Overseas Publishers Association) N.V.Reprints available directly from the publisher Published by license underPhotocopying permitted by license only the Harwood Academic Publishers imprint,

part of Gordon and Breach Publishing,a member of the Taylor & Francis Group.

NUTRITION KNOWLEDGE, ATTITUDES,AND BEHAVIORS AMONG LATINOS INTHE USA: INFLUENCE OF LANGUAGE

RAFAEL PÉREZ-ESCAMILLA1,*,DAVID HIMMELGREEN2, HARBY BONELLO3,

ANIR GONZÁLEZ3, LAUREN HALDEMAN4,IVETTE MÉNDEZ3 and SOFIA SEGURA-MILLÁN3

1Associate Professor & Extension Nutrition Specialist,Department of Nutritional Sciences, University of Connecticut,

Storrs Conn. 06269-4017;2Visiting Assistant Professor, Department of Applied

Anthropology, University of South Florida. At the time of thestudy, Hispanic Health Council's Associate Director for Research;

3Hispanic Health Council Inc., Hartford, Conn.;4Doctoral student at the Department of Nutritional Sciences,

University of Connecticut, Storrs, Conn.

(Received December 16, 1999; in final form September 25, 2000)

The objectives of this study are to: (a) assess Latino's nutrition knowledge, atti-tudes, behaviors, and sources of nutrition information, and (b) examine theassociation of these with language use at home. Household-to-household inter-views were conducted in five predominantly Latino neighborhoods in Hartford,Connecticut in households with at least one child 12 years of age. The typicalLatina respondent was a woman in her early 30s who was the mother of at leastone child living in the household (N = 426). The vast majority of Latinos werePuerto Rican (95.8%) and they spoke only Spanish (41.8%), only English(6.1%) or both English and Spanish (52.1%) at home. As many as 73.9% ofrespondents received food stamps and only 9.2% had more than high schooleducation. Respondents were familiar with the USDA's Food Guide Pyramid(93.4%) and with food labels (93.7%). Fifteen percent knew the recommendedservings for breads and cereals and 18.3% reported reading food labels always.

* Corresponding author. Tel.: (860) 486-5073; Fax: (860) 486-3674;E-mail: [email protected]

321

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

322 R. PEREZ-ESCAMILLAJSr^lL.

Respondents had a positive nutrition attitude but lacked specific knowledge ofterms such as "saturated fat" and "neural tube defects", and were unable toidentify good food sources of folate, calcium, and vitamin A. Friends/relatives,doctor, WIC, and television were the main sources of nutrition information.Speaking only Spanish at home (vs English or English and Spanish) was associ-ated with nutrition knowledge and attitudes, and a more traditional pattern offood consumption.

KEY WORDS: Children, food intake, Food Guide Pyramid, food labels,Hispanic, language, Latino, nutrition knowledge, obesity

INTRODUCTION

Low-income caretakers and their children are likely to have poorerdietary practices than their wealthier counterparts (Buttriss,1997; Kirby et al, 1995; Morton and Guthrie, 1997; Zive et al,1998). This social class differential has important public healthimplications as a higher acquisition of nutrition awareness andknowledge by higher-income groups has been hypothesized to beresponsible, at least in part, for the inverse association betweensocial class, life style behaviors, and the risk of ischemic heart dis-ease mortality seen today in most industrialized nations (Kunztetal.,1999).

Nutrition knowledge, attitudes and/or beliefs have been associ-ated with food intake behaviors within different socio-economicclasses (Harnack et al, 1997; Patterson et al., 1996; Tepper andNayga, 1996). Higher income populations are more knowledge-able about nutrition and health than their more disadvantagedcounterparts (American Dietetic Association, 1998; Axelson etal.,1985; Buttriss, 1997; Caliendo et al, 1982; Cotugna et al., 1992;Hyman et al., 1993; Interagency Board for Nutrition Monitoringand Related Research, 1995; Kirby et al., 1995; Langenhoven etal, 1991; She&etal, 1991; Stephensone/o/., 1987; Variyam et al,1996; Vega etal, 1987; Zive etal, 1998). Experimental (Brunneret al, 1997; Byers et al, 1995; Hunt et al, 1993; Perry et al, 1998;Sorensen et al, 1999; Wechsler et al, 1998) and quasi-experi-mental (Foerster etal, 1998; Regerera/., 1998) studies have shownthat nutrition education and/or social marketing interventions

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

LATINOS NUTRITION KNOWLEDGE 323

are effective at changing food behaviors and/or reducing riskfactors for chronic diseases in children and/or adults. Thus, it isimportant to improve nutrition knowledge, attitudes, and beha-viors among low-income groups via culturally competent inter-ventions (Bradbardef al, 1997; Bronner, 1996).

Studies are needed to assess the food and nutrition know-ledge, attitudes, and practices among minorities. Latinos represent11% of the USA population and experience a disproportionateburden of diet—and in many instances physical inactivity—relateddiseases (e.g., cardiovascular disease, certain types of cancers,diabetes mellitus type II). Among Latinos, Puerto Ricans experi-ence higher poverty rates and health problems than Cuban-Americans and Mexican-Americans (Aguirre-Molina and Molina,1994). Unfortunately, little is known about the current nutritionknowledge, attitudes and behaviors among Puerto Ricans livingin the Continental USA. In particular, few studies have addressedin this community the relationship between language spoken athome (Spanish vs English) and nutrition knowledge, attitudesand behaviors. This is a major knowledge vacuum as language isa potent indicator of acculturation (Cobas et al., 1996).

The specific aims of this study were to assess among urbanLatinos in the USA: (a) knowledge of the Food Guide Pyramid,food labels, infant feeding, dietary fat and cholesterol, andspecific nutrients (folate/folic acid (Perez-Escamilla etal., 1999),vitamin A, iron, and calcium), (b) attitudes towards nutrition,(c) selected food intake behaviors, (d) sources of nutritioninformation, and (e) if nutrition knowledge and attitudes, andfood intake behaviors are associated with the language spokenat home.

METHODS

Survey Design

This study was approved by the Human Subjects ReviewCommittees of the University of Connecticut and the HispanicHealth Council. A household-to-household food and nutrition

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

324 R. PEREZ-ESCAMILLA£Ty4L.

knowledge, attitudes and behaviors community survey wasconducted in the five predominantly Latino neighborhoods ofinner-city Hartford. Data were collected between January 1 andSeptember 30, 1997. The criterion for selecting the neighbor-hoods was that, based on census data, at least half of its residentsidentified themselves as Latino. Sample size estimations (Jekeletal., 1996) indicated that 500 respondents were needed to obtaina representative assessment of the nutrition knowledge, attitudesand practices of the population living in these neighborhoods.The desired proportion of respondents from each of the fiveneighborhoods was selected based on the total population perneighborhood as indicated by official census data.

Households were selected if they included at least one child12 years old or younger. Interviewers were instructed to selectrandomly a street in the heart of the neighborhood and toconduct interviews until the target sample size was recruited.Respondents were provided with a nutrition education packetat the end of the interview. Results from the two neighborhoodswhere detailed non-participant data were collected indicatethat interview refusal rate was 17%. Respondents were inter-viewed in either Spanish (67%) or English (33%) by the fieldsupervisor and three trained bilingual and bicultural interview-ers. Data were entered and cleaned by one staff member whowas also fully bilingual.

The structured survey instrument was developed specificallyfor this study following recommended procedures (Fink, 1995).It was first written in English and then translated into Spanish bya Puerto Rican staff member. The survey was not back-translatedbut we ensured that the instrument was clearly and easily under-stood by low-literacy respondents in any of the two languages byapplying it to five caretakers per language prior to the beginningof formal data collection. The survey content was chosen basedon key nutrition education and health objectives for the nation(US Department of Health and Human Services, 2000). Contentvalidity was confirmed by six expert community nutritionists andtwo community staff members.

Respondents were shown a color picture of the Food GuidePyramid (US Department of Agriculture, 1992) where group

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


servings and words had been deleted to find out if they werefamiliar with it. If so, they were asked the recommended dailyservings for each of the five food groups. Respondents were readthree servings options and were also allowed to report "don'tknow" as a fourth option. Interviewees were shown a food labelto find out if they were familiar with it. If so, they were asked ifthey read food labels to decide which foods to buy and were pro-vided with the following response options: "never", "sometimes"or "always". If they responded "sometimes" or "always" thenthey were asked to report if they looked at the following whenreading food labels: serving size, calories, total fat, ingredients,sodium, and cholesterol.

Respondents were asked if they had heard about saturated fatand if so they were read a list of five foods and asked to report ifeach food was a good source of saturated fat with the possibleresponses "yes", "no", and "don't know". A similar approachwas followed with cholesterol except that four different foodswere listed. All interviewees were asked for each of five foods ifthey were good sources of calcium and for a different set of fivefoods if they were rich in vitamin A. Respondents were asked ifthey knew if each of four nutrients—iron, protein, calcium, andphosphorus—was needed by a child diagnosed as anemic by aphysician. Possible answers were "yes", "no", and "don't know".

Three sets of questions were asked to assess knowledge offolate/folic acid and the prevention of neural tube defects(Perez-Escamilla et al., 1999). First, they were asked if they hadever heard about the terms "spina bifida" or "neural tubedefects". Second, they were asked for each of four nutrients—iron, calcium, folic acid, protein—if it was capable of preventingbirth defects if consumed by the mother very early in pregnancy.Third, respondents were asked for each of six foods to report ifthey were good sources of folic acid with possible responsesbeing "yes", "no", and "don't know".

The survey probed for infant feeding knowledge by askingrespondents if they knew how old a baby should be before intro-ducing baby food and the appropriate age to start feeding wholecow's milk to a child. For both questions they were read fiveoptions from which they had to select one.

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

326 R. PEREZ-ESCAMILLA ETAL.

Attitudes toward nutrition were assessed by asking respond-ents "how important do you think nutrition is for children'shealth?", and "would you be interested in learning more aboutgood nutrition?". Respondents were asked if they believed child-hood obesity posed serious health risks. Usual food intake beha-vior of the caretaker and children between two and five years ofage (based on caretaker's report) was assessed with a six-itemfood frequency questionnaire listing the following: fruits, fruitjuice (artificially flavored beverages were likely to be reportedunder this category), viandas (traditional starchy vegetables),green leafy and other vegetables (e.g., lettuce, tomato, carrots),fish and yogurt. The latter two items were chosen as our previouswork in this community (Perez-Escamilla et al., 1997) indicateda low consumption of these foods. Only children under fivewere included in this assessment as caretakers are unlikelyto report food frequencies accurately for children who arealready attending school and consuming foods outside of thecaretakers presence. Children under two were not included asit would have been necessary to add a lengthy section on infantfeeding practices to the survey. If more than one child quali-fied for the dietary assessment only the youngest one waschosen.

Data Analyses

Data analyses are based on the 426 Latino respondents. Therewere 45 African American and 29 respondents who were excludedbecause no meaningful results could be obtained from these smallsubgroups. Data entry and statistical analyses were performedusing SPSS for Windows (SPSS Inc., 1996). All statistics are pre-sented by language usually spoken at home (Spanish (n = 178) vsEnglish and Spanish (n = 222)/ English only (n = 26)). Categor-ical variables are compared between language subgroups usingX2 analyses and continuous variables are compared withStudent's Mests. Spearman's correlation analysis was con-ducted to assess the association between the daily frequencyof food intake between caretakers and their two to five yearold children.

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


RESULTS

Sample Socio-Economic, Demographic, and Food AssistanceCharacteristics

The typical respondent was a woman in her early 30s who wasthe mother of at least one child living in the household. Spanish-only speakers were more likely (p < .05) to be female than theirEnglish speaking counterparts (94.9% vs 86.3%, respectively).Almost twice as many Spanish-only respondents were grand-parents of the study children (20.8% vs 12.5%). As expected, thevast majority of respondents identified themselves as Puerto Ricanand reported that they either spoke only Spanish or both Englishand Spanish at home. Spanish-only respondents were less likelyto identify themselves as Puerto Rican than English speakers(93.3% vs 97.6%, respectively). The level of formal educationwas low, with Spanish-only speakers being significantly less likelythan English speakers to have graduated from high school. Thevast majority of households had access to a refrigerator, televisionset and radio but not a CD player set or a home computer. Twoout often respondents did not have a phone line in the householdand less than half had access to a car. English speakers were morelikely (p<.05) than Spanish-only speakers to have access to a carand microwave oven, and tended to be more likely to have acomputer (p = .082) and CD player (p = .091) at home (Table I).

Almost 7 out of every 10 respondents were receiving welfare(i.e., Aid to Families with Dependent Children (AFDC)) withEnglish speakers being less likely than Spanish-only respondentsto be welfare recipients (68.1% vs 79.7%, p = .008). The lan-guage group difference in Food Stamp Program participation rateswas less pronounced (71.0% vs 78.0%, p = .105) than with AFDC.Fifty two percent of the households were participating in theSupplemental Food Program for Women, Infants, and Children(WIC), 51.7% in the School Breakfast Program, and 70% in theSchool Lunch Program. Spanish-only respondents were morelikely than English speakers to participate in the School Lunchprogram (75.8% vs 65.3%,p = .020) and tended to be more likelyto participate in the School Breakfast Program (57.1% vs 47.8%,

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

328 R. FEREZ-ESCAMILLA ETAL.

TABLE ISample demographic, cultural, and socio-economic characteristics by language

Variable

Respondent's gender% femaleRespondent's age (yrs)Mean ± std. dev.

Children < 12 yrs (#)Mean ± std. dev.

Children <5yrs (#)Mean ± std. dev.Child relationshipParent (%)Grandparent (%)Sibling (%)Babysitter (%)Other (%)

Language at homeEnglish (%)Spanish (%)Both (%)Latino ethnicityPuerto Rican (%)Dominican (%)Other (%)Formal education< High school (%)High school (%)> High school (%)AppliancesRefrigerator (%)Washing machine (%)Computer (%)CD player (%)Microwave oven (%)TV(%)Radio (%)Phone (%)Car(%)

(N

nc

383

33.3

2.0

0.95

30968128

29

26178222

4087

11

25013739

42433744

250290424413356203

All= 426)

%

89.9

±12.2

+ 1.1

+ 0.89

72.516.02.81.96.8

6.141.852.1

95.81.62.6

58.732.2

9.2

99.579.110.358.768.199.596.983.647.7

English"(AT =248)

" c

214C

31.2

1.98

0.96

18131105

21

690

223

24242

1348727

24719931

154179247241203136

%

86.3

±11.8

+ 1.05

+ 0.90

73.012.54.02.08.5

14.60

47.6

97.61.60.8

54.035.110.9

99.680.212.562.172.299.697.281.954.8

Spanish(AT =

nc

169

36.6

2.06

0.94

12837238

0178

0

16639

1165012

1771381396

11117717215367

= 178)

%

94.9

±12.3

±1.10

±0.88

71.920.8

1.11.74.5

0100

0

93.31.75.1

65.228.1

6.7

99.477.5

7.353.962.499.496.686.037.6

Pb

0.003

< 0.001

0.445

0.7710.040

< 0.001

0.024

0.058

1.0000.4970.0820.0910.0321.0000.7460.260

< 0.001

a 222 spoke English and Spanish.bp-value corresponding to \2 analyses (categorical variables) or Student's /-test

(continuous variables) comparing English vs Spanish-only speakers.c subgroup sample size corresponding to indicated category.

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


p — .059). In terms of emergency food assistance 12.5% reportedaccessing food banks, 16.5% food pantries, and 4.0% consumingmeals at soup kitchens. There were no significant differencesbetween language subgroups in use of emergency food assistance.

Food Guide Pyramid Knowledge

The majority of respondents (93.4%) were familiar with theUSDA Food Guide Pyramid and among those who were familiarwith it, 92.8% knew that it is a tool for better eating. However,respondents were not very accurate when answering questionsthat probed for knowledge about the Food Guide Pyramid. Thepercentage of respondents who knew the recommended servingsfor the food groups was: 67.8% for fruits, 40.8% for vegetables,70.2% for meats and alternates, 58.2% for dairy products, and14.8% for breads and cereals. English speakers were more likelythan Spanish-only respondents to know the minimum recom-mended daily fruit servings (71.8% vs 62.4%,/? = .040).

Food Label Knowledge and Use

The vast majority of respondents (93.7%) indicated that they werefamiliar with food labels with English speakers being morefamiliar with them than Spanish-only respondents (96.8% vs89.3%, p = .002). However, among those who were familiar withthem, 23.8% never used them, 57.9% used them sometimes, andonly 18.3 % of food label users reported reading them always whendeciding which foods to buy. When food label users were askedabout the specific information they looked at in food labels, thevast majority indicated that they looked at calories (91.1%) and fatcontent (88.5%), followed by cholesterol (85.5%), ingredients(74.0%), sodium (66.8%), and serving size (64.5%). There wereno significant differences between language groups in food labeluse or specific items respondents looked at when using the labels.

Dietary Fat and Cholesterol Knowledge

Close to half of respondents (46.2%) indicated that they werefamiliar with the term "saturated fat" with English speakers

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

330 R. PEREZ-ESCAMILLA£T,4L.

being significantly more familiar with this term than Spanish-only respondents (51.6% vs 38.8%,p = .009). Among those whowere familiar with this term 92.9% reported that pork was a goodsource of saturated fat followed by rice (13.7%), potatoes(12.7%), bananas (6.6%), and broccoli (3.6%). Interestingly,19.3% of respondents stated that they "did not know" if bananaswere a good source of saturated fat. This figure was 13.7% forrice, 11.2% for potatoes, and 7.6% for broccoli. There were nosignificant language group differences in knowledge about thesaturated fat content of different foods.

The vast majority of respondents (94.4%) indicated that theywere familiar with the term "cholesterol". Among those whowere familiar with this term 82.6% reported that chicken was agood source of cholesterol followed by rice (23.6%), sweet pota-toes (11.2%), and papaya (7.7%). It is noteworthy that for plantbased products a high percentage of caretakers indicated thatthey "did not know" if these were good sources of cholesterol. Asa result only 57.5% reported that sweet potatoes, 64.7% thatpapaya, and 59.0% that rice were not good cholesterol sources.English speakers were more likely to report than Spanish-onlyrespondents that chicken (87.2% vs 76.2%,p = .004) and papaya(10.3% vs 4.2%,p = .024) are good cholesterol sources. A similarfinding was obtained for sweet potatoes but was only marginallysignificant (13.7% vs 7.7%, p = .063).

Anemia, Dietary Calcium, and Vitamin A Knowledge

When asked about specific nutrients 93.7% responded that ironis likely to be needed by an anemic child. However, only 23.2%indicated that protein, 26.8% that calcium, and 36.2% thatphosphorus were not likely to be needed. Based on a food listread to them, 96.5% of respondents identified milk as a goodsource of calcium, followed by: apples (47.7%), corn (41.3%),rice (40.6%), and pork (5.2%). Spanish-only respondents weremore likely to know than English speakers that pork is not agood source of calcium (97.8% vs 92.7%, p = .021) and alsotended to know more that apples are not good sources of thismineral (57.3% vs 48.8%,p = .083). A significant proportion of

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


participants answered that they "did not know" if pork (13.6%),apples (20.0%), corn (26.3%), or rice (21.4%) were good calciumsources.

In terms of vitamin A, 65.3% of individuals identified carrotsas good sources of this vitamin, followed by: bananas (44.8%),peanut butter (44.8%), and raisins (39.2%). A significant propor-tion of participants answered that they "did not know" if carrots(27.2%), bananas (33.3%), or peanut butter (32.4%) were goodvitamin A sources or not. Vitamin A knowledge outcomes werenot associated with the respondents' language.

FolicAcid and Neural Tube Defects Knowledge

As previously reported (Perez-Escamilla etal., 1999), knowledgeof folic acid and neural tube defects was exceedingly low. Only16.7% of respondents reported ever hearing about "spina bifida"or "neural tube defects". Likewise, only 11.3% correctly identi-fied folic acid as the nutrient capable of preventing these defects.Over 83% responded that they didn't know which foods—apples,pork, orange juice, beans, milk, and/or spinach—were good sourcesof this vitamin. Folic acid knowledge was not associated withrespondents' language.

Infant Feeding Practices Knowledge

Only 62.1% of caretakers knew that the appropriate age to intro-duce infants to semi-solid foods is four to six months of age.Almost one-third of respondents indicated that these foodscould be introduced before this age and 4.7% indicated thatsemi-solid food could be introduced after this age range. One offive caretakers indicated that whole cow's milk could be fed toinfants before they are one year old. Respondents' language wasnot associated with infant feeding knowledge.

Attitudes towards Nutrition and Childhood Obesity

The vast majority of respondents indicated that they would liketo learn more about nutrition and that proper nutrition waseither important or very important for children's health. When

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


asked about specific medical conditions the majority of care-takers responded that childhood obesity can lead to heart disease,high blood pressure, and/or diabetes. Spanish speakers weremore likely than English speakers to know that childhood obesitymay lead to heart disease (96.6% vs 90.3%, p = .033), and dia-betes (75.3% vs 66.1%, p = .039). English speakers tended to bemore likely to report that childhood obesity may lead to goodhealth (13.7% vs 7.3%,p = .097). When read a list of options, thevast majority responded that preparing less fried foods, exercise,and increasing fruit juice consumption were healthy ways for achild to lose weight. A small percentage reported that this goalshould be achieved by limiting fruit or vegetable, and/or skippingbreakfast (Table II).

Food Consumption Patterns of Caretakers and Children Two toFive Years Old

The overwhelming majority of caretakers and children usuallyconsumed fruits and fruit juices. A significantly higher percent-age of Spanish speaking caretakers consumed traditional starchyroot and non-root vegetables or "viandas" when compared withEnglish speakers (93.3% vs 85.1%, p = .009). Most caretakersand children consumed vegetables other than "viandas" (e.g.,lettuce, tomatoes). Children living in Spanish speaking house-holds tended to have a lower consumption of these vegetablesthan their English speaking counterparts (80.9% vs 88.9%,p = .094). About three of every four caretakers and two ofevery three children consumed fish. Yogurt was not widelyconsumed and Spanish speaking caretakers (38.8% vs 54.8%,p = .001) and children (47.9% vs 63.5%, p = .021) were lesslikely to consume it than their English speaking counterparts(Table III).

Maternal and child daily frequencies of food group intakeswere correlated with each other (/x.001). The Spearman'scorrelation coefficient were: 0.580 for fruits, 0.538 for fruit juices/drinks, 0.572 for viandas, 0.591 for vegetables, 0.611 for fish, an0.519 for yogurt. Spanish-only speaking caretakers had a lowerdaily frequency of consumption of fruit juices/drinks than their

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

TABLE IINutrition attitudes and childhood obesity by language

Interested in learning moreabout nutrition?Yes

How important is nutrition forchildren's health?Somewhat importantImportantVery importantCan the following conditionsresult if a child is overweight?Heart disease

YesNoDon't know

High blood pressureYesNoDon't know

(N

nc

408

351

372

3961515

3791631

All= 426)

%

95.8

0.712.087.3

93.03.53.5

89.03.87.3

English"(N =

nc

236

328

217

2241311

2161220

248)%

95.2

1.211.387.5

90.35.24.4

87.14.88.1

Spanish(iV =nc

172

023

155

17224

1634

11

178)%

96.6

0.012.987.1

96.61.12.2

91.62.26.2

Ph

0.458

0.303

0.033

0.274

Z

oin

3o

§o

aow

u>

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

TABLE II (continued)

DiabetesYesNoDon't know

Good healthYesNoDon't know

Is this a healthy way forchildren to reduce weight?Prepare less fried foods

YesNoDon't know

Limit fruit intakeYesNoDon't know

Limit vegetable intakeYesNoDon't know

All(N =

rf

2985672

47361

18

406173

26395

5

21404

1

426)

%

70.013.116.9

11.084.74.2

95.34.00.7

6.192.7

1.2

4.994.8

0.2

English3

(iV =248)

nc

1644143

34205

9

236102

17229

2

12236

0

%

66.116.517.3

13.782.73.6

95.24.00.8

6.992.30.8

4.895.2

0

Spanish(N =

nc

1341529

13156

9

17071

9166

3

9168

1

178)

%

75.38.4

16.3

7.387.65.1

95.53.90.6

5.193.3

1.7

5.194.4

0.6

0.039

0.097

0.955

0.538

0.494

mNWc/sO>

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

Exercise 0.399YesNoDon't know 1 0.2 1 0.4 0 0.0 21

Increase fruit juice ooconsumption 0.162

Yp™ *?z:o oc rt 111 oc 1 1C1 OA O ^-i

400251

3625212

233994

93.95.90.2

85.012.22.8

5.493.70.9

235121

211334

162320

94.84.80.4

85.113.31.6

6.593.50

165130

151198

71674

92.77.320.0

84.810.74.5

3.993.82.2

No 52 12.2 33 13.3 19 10.7 2Don't know 12 2.8 4 1.6 8 4.5 -

Skip breakfast 0.034 §YesNoDon't know

ra 222 spoke English and Spanish. Qb/>-value corresponding to x2 analyses (categorical variables) or Student's (-test (continuous variables) comparing English vs Spanish-only O

speakers.c subgroup sample size corresponding to indicated category.

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

OJ

TABLE IIISelected foods consumed by Latino caretakers and children two to five years old by language

FruitsViandasc

Other vegetablesJuicesFishYogurt

All(N =

nd

407377393404336205

426)

%

95.588.592.394.878.948.1

(Caretakers

English3

(N =

na,d

239211226236189136

:248)

%

96.485.191.195.276.254.8

Spanish(N =

nd

16816616716814769

178)

%

94.493.393.894.482.638.8

Pb

0.3270.0090.3050.7200.1120.001

(N

nd

220156188218145125

All= 220)

%

99.570.985.599.165.956.8

Children

English3

(N =

na,d

12687

1121248480

126)

%

99.269.088.998.466.763.5

Spanish(N

nd

946976946145

= 94)

%

10073.480.910064.947.9

Pb

1.000.4820.0940.5080.7840.021

* 222 spoke English and Spanish.b/?-value corresponding to x2 analyses comparing English vs Spanish speakers.c Viandas: traditional starchy root or non-root vegetables such as plantain, sweet potatoes, potatoes, yuca, name.d subgroup sample size corresponding to indicated food category.

*ora-sam

mCO

I

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


English speaking counterparts (medians: 2 vs 3 times per day,p<.001).

Sources of Nutrition Information and Mass Media Exposure

Over 90% of respondents recalled ever receiving nutrition informa-tion. The most common channels for nutrition information were:friends/relatives, followed by doctor's office, WIC program, andtelevision. Less than half reported receiving nutrition educationinformation from radio, newspapers, billboards, grocery stores,or botanicas (i.e., folk medicine stores) (Table IV).

DISCUSSION

We had previously reported that low-income Latino preschoolersliving in Hartford Connecticut are at risk of poor nutrition and

TABLE IVSources of nutrition information by language

Ever heard about nutrition?Where?

FamilyFriendsDoctor's officeWICd

TelevisionMagazinesNewspapersRadioBillboardsGrocery storesBotanica (folk medicine store)

All(N =

n"

393

17914532632125620514114613911311

426)

%

92.3

45.536.983.081.765.152.335.937.235.428.82.8

Englishb

(N =

na

232

11794

199193153123908184809

248)

%

93.5

50.440.585.883.265.953.038.834.936.234.5

3.9

Spanish(AT =

if

161

6251

12712810382516555332

178)

%

90.4

38.531.778.979.564.051.331.740.434.220.5

1.2

Pc

0.238

0.0200.0740.0740.3530.6860.7310.1480.2710.6770.0030.212

a subgroup sample size corresponding to indicated category.b 222 spoke English and Spanish.cp-value corresponding to x2 analyses comparing English vs Spanish speakers.d WIC: Supplemental Food Program for Women, Infants, and Children.

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

338 R.PEREZ-ESCAMILLA£T,4L.

health outcomes including: low birth weight, low breastfeedingrates, low intake of fresh fruits and vegetables, high fat intake,obesity, and physical inactivity (Perez-Escamilla et al., 1997). Thiscommunity survey, where the typical respondent was a mother inher early 30s, provides strong evidence that their caretakers lackbasic nutrition knowledge that can help improve the dietarychoices that they make for themselves and their households.These findings are in full agreement with our focus groupsresearch in this community (Haldeman et al., 2000)

The overwhelming majority of respondents were familiar withthe USDA's Food Guide Pyramid, but were not very cognizantof its content. In agreement with our findings, a recent analysisof the 1994 USDA CSFII/DHKS survey (Morton and Guthrie,1997) showed that few respondents recalled the correct numberof servings of the breads and cereals group. The American DieteticAssociation (ADA) Nutrition Trends survey (American DieteticAssociation, 1998), a nationally representative telephone surveyof adults, found that awareness about the Food Guide Pyramidincreased from 58% in 1995 to 67% in 1997. The much higherpercentage of respondents in our survey who were familiar withthe Food Guide Pyramid in comparison to the ADA survey, maybe explained by the fact that in our survey, respondents wereprompted with a sample pyramid that excluded the recommendedservings per group. It is quite possible that phone surveys misspeople who have seen the pyramid but simply may not be familiarwith its "official" name.

The vast majority of respondents were familiar with foodlabels but used them very infrequently probably because they aredifficult for them to understand (Haldeman et al., 2000). TheADA Nutrition Trends survey (American Dietetic Association,1998) found that a higher percentage of the population payedlittle or no attention to food labels in 1997 (36%) than in 1995(29%). During the same period of time the percentage whopayed "very close" attention to food labels declined from 33% to27%. Morton and Guthrie (1997) report that among CSFII/DHKS respondents from households where children lived, lowincome individuals were significantly less likely than their higher-income counterparts (59% vs 71%, respectively) to "sometimes" or

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


"often" use the nutrition panel in food labels. In agreement withour findings, that survey also showed that individuals were mostinterested in: total fat, calories, saturated fat, and cholesterol andpaid the least attention to the fiber content of the food product.

Although respondents were quite familiar with the Food GuidePyramid and food labels, they were unfamiliar with "specialized"topics such as "saturated fat", "folic acid & neural tube defects"(Perez-Escamilla etal, 1999), and infant feeding recommendations.Furthermore, in many instances they were unable to adequatelyidentify good food sources of calcium, vitamin A, and folate.

Respondents were very interested in nutrition, thought thatnutrition was important to the health of their children, and werefully aware of the negative health consequences of childhoodobesity. In agreement with this, recent studies have shown thatthe general population as well as low income groups tend to havepositive attitudes/beliefs towards nutrition (American DieteticAssociation, 1998; Bradbard et al, 1997; Morton and Guthrie,1997). However, these studies also indicate that more efforts areneeded to specifically address the needs of low-income groups. Itis possible that the strong interest for nutrition reflected in thisand previous studies was influenced in part by the survey processitself thus, "social desirability" may also explain in part theseresults. The strategy in our study to minimize this possibility wasto work with highly skilled bilingual and bicultural interviewersfrom the community.

Our findings document a strong correlation between the foodintake patterns of caretakers and their children. This is in agree-ment with previous studies suggesting that caretakers do influencethe food practices of their children (Borah-Gidens and Falciglia,1993; Bradbard et al., 1997; Colavito et al., 1996; Contento et al.,1993; Lin etal., 1996; Zive etal, 1998).

In agreement with previous studies, on balance our findingssuggest that acculturation may have a negative influence on healthand nutrition outcomes (Black and Markides, 1993; Guendel-man and Abrams, 1995; Kaplan and Marks, 1990; Marin et al.,1989; Rassin et al, 1994; Stern et al, 1982). There were significantdifferences in nutrition knowledge and attitudes, and food intakebehaviors associated with the language used at home. In particular,

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


Spanish-only speakers were less likely to know the recommendeddaily servings of fruits, and less likely to be familiar with foodlabels, and the term "saturated fat". Furthermore, they were lesslikely than their English speaking counterparts to know thatchicken is a good source of cholesterol but Spanish speakerswere more likely to know that pork is not a good source of cal-cium and to be more aware of the health risks associated withchildhood obesity. As expected, Spanish-only speaking caretakerswere more likely to consume viandas (i.e., starchy root or non-root vegetables) which are a traditional component of the PuertoRican and Dominican Republic diet. Spanish-only speaking care-takers and their children were less likely to consume yogurt which isnot a typical food in the Puerto Rican and/or Dominican Republicdiet. In addition Spanish speakers had a lower frequency ofconsumption of fruit juices/drinks. These findings suggest thatacculturation may have a significant influence on the food andnutrition knowledge, attitudes and behaviors of individuals fromthe Hispanic Caribbean living in the Continental USA. BecauseSpanish-only speakers had a lower socio-economic status thantheir English speaking counterparts it is possible that poverty isalso associated with some of these results although, contrary tothe findings, the expectation was for English speakers, who werewealthier, to have had overall better nutrition knowledge andattitudinal outcomes.

These findings call for the development of culturally-appro-priate bilingual nutrition education initiatives that address thechild directly and indirectly through their caretakers. To be ableto develop these, it is important to understand the main channelsthrough which the target audience receives or can receive nutri-tion information. Survey respondents indicated that the principalchannels of nutrition information were: family/friends, followedby doctor's office, WIC program, television, and magazines. TheADA Nutrition Trends survey (1998) found that the top fivechannels through which Americans receive food/nutrition informa-tion are: television, magazines, newspapers, family or friends,and books. Television was considered a "very valuable" sourceof nutrition information by only 24% of respondents. In fact,the public considered dietitians/nutritionists, doctors, specialty

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


magazines, and women's magazines to be the most valued sourcesof nutrition information. The ADA survey findings are in generalagreement with a representative survey conducted in the UnitedKingdom (Buttriss, 1997). The fact that doctor's office and WICwere important sources of nutrition information in our's but notin other surveys, is likely to be due to the nature of our samplewhich consisted mostly of low income mothers of young children.

Level of acculturation must be taken into account whenselecting language, message content, media outlets and othersources to deliver public health nutrition information (Lefebvreet al., 1995; Perez-Escamilla and Himmelgreen, 1999; Siegeland Doner, 1998). In this study Spanish-only speakers weresignificantly less likely to receive nutrition information throughfamily or friends. It is possible that this subgroup has beenresiding for a shorter period of time in the USA and needs torely more on culturally competent information from sourcesother than kinship to learn to adopt desirable health behaviors.

ACKNOWLEDGMENTS

This project represents a partnership between the University of Connecticut,Storrs and the Hispanic Health Council, Hartford, Conn., in collaboration withthe Connecticut Children's Medical Center, Hartford Hospital, and the StateDepartment of Social Services. Funded by the US Department of AgricultureFood Stamp Program through a Family Nutrition Program grant to the Uni-versity of Connecticut and by a grant from the Storrs Agricultural ExperimentStation (SAES) to Rafael Perez-Escamilla. This is contribution No. 1985 fromSAES. We are very grateful to Maria Diaz, Arelys Pedraza, and Jocelyn Cruzfor conducting interviews. We thank Ann M. Ferris, Ph.D., R.D. for her supportto this project. This work is dedicated to the memory of Carmen Santacruzde Costas.

REFERENCES

Aguirre-Molina, M. and C.W. Molina (1994). Latino populations: Who arethey? In C.W. Molina and M. Aguirre-Molina. (eds.), Latino health in theUS: A growing challenge. American Public Health Association, WashingtonD.C., pp. 3-22.

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


American Dietetic Association (accessed December 16, 1998). The AmericanDietetic Association 1997 Nutrition Trends Survey. Key findings. Availableat http://www.eatright.org/pr/press090397d.html.

Axelson, M.L., T.L. Federline and D. Brinberg (1985). A meta-analysis of food-and nutrition-related research. J. Nutr. Educ., 17, 51-54.

Black, S.A. and K.S. Markides (1993). Acculturation and alcohol consumptionin Puerto Rican, Cuban-American, and Mexican-American women in theUnited States. American Journal of Public Health, 83, 890-893.

Borah-Gidens, J. and G.A. Falciglia (1993). A meta-analysis of the relation-ship in food preferences between parents and children. J. Nutr. Educ.,25, 102-108.

Bradbard, S., E.F. Michaels, K. Fleming and M. Campbell (May 30, 1997).Understanding the food choices of low income families. Lisboa Associates,Inc., Washington D.C.

Bronner, Y.L. (1996). Nutritional status outcomes for children: ethnic, cultural,and environmental contexts. J. Am. Diet. Assoc., 96, 891-903.

Brunner, I., I. White, M. Thorogood, A. Bristow, D. Curie and M. Marmot(1997). Can dietary interventions change diet and cardiovascular risk fac-tors? A meta-analysis of randomized controlled trials. Am. J. Public Health,87, 1415-1422.

Buttriss, J.L. (1997). Food and nutrition: attitudes, beliefs, and knowledge inthe United Kingdom. Am. J. Clin. Nutr., 65(Suppl.), 1985S-1995S.

Byers, T., R. Mullis, J. Anderson, L. Dusenbury, R. Gorsky, C. Kimber,K. Krueger, S. Kuester, A. Mokdad, G. Perry and C.A. Smith (1995). Thecosts and effects of a nutritional education program following work-sitecholesterol screening. Am. J. Public Health, 85, 650-655.

Caliendo, M.A., G. Booth and P. Moser (1982). Iron intakes and serum ferritinlevels in developmentally delayed children. An assessment of maternalknowledge and attitudes. J. Am. Diet. Assoc., 81, 401-406.

Cobas, J.A., H. Balcazar, M.B. Benin, V.M. Keith and Y. Chong (1996). Accul-turation and low-birthweight infants among Latino women: a reanalysis ofHHANES data with structural equation models. Am. J. Public Health, 86,394-396.

Colavito, E.A., J.F. Guthrie, A.A. Hertzler and R.E. Webb (1996). Relation-ship of diet-health attitudes and nutrition knowledge of household mealplanners to the fat and fiber intakes of meal planners and preschoolers.J. Nutr. Educ., 28, 321-329.

Contento, I.R., C. Basch, S. Shea, B. Gutin, P. Zybert, J.L. Michela and J. Rips(1993). Relationship of mothers' food choice criteria to food intake ofpreschool children: Identification of family subgroups. Health Educ. Quar-terly, 20, 243-259.

Cotugna, N., A.F. Subar, J. Heimendinger and L. Kahle (1992). Nutrition andcancer prevention knowledge, beliefs, attitudes, and practices: the 1987National Health Interview Survey. J. Am. Diet. Assoc., 92, 963-968.

Fink, A. (1995). How to design surveys. SAGE publications, Thousand Oaks, CA.

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


Foerster, S.B., J. Gregson, D.L. Beall, M. Hudes, H. Magnuson, Livingston,M.A. Davis, A.B. Joy and T. Garbolino (1998). The California children's 5a Day-Power Play! Campaign: Evaluation of a large-scale social marketinginitiative. Family and Community Health, 21, 46-66.

Guendelman, S. and B. Abrams (1995). Dietary intake among Mexican-American women: generational differences and a comparison with whitenon-Hispanic women. Am. J. Public Health, 85, 20-25.

Haldeman, L., R. Pérez-Escamilla, A. Ferris, L. Drake, D. Himmelgreen,H. Bonello, A. González, S. Segura-Millán, I. Méndez, A. Bermúdez andN. Romero-Daza (2000). Development of a color-coded food label forlow literacy Latino caretakers. J. Nutr. Educ., 32, 152-160.

Harnack, L., G. Block, A. Subar, S. Lane and R. Brand (1997). Association ofcancer prevention-related nutrition knowledge, beliefs, and attitudes tocancer prevention dietary behavior. J. Amer. Diet. Assoc., 97, 957-965.

Hunt, M., G. Sorensen and J. Hebert (1993). Impact of worksite cancer pre-vention program on eating patterns of workers. J. Nutr. Educ., 25, 236-244.

Hyman, D.J., D.G. Simons-Morton, K. Ho, J.K. Dunn and D.S. Rubovits(1993). Cholesterol-related knowledge, attitudes, and behaviors in a low-income, urban patient population. Am. J. Prev. Med., 9, 282-289.

Interagency Board for Nutrition Monitoring and Related Research (1995).Third report on nutrition monitoring in the United States, Vol. 1. WashingtonDC: US Government Printing Office, p. 219.

Jekel, J.F., G.E. Elmore and D.L. Katz (1996). Epidemiology biostatistics andpreventive medicine. Saunders, Philadelphia PA, pp. 159-165.

Kaplan, M. and G. Marks (1990). Adverse effects of acculturation: psycho-logical distress among Mexican-American young adults. Social Science andMedicine, 31, 1313-1319.

Kirby, S.D., T. Baranowski, K.D. Reynolds, G. Taylor and D. Binkley (1995).Children's fruit and vegetable intake: socioeconomic, adult-child, regional,and urban-rural influences. J. Nutr. Educ., 27, 261-271.

Kunzt, A.E., F. Groenhof, O. Andersen, J.K. Borgan, G. Costa, G. Desplanques,H. Filakti, M.R. Giraldes, F. Faggiano, S. Harding, D. Vågerö, T. Valkonenand J.P. Mackenbach (1999). Occupational class and ischemic heart diseasemortality in the United States and 11 European countries. Am. J. PublicHealth, 89, 47-53.

Langenhoven, M.L., J.E. Rossouw, P.L. Jooste, D.O. Chalton, A.S. Swanepoel,L.J. Rossouw, P.C. Jordaan and M. Steyn (1991). Change in knowledge ina coronary heart disease risk factor intervention study in three communities.Soc. Sci. Med., 33, 71-76.

Lefebvre, C., D. Lurie, L. Goodman, L. Weinberg and K. Loughrey (1995).Social marketing and nutrition education: Inappropriate or misunderstood?J. Nutr. Educ., 27, 146-150.

Lin, B.H., J. Guthrie and J.R. Blaylock (1996). The diets of America's children:influence of dining out, household characteristics, and nutrition knowledge.Economic Research Service/USDA, pp. 1-37.

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


Marin, G., E. Perez-Stable and B. Vonoss Marin (1989). Cigarette smokingamong San Francisco Hispanics: the role of acculturation and gender. Am. J.Public Health, 79, 196-198.

Morton, J.F. and J.F. Guthrie (1997). Diet-related knowledge, attitudes andpractices of low-income individuals with children in the household. FamilyEconomics and Nutr. Rev., 10, 2-16.

Patterson, R.E., A.R. Kristal and E. White (1996). Do beliefs, knowledge, andperceived norms about diet and cancer predict dietary change? Am. J. PublicHealth, 86(10), 1394-1400.

Pérez-Escamilla, R., D. Himmelgreen, S. Segura-Millán, A. González, I. Méndezand L. Haldeman (1999). Knowledge of folic acid and neural tube defectsamong inner-city residents: Have they heard about it? J. Am. Diet. Assoc.,99, 80-83.

Pérez-Escamilla, R. and D. Himmelgreen (1999). Promoting better nutrition ininner-city Hartford: The iSalud! Social marketing campaign. Storrs andHartford, Conn.: University of Connecticut. Connecticut Family NutritionProgram Technical Report no. 2.

Pérez-Escamilla, R., D. Himmelgreen and A. Ferris (1997). Community nutri-tional problems among Latino children in Hartford. Storrs and Hartford,Conn.: University of Connecticut. Connecticut Family Nutrition ProgramTechnical Report no. 1.

Perry, C.L., D.B. Bishop, G. Taylor, D.M. Murray, R.W. Mays, B.S. Dudovitz,M. Smyth and M. Story (1998). Changing fruit and vegetable consumptionamong children: the 5-a-day power plus program in St. Paul, Minnesota.Am. J. Public Health, 88, 603-609.

Rassin, D.K., K.S. Markides, T. Baranowski, C.J. Richardson, W.D. Mikrut andD.E. Bee (1994). Acculturation and the initiation of breastfeeding. Journalof Clinical Epidemiology, 47, 739-746.

Reger, B., M.G. Wootan, S. Booth-Butterfield and H. Smith (1998). 1% orless: a community-based nutrition campaign. Public Health Reports, 113(5),410-420.

Shea, S., A.D. Stein, C.E. Basch, R. Lantigua, C. Maylahn, D.S. Strogatz andL. Novick (1991). Independent associations of educational attainment andethnicity with behavioral risk factors for cardiovascular disease. Am. J.Epidemiol., 134, 567-582.

Siegel, M. and L. Doner (1998). Marketing public health: Strategies to promotesocial change. Aspen Publishers, Inc., Gaithersburg, MD.

Sorensen, G., A. Stoddard, K. Peterson, N. Cohen, M.K. Hunt, E. Stein,R. Palombo and R. Lederman (1999). Increasing fruit and vegetable con-sumption through worksites and families in the Treatwell 5-a-Day Study.Am. J. Public Health, 89(1), 54-60.

SPSS Inc. (1996). SPSS for Windows: version 7. SPSS Inc., Chicago IL.Stephenson, M.G., A.S. Levy, N.L. Sass and W.E. McGarvey (1987). 1985

NHIS findings: nutrition knowledge and baseline data for the weight-lossobjectives. Public Health Rep., 102, 61-67.

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5


Stern, M., J. Pugh, S. Parten and H. Hazuda (1982). Knowledge, attitudes andbehaviors related to obesity and dieting in Mexican-Americans and Anglos:the San Antonio Heart Study. Am. J. Epidemiol. 115, 917-927.

Tepper, B.J. and R.M. Nayga (1996). Awareness of the link between bonedisease and calcium intake is associated with higher dietary calcium intakein women aged 50 years and older: Results of the 1991 CSFII-DHKS.J. Amer. Diet. Assoc., 98, 196-198.

US Department of Agriculture (1992). Food Guide Pyramid: A guide to dailyfood choices. US Department of Agriculture, Human Nutrition InformationService, Washington, D.C., Home and Garden Bulletin No. 232.

US Department of Health and Human Services (2000). Healthy People 2010(Conference Edition, in Two Volumes). Washington, D.C., January.

Variyam, J.N., J. Blaylock and D.M. Smallwood (1996). Modeling nutritionknowledge, attitudes, and diet-disease awareness: the case of dietary fibre.Stat. Med., 15, 23-35.

Vega, W.A., J.F. Sallis, T. Patterson, J. Rupp, C. Atkins and P.R. Nader (1987).Assessing knowledge of cardiovascular health-related diet and exercisebehaviors in Anglo- and Mexican-Americans. Prev. Med., 16, 696-709.

Wechsler, H., C.E. Basch, P. Zybert and S. Shea (1998). Promoting the selec-tion of low-fat milk in elementary school cafeterias in an inner-city Latinocommunity: evaluation of an intervention. Am. J. Public Health, 88(3),427-433.

Zive, M.M., G.C. Frank-Spohrer, J.F. Sallis, T.L. McKenzie, J.P. Elder, C.C.Berr, S.L. Broyles and P.R. Nader (1998). Determinants of dietary intakein a sample of white and Mexican-American children. J. Amer. Diet. Assoc.,98, 1282-1289.

Dow

nloa

ded

by [

Uni

vers

ity o

f So

uth

Flor

ida]

at 0

9:27

07

May

201

5

Documents

Nutrition knowledge, attitudes, and behaviors among Latinos in the USA: Influence of language