Type 2 diabetes is a costly chronic illness that is increasing in prevalence and associated with significant health problems, including heart disease.1  Furthermore, type 2 diabetes and heart disease share multiple lifestyle risk factors that tend to co-occur for many adults.2 

Research has established the health benefits of adopting Mediterranean-style eating practices,3  engaging in physical activity,4,5  managing stress,6,7  and using social-environmental support to initiate and sustain health-related behaviors.810  Nevertheless, multiple–risk-factor intervention studies are rare11-13  and sorely needed, particularly to understand their potential to reach and benefit underserved populations.

Multiple-behavior–change interventions appear necessary in light of the co-occurrence of risk factors,2  yet they are complex and demanding for both service providers and patients. Providers must have multiple competencies or the resources to assemble an interdisciplinary team with expertise in nutrition, exercise, smoking cessation, stress management, and motivational strategies. They must weigh the costs and benefits of sequential and simultaneous approaches to changing multiple behaviors, although thus far, those approaches seem to produce comparable effects.14  Patients must comprehend many intervention methods and devote sufficient effort to each.

The purpose of this article is to describe the structure and content of the Mediterranean Lifestyle Program (MLP) and its results during 7 years of assessments, as well as a cultural adaptation of the MLP for Latinas (¡Viva Bien!) that was offered to members of a large health maintenance organization (HMO) and a community health center in the Denver, Colo., metropolitan area and its results during 2 years of evaluation. The adaptation of the MLP into ¡Viva Bien! was intended to expand the generalizability of the intervention and to test its application in collaboration with health organizations, two important steps in developing an intervention that can be disseminated broadly.

The MLP is a multiple-behavior–change intervention that was evaluated initially with a predominantly European American sample of 279 postmenopausal women with type 2 diabetes in Lane County, Ore.15  Because postmenopausal women with diabetes are at particularly high risk for heart disease, the MLP had the joint goals of reducing the risk for heart disease and improving the self-management of diabetes.

The program was modeled on intervention procedures that were found to be effective in reducing heart disease risk in middle-aged men11  and with women in the Women's Lifestyle Heart Trial.12  After an intense 6-month intervention period, the MLP extended intervention activities for an additional 18 months with the goal of improving the maintenance of its initial beneficial effects. The MLP is unique among diabetes lifestyle interventions in that it provides an intense, multi-component intervention intended to improve a number of outcomes, including those with special relevance to heart disease.

The conceptual model underlying the MLP specified four content areas that corresponded to diabetes and heart health risk factors: insufficient physical activity, unhealthful diet, unmanaged stress, and lack of social support. Hour-long segments of intervention sessions were devoted to each content area. Because of the small number of smokers enrolled in the MLP (and ¡Viva Bien!), individualized assistance was provided for smoking cessation.

Social cognitive theory guided behavior change in the MLP and ¡Viva Bien! Intervention sessions were action oriented, including modeling of target behaviors and practice in performing those behaviors. Sessions were primarily group occasions for exercising, reducing stress, eating healthfully, providing and receiving social support, and observing peers who were doing the same. Limited time was devoted to didactics. Women received rewards for behavior change, largely in the form of recognition from staff and fellow participants and occasionally in the form of inexpensive prizes and certificates. Within this conceptual framework, intervention activities were hypothesized to have a crucial proximal effect on self-efficacy, problem solving, and social support—general psychological assets that would aid in improving physical activity, healthful eating, stress reduction, and smoking cessation.

The MLP's efficacy was evaluated in a clinical trial that randomly assigned 279 women to either usual care (UC) from their existing health providers (n = 116) or usual care plus the MLP (n = 163). All participants were recruited from the primary care practices where participants received their medical care for diabetes. Fifty-one percent of the confirmed eligible primary care patients who were contacted began the program. At baseline, participants had an average BMI exceeding 35 kg/m2 and a mean age of 61 years (range 39–74), and 94% were non-Hispanic whites.

Participants in the UC condition continued with their regular medical care and did not receive any of the MLP intervention activities. UC was directed at diabetes control, management of diabetes complications, and monitoring of other health factors such as cholesterol and hypertension.

Participants assigned to the MLP condition began with a 2½-day non-residential retreat, during which the women were introduced to staff members and to each other, heard inspirational testimonials, and received an overview of all program components. The intensity of the retreat was designed to signal a distinct beginning to lifestyle change, elevate belief in the possibility of change, and build solidarity.

The retreat was followed by weekly 4-hour meetings throughout a 6-month period. Weekly meetings devoted 1 hour to each of the four components: physical activity, stress management, a Mediterranean Diet–style potluck, and support groups. An exercise physiologist, stress management leader, and support group leader were present at every program meeting. Sessions were conducted at a research site that had facilities for preparing foods, a large floor for conducting exercise and stress-management activities, and small rooms for support group meetings.

Motivational techniques such as contests, self-monitoring, and group and individual rewards were used to encourage attendance. Small incentives (candles, refrigerator magnets, and pins) were given to women for recording adherence to program components. In addition, $100 cash prizes were given for excellent attendance. Of all the motivational techniques used, we believe the most effective was telephone calls from support group leaders and other group members when participants missed meetings.

Dietary practices. A registered dietitian taught participants about the Mediterranean-style alpha-linolenic acid–rich diet.3  The diet recommended more whole-grain bread; more root vegetables, green vegetables, and legumes; more fish and poultry; less red meat; daily fruit; and avoidance of butter and cream, which was to be replaced by olive and canola oil products. For the weekly meetings, participants brought dishes to share in potluck style. Meals were occasions to receive feedback on food preparation and portion control. Participants were asked intermittently to complete and bring to the weekly meetings a simple self-monitoring log of their adherence to components of the Mediterranean diet.

Physical activity. Participants were advised to build up to 1 hour of moderate aerobic activity per day, at least 3 days per week. They were encouraged to engage in a variety of physical activities, but walking was recommended for most. At the retreat and weekly meetings, participants could choose between 1-hour aerobic sessions led by an exercise physiologist or an outdoor walk led by trained exercise assistants. Resistance training was also included. Women used exercise bands and dumbbell weights at the retreat and weekly meetings and were given a set to take home. Details of the physical activity recommendations were described and illustrated in the program guidebook and on a take-home exercise video.

Stress management. Participants were instructed in yoga, progressive deep relaxation, meditation, and directed or receptive imagery.11,16  Stress-management leaders were certified yoga instructors. Participants were asked to practice the techniques for at least 1 hour per day and were provided videotapes for home use.

Support groups. One professional with at least master's degree–level training in counseling psychology and one peer leader led each support group. Professional and peer leaders received extensive training in the supportive-expressive group therapy model used with the chronically and terminally ill.17  A clinical psychologist who was a research project staff member provided weekly supervision to group leaders.

Maintenance procedures: 6–24 months. After the first 6 months of the intervention, MLP participants were further randomized either to continue with group meetings (39 meetings spread during the next 18 months led by lay leaders) or to a personalized support-enhancement condition, which met just four times. The personalized-support condition used an interactive computer program designed to support improvements in the lifestyle behaviors acquired during the first 6 months. However, analyses of follow-up data revealed no meaningful differences between the two maintenance conditions, so they were combined and compared to the UC condition in all statistical analyses.

Program participation

Through the first 24 months of the project, 85% (237 of 279) of participants were retained. Retained participants and dropouts were comparable on almost all baseline characteristics (data not shown). Compared to those retained, dropouts were somewhat younger at initial diagnosis, had taken medications longer, and were more likely to be employed.

Attendance at weekly sessions through the first 6 months was moderate. Of the 23 total meetings, the mean number of sessions attended was 12.4 (range 0–20, SD 5.7).

In the maintenance phase from 6 to 24 months, 39 meetings were offered to those assigned to the support group condition. Those participants attended a mean of 19.4 sessions (range 0–38, SD 13.2). Of the four in-person sessions offered to those in the computer-assisted personalized condition, participants completed a mean of 2.5 sessions (range of 0–4, SD 1.8). There was no strong dose-response relationship between program attendance and outcomes, although attendance was significantly related to physical activity at 6 months (r = 0.31, P = 0.01). MLP participants who completed a satisfaction survey were well satisfied with the program overall, providing a mean rating of 4.22 (SD 0.94) on a 5-point scale, with 5 indicating greatest satisfaction.

Intervention outcomes

Participants were assessed on a battery of measures at baseline, after 6 months, and annually from 12 through 84 months. The effects of the MLP intervention through the first 2 years of data collection were reported in two publications.15,18  Findings from an additional 5-year follow-up period (7 years total) also have been reported.19 

Tests were conducted to determine whether the MLP intervention improved the proximal constructs of social support, self-efficacy, and problem solving. Compared to UC, the MLP significantly improved (effect sizes in parentheses) problem solving at 6 months (0.27), 24 months (0.16), and 48 months (0.16); self-efficacy at 6 months (0.35) and 24 months (0.43); and overall perceptions of social support at 6 months (0.67) and 12 months (0.43). There were no additional intervention effects beyond those assessment periods.

At the 6-, 12-, and 24-month assessments, the MLP intervention reduced participants' percentage of calories from saturated fat (effect sizes of 0.67, 0.67, and 0.33, respectively) and increased physical activity (effect sizes of 0.67, 0.47, and 0.41, respectively). Analyses showed a beneficial intervention effect on stress-management practice at the 6-month assessment (0.66). Beneficial intervention effects on fat consumption, physical activity, and stress management were not detected after the 24-month assessment.

Compared to UC, the M L P resulted in significantly greater reductions in A1C and BMI at the 6-month assessment,20  but those effects were not found at subsequent assessments.

There were many encouraging outcomes from the MLP trial. Consistent with the conceptual model, the intervention succeeded in improving the psychosocial assets of problem solving, self-efficacy, and social support that were thought to be mechanisms for improving multiple lifestyle behaviors. Also, there was good evidence that the MLP led to decreased saturated fat consumption, greater physical activity, more stress-management activity, better blood glucose control, and reduced body weight; however, those effects were limited primarily to the first 2 years of assessments. After a relatively intense 6 months of treatment, less intense intervention activities through 24 months did not result in sustained improvements beyond the termination of those efforts.

The composition of the sample was a limitation because it comprised almost exclusively European American women from the Pacific Northwest. Longer-term maintenance strategies and intervention generalizability were addressed in a subsequent project that extended the full set of intervention components to 24 months and delivered them to a sample of Latinas.

¡Viva Bien!: Extending the MLP to Latinas in a Large HMO and Community Health Center

To expand the applicability of the MLP multiple-behavior–change framework, a study was done with a sample comprising Hispanic women (Latinas) in the Denver, Colo., metropolitan area. Participants were drawn from a large HMO and a community health center that served low-income families.

Latinas have a greater prevalence of type 2 diabetes and more diabetes complications than non-Hispanic whites.21  Studies controlling for socioeconomic status have found reduced disparities for some health outcomes but not for diabetes in Latinos.22,23 

Cultural adaptation

Extending the MLP to Latinas called for the cultural adaptation of the intervention. Procedures for modifying evidence-based interventions to increase engagement and efficacy with subcultural groups are growing in both sophistication and standardization.24  We adopted a conservative approach to adaptation by maintaining the core elements of the MLP and only modifying features when there was evidence from our focus groups or pilot testing indicating that alterations would improve the appeal and cultural fit.25 

At the same time, the participatory nature of the intervention ensured that participants would be able to incorporate intervention elements into their unique social-ecological environments. For example, modifications were made to the Mediterranean-style diet by giving participants opportunities to incorporate food staples that were consistent with MLP principles and common in Latin-American countries. Spanish-speaking staff, Spanish-language materials, Latin music during exercise sessions, and other modifications were made to make the intervention more accessible and appealing to participants.

All of the basic MLP components were maintained with the exception of support groups. We modified the supportive–expressive group therapy model used in the MLP not strictly for cultural considerations, but rather to more explicitly teach problem solving and to mobilize social support among family members, friends, and neighbors. In mediation analyses of the MLP, we had found evidence that improvements in problem solving26  and social support resources27  partially accounted for intervention effects. Support groups continued to be occasions when women could share successes and difficulties in making lifestyle changes, but those general “check-in” meetings were supplemented with structured sessions devoted to mobilization of social support outside the group and to learning basic problem-solving strategies and their application in daily living.

¡Viva Bien! results

Program participation. Procedures for recruiting 280 Latinas from a large HMO and a community health center have been reported previously.28  Of the eligible patients, 61% agreed to participate. Participants were between 55 and 60 years of age (mean 57.11, SD 10.09), had been diagnosed with diabetes for a mean of almost 10 years, were obese (mean BMI 34.3 kg/m2), and had a baseline A1C > 8%.

Participants were assigned randomly to UC through their HMO or community health center (n = 138) or to UC plus ¡Viva Bien! (n = 142). ¡Viva Bien! sessions were conducted weekly for the first 6 months, every other week for months 7–12, monthly for months 13–18, and every other month for months 19–24. Assessments were conducted at baseline and then 6, 12, and 24 months later. The same concepts reported for MLP results were assessed in ¡Viva Bien!.

For ¡Viva Bien! participants, weekly meeting attendance during the first 6 months averaged 65%, declined to 48% for meetings between 7 and 12 months, and averaged 46% for meetings between 13 and 24 months. Attrition rates were 22.5% at 6 months, 30.0% at 12 months, and 38.6% at 24 months with no significant differences between treatment conditions in attrition at any time point.

Unlike in the MLP, in ¡Viva Bien! there was a significant dose-response relationship bet ween prog ram attendance and most outcomes, including social support, use of supportive resources, adherence to the recommended diet, physical activity, stress-management practice, A1C, and 10-year coronary heart disease risk. As in the MLP, ¡Viva Bien! participants were well satisfied with the program overall, providing a mean rating of 4.38 (SD 0.54) across 48 items on a 5-point scale, with 5 indicating greatest satisfaction.

¡Viva Bien! outcomes

Consistent with the proximal effects expected of the intervention, the ¡Viva Bien! condition improved considerably more than UC at the 6-, 12-, and 24-month assessments of problem solving (respective effect sizes of 0.50, 0.50, and 0.75) and perceived support (respective effect sizes of 1.00, 0.85, and 0.75). For self-efficacy, significant intervention effects were found at the 6- and 12-month assessments (respective effect sizes of 0.46 and 0.14).

A significant intervention effect was found for participants' percentage of calories from saturated fat at the 6-, 12-, and 24-month assessments (respective effect sizes of 1.00, 0.33, and 0.33). Unlike in the MLP trial, there were no significant intervention effects for the practice of stress management or for physical activity. There were slight reductions in A1C and BMI between baseline and the 6-month assessment, but no clear intervention effects across the 24 months of assessment for the two outcome measures.

Discussion of the MLP and ¡Viva Bien!

The MLP and its cultural adaptation, ¡Viva Bien!, are multiple-behavior–change interventions that address prominent lifestyle risk factors for diabetes progression and heart disease in a high-risk, understudied population. Both interventions were successful in improving short- and medium-term psychosocial mechanisms, particularly problem solving and social support, hypothesized to be important assets for changing multiple lifestyle behaviors.

Mediational analyses of MLP data provided evidence that social support27  and problem solving26  partially mediated intervention effects on diet and physical activity. It was encouraging that both interventions succeeded in reducing the consumption of saturated fat through the first 2 years of the programs.

The MLP was effective in increasing physical activity through the first 2 years, but ¡Viva Bien! did not show similar effects. It is possible that increasing physical activity is particularly difficult for Latinas and might require additional behavior-change strategies. In a review of culturally competent interventions for Latino adults with type 2 diabetes, Whittemore29  observed that interventions have been more successful in improving diet than physical activity and that intervention engagement and participation have been modest. Those observations mirror the results for ¡Viva Bien! There is more work to be done on ¡Viva Bien! to refine the adaptation and strengthen its impact on multiple lifestyle factors.

There is also more work to be done to develop multiple-behavior–change interventions that show sustained effects after intervention activities taper and ultimately terminate. With the possible exception of problem solving, which showed an intervention effect at the 48-month assessment in the MLP, gains made in psychosocial therapeutic mechanisms, lifestyle behaviors, and glycemic control did not persist when program sessions stopped or were reduced substantially. The various outcome variables were similar in that respect.

The next challenges for multiple-behavior–change interventions are to make modifications to decrease their cost and increase their efficiency, adoption potential, and sustainability. If there are strategies for practitioners to provide multiple-behavior intervention components efficiently, those strategies might be extended for long intervals to address the problem of maintenance, as well.

For example, it is conceivable that participants could be encouraged to implement the activities included in the 4-hour intervention sessions outside of the practice setting. Intervention components could be carried out in community recreation centers30  or at home, guided by DVDs, books, computer programs, or other media such as those produced for the MLP and ¡Viva Bien! Practitioners could serve as coordinators or coaches who would monitor progress, trouble-shoot difficulties, and provide both encouragement and accountability that would be lacking in purely self-administered interventions. Doing this on a large scale might require technologies to automate patients' reports of intervention activity and health outcomes.31  Because intervention components would be self-directed with the aid of media, technologies, and practitioner support, they could be extended for significant time periods to bolster the maintenance of multiple behavior change.

We suspect that practitioners can help patients maintain the behaviors they successfully change by sustaining contact with patients and supporting the continuation of intervention activities in some form. We plan to continue our research to develop feasible intervention methods that practitioners could adopt to improve the multiple risk factors that people with type 2 diabetes often confront.

This work was supported by grants from the National Heart, Lung, and Blood Institute (MLP: R01-HL62156 and R01-HL077120; ¡Viva Bien!: R18-HL076151). The authors have no potential conflicts of interest relevant to this article. The authors are deeply indebted to the dedicated and committed women who participated in these studies.

1.
Gaede
P
,
Vedel
P
,
Larsen
N
,
Jensen
GV
,
Parving
HH
,
Pedersen
O
:
Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes
.
N Engl J Med
348
:
383
393
,
2003
2.
Fine
LJ
,
Philogene
S
,
Gramling
R
,
Coups
EJ
,
Sinha
S
:
Prevalence of multiple chronic disease risk factors: 2001 National Health Interview Survey
.
Am J Prev Med
27
:
18
24
,
2004
3.
de Lorgeril
M
,
Renaud
S
,
Mamelle
N
,
Salen
P
,
Martin
J-L
,
Monjaud
I
,
Guidollet
J
,
Touboul
P
,
Delaye
J
:
Mediterranean alpha-linolenic acid–rich diet in secondary prevention of coronary heart disease
.
Lancet
343
:
1454
1459
,
1994
4.
Mekary
RA
,
Feskanich
D
,
Hu
FB
,
Willett
WC
,
Field
AE
:
Physical activity in relation to long-term weight maintenance after intentional weight loss in premenopausal women
.
Obesity
18
:
167
174
,
2010
5.
Elfhag
K
,
Rossner
S
:
Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain
.
Obes Rev
6
:
67
85
,
2005
6.
Rozanski
A
,
Blumenthal
JA
,
Davidson
KW
,
Saab
PG
,
Kubzansky
L
:
The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology
.
J Am Coll Cardiol
45
:
637
651
,
2005
7.
Yusuf
S
,
Hawken
S
,
Ôunpuu
S
,
Dans
T
,
Avezum
A
,
Lanas
F
,
McQueen
M
,
Budai
A
,
Pais
P
,
Varigos
J
,
Lisheng
L
,
on behalf of the INTERHEART Study Investigators
:
Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case control study
.
Lancet
364
:
937
952
,
2004
8.
White
AM
,
Philogene
GS
,
Fine
L
,
Sinha
S
:
Social support and self-reported health status of older adults in the United States
.
Am J Public Health
99
:
1872
1878
,
2009
9.
Anderson
ES
,
Winett
RA
,
Wojcik
JR
,
Williams
DM
:
Social cognitive mediators of change in a group randomized nutrition and physical activity intervention: social support, self-efficacy, outcome expectations and self-regulation in the Guide-to-Health Trial
.
J Health Psychol
15
:
21
32
,
2010
10.
Beverly
EA
,
Miller
CK
,
Wray
LA
:
Spousal support and food-related behavior change in middle-aged and older adults living with type 2 diabetes
.
Health Educ Behav
35
:
707
720
,
2008
11.
Ornish
D
,
Brown
SE
,
Scherwitz
LW
,
Billings
JH
,
Armstrong
WT
,
Ports
TA
,
McLanahan
SM
,
Kirkeeide
RL
,
Brand
RJ
,
Gould
KL
:
Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial
.
Lancet
336
:
129
133
,
1990
12.
Toobert
DJ
,
Glasgow
RE
,
Radcliffe
JL
:
Physiologic and related behavioral outcomes, from the Women's Lifestyle Heart Trial
.
Ann Behav Med
22
:
1
9
,
2000
13.
Prochaska
JJ
,
Nigg
CR
,
Spring
B
,
Velicer
WF
,
Prochaska
JO
:
The benefits and challenges of multiple health behavior change in research and in practice
.
Prev Med
50
:
26
29
,
2010
14.
Vandelanotte
C
,
Reeves
MM
,
Brug
J
,
De Bourdeaudhuij
I
:
A randomized trial of sequential and simultaneous multiple behavior change interventions for physical activity and fat intake
.
Prev Med
46
:
232
237
,
2008
15.
Toobert
DJ
,
Strycker
LA
,
Glasgow
RE
,
Barrera
M
,
Angell
K
:
Effects of the Mediterranean Lifestyle Program on multiple risk behaviors and psychosocial outcomes among women at risk for heart disease
.
Ann Behav Med
29
:
128
137
,
2005
16.
Toobert
DJ
,
Glasgow
RE
,
Nettekoven
L
,
Brown
JE
:
Behavioral and psychosocial effects of intensive lifestyle management for women with CHD
.
Patient Educ Couns
35
:
177
188
,
1998
17.
Spiegel
D
,
Classen
C
:
Group Therapy for Cancer Patients: A Research-Based Handbook of Psychosocial Care
.
New York
,
Basic Books
,
2000
18.
Toobert
DJ
,
Glasgow
RE
,
Strycker
LA
,
Barrera
M
,
Ritzwoller
DP
,
Weidner
G
:
Long-term effects of the Mediterranean lifestyle program: a randomized clinical trial for postmenopausal women with type 2 diabetes
.
Int J Behav Nutr Phys Act
4
:
1
12
,
2007
19.
Toobert
DJ
,
Strycker
LA
,
Glasgow
R
,
Barrera
M
 Jr
:
Seven-year follow-up of a multiple-health–behavior diabetes intervention
.
Am J Health Behav
34
:
680
694
,
2010
20.
Toobert
DJ
,
Glasgow
RE
,
Strycker
LA
,
Barrera
M
,
Radcliffe
JL
,
Wander
RC
,
Bagdade
JD
:
Biologic and quality of life outcomes from the Mediterranean Lifestyle Program: a randomized clinical trial
.
Diabetes Care
26
:
2288
2293
,
2003
21.
Kirk
JK
,
Passmore
LV
,
Bell
RA
,
Narayan
KMV
,
D'Agostino
RB
 Jr
,
Arcury
TA
,
Quandt
SA
:
Disparities in A1C levels between Hispanic and non-Hispanic white adults with diabetes: a meta-analysis
.
Diabetes Care
31
:
240
246
,
2008
22.
Whitfield
KE
,
Clark
R
,
Weidner
G
,
Anderson
NB
:
Sociodemographic diversity and behavior medicine
.
J Consult Clin Psychol
70
:
463
481
,
2002
23.
Saydah
S
,
Cowie
C
,
Eberhardt
MS
,
De Rekeneire
N
,
Narayan
KM
:
Race and ethnic differences in glycemic control among adults with diagnosed diabetes in the United States
.
Ethn Dis
17
:
529
535
,
2007
24.
Castro
FG
,
Barrera
M
 Jr
,
Holleran Steiker
LK
:
Issues and challenges in the design of culturally adapted evidence-based interventions
.
Ann Rev Clin Psychol
6
:
213
239
,
2010
25.
Osuna
D
,
Barrera
M
 Jr
,
Strycker
LA
,
Toobert
DJ
,
Glasgow
RE
,
Geno
CR
,
Almeida
F
,
Perdomo
M
,
King
D
,
Doty
AT
:
Methods for the cultural adaptation of a diabetes life-style intervention for Latinas: an illustrative project
.
Health Promot Pract
.
In press
26.
Glasgow
RE
,
Toobert
DJ
,
Barrera
M
,
Strycker
LA
:
Assessment of problem solving: a key to successful diabetes self-management
.
J Behav Med
27
:
477
490
,
2004
27.
Barrera
M
 Jr
,
Strycker
LA
,
MacKinnon
DP
,
Toobert
DJ
:
Social-ecological resources as mediators of two-year diet and physical activity outcomes in type 2 diabetes patients
.
Health Psychol
27
(
Suppl. 2
):
S118
S125
,
2008
28.
Toobert
DJ
,
Strycker
LA
,
Glasgow
RE
,
Osuna
D
,
Doty
TA
,
Barrera
M
 Jr
,
Geno
CR
,
Ritzwoller
DP
:
¡Viva Bien!: overcoming recruitment challenges in a multiple-risk-factor diabetes trial
.
Am J Health Behav
34
:
432
441
,
2010
29.
Whittemore
R
:
Culturally competent interventions for Hispanic adults with type 2 diabetes: a systematic review
.
J Transcultural Nurs
18
:
157
166
,
2007
30.
Ackermann
RT
,
Finch
EA
,
Brizendine
E
,
Zhou
H
,
Marrero
DG
:
Translating the Diabetes Prevention Program into the community: the DEPLOY pilot study
.
Am J Prev Med
35
:
357
363
,
2008
31.
Glasgow
RE
,
Bull
SS
:
Making a difference with interactive technology: considerations in using and evaluating computerized aids for diabetes self-management education
.
Diabetes Spectrum
14
:
99
106
,
2001