1. Mindy Gray
George Washington University
POLICY BRIEF
Place Photo Here,
Otherwise Delete Box
July 8 2013
Health Disparities Among
Hispanics in Loudoun County,
Virginia

2. AS OF 2010, HISPANICS & LATINOS ACCOUNTED FOR ABOUT 12% OF LOUDOUN
COUNTY’S POPULATION.
Between 2000 and 2010, the population of Hispanics in Loudoun County increased from 10,089
to 38,576, representing a 282.4% increase of this population. Loudoun County, as a whole, has
shown an 84.1% increase in the number of residents in the last decade, and is currently the fifth
fastest growing county in the United States (“Loudoun county 2010,” 2011). Hispanics make up
the second fastest growing population in the region, and, according to Doctor David Goodfriend,
Director of the Loudoun County Health Department, many of these Hispanic individuals are
recent immigrants to the area. Most of Loudoun County’s growth, writes Gibson (2011) is
concentrated in the eastern areas, particularly in Sterling, where the “percentage of Hispanics
has risen from 11 percent to 33 percent” in the last ten years. The distribution by county can be
seen below.
Mindy Gray
George Washington University
BACKGROUND
July 8 2013
(“Loudoun county race,”
2011)

3. THE HISPANIC POPULATION CONTINUES TO GROW
Gibson explains that the Hispanic population tripled to over 38,000 residents in the last ten years
(Gibson, 2011). This has been particularly reflected in school enrollments; in 2000, 78% of
Loudoun students were non-Hispanics but in 2010, this number fell to 61% (Gibson, 2011). As a
result, by 2019, it is expected that Loudoun County would need 21 additional schools to
accommodate this growing population. Additionally, many schools have had to adapt to non-
English speakers. Sugarland Elementary School in Sterling created a program called Sheltered
Instruction Observation Protocol, or SIOP,an initiative funded by the U.S. Department of
Education, Gibson explains (2010). The program was designed to assist non-English speaking
students to succeed in school. Unfortunately, Sugarland Elementary is the only school to
implement such a program and its teachers are the only adults trained in this type of
education in the area. Sugarland’s enrollment is 59% Hispanic students (Gibson, 2010).
Between 2000 and 2010, the number of students learning English as a second language in
Loudoun County increased from 506 to 5191 (Gibson, 2010). It is expected that Hispanic
population will continue to grow, continuing to make up a large percentage of Loudoun County
in future years. So far, the school has seen better outcomes not just for non-English speaking
students, but Angela Robinson, the school’s principal said that they “started to see all kids do
better” (Gibson, 2011). In 2009, 91% of Hispanic third graders passed their state history test.
The year prior, this statistic was 78%, says Gibson (2011).
There are clearly benefits to the SIOP program, and expanding the curriculum to incorporate
healthy eating habits, the importance ofphysical activity, and including the students’
families, who may not speak English, in this learning can potentially create a generation of
minority students who have the knowledge to make better health decisions. They also have
the benefit of speaking more than one language, which is an asset to providing education to
others in severalways. The children can come home with this knowledge about making healthy
decisions and can teach their family members, in their native languages, what they learned
through their program. Empowering these children to make an impact on their family’s health,
even at such a young age,can tremendously impact the future of Loudoun County.
“THESE KIDS
ARE NOT
WITHOUT
KNOWLEDGE;
THEY’RE
WITHOUT
LANGUAGE”
- Angela Robinson, Principal
of Sugarland Elementary
School
Doctor David Goodfriend is the director of the Loudoun
County Health Department. His office, located in Leesburg,
Virginia, operates under the Virginia State Department of
Health. His office is responsible for performing health
assessments across Loudoun County, and the county is
currently preparing for this year’s public health assessment.
Doctor Goodfriend mentioned that Hispanic population in
Loudoun County tends to be younger in age (personal
communication, July 2, 2013).

4. Across the United States, minorities, as a whole, have a “higher prevalence of
diabetes, strokes, and other largely preventable diseases and conditions than
their white counterparts” (Bahls, 2011). Since 2007, writes Bahls, inpatient care
for Hispanics and Latinos with heart failure has gotten worse, which is
perpetuated by “socioeconomic, language, and cultural barriers” that contribute
to more hospital admissions and poorer health outcomes (2011). Hispanics and
Latinos historically have had lower health coverage rates than whites, a finding
that was confirmed by Doctor Goodfriend of the Loudoun County Health
Department. The Loudoun County Free Clinic is available for Loudoun County
residents who have a household income “at or below 200% of the federal
poverty level” (“Loudoun county free,” 2009). Doctor Goodfriend said that
many of the patients that are seen at the clinic are minorities, and many
Hispanic families visit the clinic for services that the clinic provides. These
families can obtain services for children’s dental, family planning, STD
screening, communicable disease services (personal communication, July 2,
2013), as well as diagnostic and laboratory testing, referrals, and education and
nutrition classes (“Loudoun county free,” 2009). Unfortunately, according to
Loudoun County’s Free Clinic website, they have only eight paid full-time
staff, five paid part-time staff, and mostly rely on volunteers that “provide
care for more than 15oo patients” (“Loudoun country free,” 2009). The
population of Loudoun County is expected to reach over 405,000 by 2020; it is
difficult to see howa small staff will be able to accommodate such a large
population, especially when the number of Hispanic citizens is expected to
continue to increase disproportionately. Goodfriend believes that Hispanics
have less access to care, confounded by language barriers and an adaptation to a
new culture. However, the local government has been unable to identify exactly
why Hispanics are so underrepresented (personal communication, July 2,
2013).
DISPARITIES IN THE HISPANIC POPULATION
ARE PREVALENT ACROSS THE UNITED
STATES
“LOUDOUN COUNTY
IS NOT A STABLE
COMMUNITY”
- Doctor David Goodfriend, Director of
the Loudoun County Environmental
Health Department
The Hispanic and Latino culture is very diverse,
making up individuals from several countries,
including Cuba, Mexico, Puerto Rico, the
Dominican Republic, South or Central America, or
“other Spanish cultures regardless of race” (Perez-
Edcamilla & Putnik, 2007). Doctor Goodfriend has
identified that many of Loudoun County’s
Hispanics are from South and Central America
(personal communication, July 2, 2013).

5. IN LOUDON COUNTY, MORBIDITY& MORTALITY RATES ARE NOTREPRESENTATIVE OF THE
POPULATION
Doctor David Goodfriend discussed the fact that much of the mortality data from recent years represents those who were long-term
residents of Loudoun County. He reported that the data was lacking for recent immigrants, because this population has seen a greater
influx in the last few years; therefore, the causes of mortality specifically for the younger Hispanic population “won’t show up in current
mortality rates, but thirty years from now, it will” (Dr. David Goodfriend, personal communication, July 2, 2013). Dr. Goodfriend
identified one potential issue: when Central and South American individuals migrate to areas like Northern Virginia, they change their
diets very quickly and significantly, increasing their risk for obesity and cardiovascular problems. One challenge is determining howto
incorporate statistics other than mortality and morbidity rates (personal communication, July 2, 2013).
Currently, the number one cause of death in Loudoun County is a result of malignant neoplasms (cancer) (“Loudoun county, Virginia,”
2009) These deaths make up 26.57% of deaths in the region. Heart and cardiovascular disease rank number two, but this number is
believed to be greater, says Dr. Goodfriend. Inaccurate data is a result of an unstable community (Dr. Goodfriend, personal c ommunication,
July 2, 2013) and as a result of the use of convenience surveys, the predominant way in which Loudoun County o btains its health data. The
county does not currently have the financial resources to more accurately collect data. The local health department found that Whites,
women, parents, English speakers, and those of higher incomes responded through “open-ended community surveys,” the way in which Dr.
Goodfriend reports that health data was collected (personal communication, July 2, 2013). State delegator Kenneth Plum reported in 2013,
that Northern Virginia’s major health issues were a result of “tobacco use, poor diet and exercise, abuse of alcohol and drugs, firearms, and
motor vehicles” (Plum, 2013). Loudoun County must address the way in which it collects its data to ensure its numbers and statistics
are accurate and reflect the true diversity and health needs of the community.
(“Loudoun county, Virginia,” 2009)

6. The traditional Hispanic diet generally consists of foods with less total fat and more fiber when compared to US diets, and,
according to Mercado & Fileti (2010) Hispanics in their home country typically eat a variety of vegetables, starches,fruits,
beans, seeds and nuts. “The quality of the Hispanic diet has been shown to decline as US habits are acquired,” (Mercado &
Fileti, 2010). Because many Hispanics families also fall below the poverty line, they must resort to inexpensive food
choices; Hispanic families often choose fast food, as a quick and inexpensive way to access food. According to Fryar &
Ervin, Hispanics between the ages of 20 and 39 got 14.5% of their caloric intake from fast food (2013).
Loudoun County does not currently have any Hispanic or Latino supermarkets,limiting the availability of
indigenous foods that Hispanic immigrants have access to. This forces the Hispanic citizens to acculturate quickly,
especially if they are used to cooking with ingredients that are not found in the United States,or at least not in the local
region.
The Office of Minority Health, an agency within the Centers for Disease Control and Prevention, has reported that
socioeconomic factors,lifestyle behaviors, social environment, and access to preventive health-care services all work
together to contribute to racial and ethnic health disparities. Education has been correlated with health risks, such as
obesity, lack of physical activity, and smoking; furthermore, recent immigrants in general have an increased risk,
according to the Office of Minority Health, “for chronic disease and injury, particularly those who lack fluency in English
and familiarity with the U.S. health-care system” (“Health disparities experienced,” 2004).
“JUST 40.7%OF HISPANICS SAID
THEIR BLOOD PRESSURE WAS UNDER
CONTROL”
- Centers for Disease Control & Prevention
WHAT IS ACCULTURATION?
Mansfield, Peugh, Torres & Wells (2010) define acculturation as “the process by which individuals of one cultural group, typically a
minority group, adapt their culture of origin to the culture of another group.” This can affect “language preference, the ado ption of
attitudes, values, customs, beliefs, and behaviors of another culture” (Mansfield et al, 2010). As Doctor Goodfriend mentioned, (personal
communication, July 2, 2013) Hispanics are acculturating very quickly and drastically into the Northern Virginia lifestyle, which is
associated with “increased fat intake, decreased fiber intake and less physical activity,” leading to a potentially increased risk for chronic
diseases (Dave et al, 2010). Loudoun County can assist the Hispanic community by assessing the degree in which families are
acculturating and determining nutritional values and attitudes, while educating the Hispanic population on proper nutrition and
can offer community outreach programs to educate this population.
Health fairs can incorporate healthy eating
tips for Hispanics, and volunteers and staff
members of the Loudoun Free Clinic can be
educated on foods common in Hispanic
culture. Clinic staff must be trained on
providing culturally sensitive care and, if
possible, providers who are Spanish-
speakers should be available to create
relationships with patients.

7. INADEQUATE NUTRITION & LANGUAGE AS BARRIERS TO CARE
Gwynn & Gwynn have found that the greatest nutritional concerns amongst Hispanics in the United States is related to “the exc essive
consumption of calories, probably accompanied by low physical activity” (n.d.). In particular, individuals immigrating from Mexico have
been found to have higher deficiencies in vitamin A, folic acid, vitamin C, iron, and calcium (Gwynn & Gwynn, n.d.). The research has
also shown that Hispanic women have a greater risk for obesity, write Gwynn & Gwynn (n.d.). Furthermore, studies have found that
Mexican Americans are two to four times more likely to have non-insulin dependent diabetes, and are more likely to suffer from
cardiovascular illness. The Centers for Disease Control and Prevention found that 26.1% of Hispanics in the United States have high
blood pressure, and of this population, 30.4% are not “taking a medication that could reduce their risk for heart attack and stroke”
(“Cardiovascular disease is,” 2013). The CDC has created educational resources to assist the Hispanic population in taking control of
their heart health, which are available through the CDC and the “Million Hearts Campaign.” Unfortunately, many Spanish-speaking
constituents would unlikely be able to visit the CDC’s website and access these publications without the appropriate translation.
Furthermore, much of the CDC’s advice encourages patients to speak with their primary care physicians about what kind of trea tment
plan should be put in place; if a Hispanic patient relies on a clinic for care, he or she probably has little time and many other
immediate issues to attend to during these short and focused meetings with the clinic physician or staff. There is also the issue of
making this information available to these patients – are all of the staff at the free clinic aware of these educational materials? Are the
clinic staff aware that they should be screening their patients for, diabetes, cardiovascular disease, and other comorbidities? If the staff is
relying on the current numbers reported for which diseases are prevalent, they may miss some key health issues that a patient may not
know about which to ask.
Dr. Goodfriend admits that focus-groups that are aimed at addressing community health issues attract those who have a specific concern
and minorities are often not represented (personal communication, July 2, 2013). Because many Hispanics do not speak English, they are
not aware of these community meetings, cannot participate because of language barriers, or lack the knowledge to express their concerns
at a town hearing. Clearly, the county needs to find a way to attract a broader range of citizens in the community, in addition to
finding ways to educate, in an effective and efficient way, Hispanic patients on healthy nutrition.
There are clearly many factors involved that contribute to health
disparities among the Hispanic population, across the United States, and
in Loudoun County, Virginia. However, Loudoun County has many
resources and there are several ways the region can address the growing
concern of health disparities among Hispanics in Northern Virginia.

8. BARRIERS THAT CURRENTLYPREVENT HISPANIC
RESIDENTS FROM APPROPRIATELYACCESSING CARE, IN
SUMMARY:
Loudoun County currently does not currently have an accurate way
to collect data, ensuring that health concerns related to Hispanics are
not represented truthfully, thereby eliminating the potential to
address these concerns. This is due to financial and time constraints
set by the Virginia Department of Health.
Because a large percentage of the Hispanics in Loudoun are recent
immigrants, mortality reporting for recent years is more reflective of
older citizens who lived in Loudoun County for many years, rather
than for the younger Hispanic population.
Schools like Sugarland Elementary Schoolin Sterling currently offer
a Sheltered Instruction Observation Protocol(SIOP), an effective,
innovative educational program designed to teach non-English
students. Unfortunately, this is the only program of its type and there
is little evidence to determine if lesson planning includes health
education.
The Loudoun County Free Clinic has a limited number of staff and
relies on volunteers for many of its services and may not be able to
accommodatethe rapidly growing Hispanic (and other minority)
population in the near future.
Hispanics that are new to the area must acculturate quickly and
change their diets drastically, leading to poorer health outcomes.
There are currently no Hispanic or Latino food markets in Loudoun
County.
There are several issues that currently need to be addressed in
Loudoun County to ensure that Hispanics’ health needs are
appropriately identified by the local government, that students and
their families are educated in making healthy choices, especially
since they do not have access to the same food choices as they did
in their home country, and that the Loudoun County Free Clinic,
which provides services to many low income, Hispanic residents,
has a plan to sustain its ability to serve a large number of people.

9. WHAT CAN BE DONE TO REDUCE DISPARITIES IN CARE FOR
THE HISPANIC POPULATION IN LOUDOUN COUNTY: AN
OVERVIEW.
The Virginia Department of Health must increase Loudoun County’s
budget to allow them to collect data that truly reflects the area’s
population. Doctor David Goodfriend reported that the town
currently uses convenience samples at town hall meetings to
determine residents’ perceived health issues in the county.
Unfortunately, these meetings are not necessarily representative of
the local population either. Using mail surveys and following up with
a telephone call from a local representative can potentially bring in
more responses. The local department of health must also translate
these surveys into Spanish, so that Spanish-speaking residents can
fully understand and participate in these surveys. Client perception
surveys are beneficial because they offer “the capacity to elicit the
views of numerous individuals, many of whom would not otherwise
participate in the program evaluation process”(“Programevaluation
and,” n.d.). The county could also utilize online resources, in both
Spanish and English, to attract Internet users in the area.
Expanding the SIOP program to include other schools in the region
to ensure that Hispanic children are proficient in English while also
expanding the curriculum to include healthy eating and nutrition
would begin this generation’s students on a path towards making
good health choices, and would also allow them to take this
information home to their parents and families. Including families
through educational programs (such as seminars or groups after
schoolor work hours) and teaching them similar information that the
children learned would also bolster this knowledge.
The Loudoun County Free Clinic must determine how much longer it
can sustain the number of citizens it serves, given the expected
increase in population. Recruiting additional volunteers or hiring
more paid staff may be necessary in the upcoming years to
accommodatethe growth of minority constituents in Loudoun
County. Resources that the Centers for Disease Control and
Prevention have created to improve health outcomes for the Hispanic
population should be available at the clinic, and staff and volunteers
should be trained in culturally competent care. The clinic should also
seek Spanish-speaking staff and should screen every Hispanic patient
for those illnesses that are endemic in the population. The clinic
should also come up with a list of questions that staff must ask every
patient to assess their risk factors for certain illnesses.

10. The local government should consider offering incentives for citizens
to open up Hispanic or Latino food markets. Another alternative is
offering foods that are commonly sold in Hispanic countries in local
Farmers Markets, which are numerous in Loudoun County.
Offering continuing education classes tailored specifically to the
Hispanic population could teach families healthy alternatives to fast
food and offer food suggestions that are similar to unavailable foods
in the region.
Unfortunately, many of these possible solutions or ways in which
to reduce health disparities in Loudoun County will prove to be
very expensive. For instance, convincing the Virginia Department
of Health to allocate additional funds for data collection is not an
easy task, nor is expanding education programs for both students
and their families.
However, given the rapidly expanding population, particularly
among minorities, it is also clear that keeping Loudoun County’s
residents healthy should be a priority and is essential to preventing
chronic illness and disease that will ultimately cost more than
many of the preventative measures that are listed above.

11. I met with Doctor David Goodfriend at his office on July 2, 2013. Doctor Goodfriend is the
director of the Loudoun County Health Department, which is located in Leesburg. Dr.
Goodfriend was incredibly friendly, open, and amenable to feedback and questions, and was
happy to provide any information that was needed at this meeting.
Dr. Goodfriend started off by discussing what his office was responsible for. Loudoun County’s
health department is state-run under the Virginia Department of Health, and there are several
activities that the Loudoun County Department of Health is required to partake in. These include
permitting and inspecting restaurants,permitting and inspecting pools, inspecting and approving
wells and septic systems, attending to other town nuisances and complaints. Finally, the office is
also responsible for signing death certificates and confirming that the deceased body is free of
any communicable disease (personal communication, July 2, 2013).
Doctor Goodfriend also discussed the free clinic, also in Leesburg, which provided services to
the lowest income individuals in Loudoun. As mentioned, the clinic provides dental services,
family planning, STD screenings, services for tracking and preventing the spread of infectious
disease, particularly tuberculosis and the flu. He said that generally, they had about twelve cases
of TB each year (personal communication, July 2, 2013). Doctor Goodfriend discussed the
importance of the clinic having a “surveillance role” through which they followed up on disease
progression and assessed patients that had been seen (personal communication, July 2, 2013).
He referred me to the Virginia Department of Health to get the specific results of the
surveillances.
With regard to the office’s legislative action, Doctor Goodfriend did mention that they were
very limited in what they could do; however, he did mention that if they felt something was a
significant enough issue, they could send it up to the Virginia State Departments for discussion.
He said that this happened rarely, but the county ordinance was able to “provide feedback
upward” (personal communication, July 2, 2013).
One thing that the department was preparing for was the public health assessment,which I
mention multiple times in my policy brief. During this assessment,the office uses present and
prior statistics, focus groups, information from the Virginia Health Department,and information
gathered that shows what the community believes are issues regarding health. As discussed,
however, doctor Goodfriend said that this data was not collected in the most accurate of ways
due to financial constraints, and within the 5000 or so responses that were received, there was an
overwhelming majority of surveys from White females and mothers who were English speaking
(personal communication, July 2, 2013). The data changed drastically, he said, because Loudoun
was considered unstable and because immigrants were coming into the area rapidly, thereby
ensuring that their voices were not being heard within these surveys or during focus groups or
town hall meetings. Doctor Goodfriend identified that they were currently considering “how to
incorporate statistics other than mortality and morbidity rates” (personalcommunication, July 2,
2013). However,it did not seem like the county was in a position to accurately collect data
through any other means.
Doctor Goodfriend was very candid in his discussion. He was proud to announce that Loudoun
County was the second healthiest County in Virginia, trailing only Fairfax. Again, however,
these statistics may be skewed and may not be representative of the entire population. Although
his clout is fairly limited, Doctor Goodfriend was certainly a good place to initiate this dialogue,
as I got the impression he also felt that this was an issue in Loudoun County. Perhaps as the
population continues to grow and the implications related to the barriers that the Hispanic
population become more apparent, Doctor Goodfriend will be able to make these
recommendations to the Virginia Department of Health to initiate change in Loudoun County.
DOCTOR DAVID GOODFRIEND: A POTENTIAL
ADVOCATE FOR THE COMMUNITY

12. References
U.S. Hispanics propel real growth in food, beverage and restaurant sectors. (2013). PR
Newswire,Retrieved from http://www.prnewswire.com/news-releases/us-hispanics-
propel-real-growth-in-food-beverage-and-restaurant-sectors-according-to-latinum-
network-90222677.html
Bahls, C. (2011). Achieving equity in health. Health Affairs,?? Voland # Retrieved from
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=53
Centers for Disease Control and Prevention, Office of Minority Health. (2004). Health
disparities experienced by hispanics --- united states. Retrieved from website:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5340a1.htm
Centers for Disease Control and Prevention, (2013). Cardiovasculardisease is the leading
cause of death among U.S.Hispanics.Retrieved from website:
http://www.cdc.gov/features/millionheartshispanic/
Dave,J. M., Evans, A. E.,Pfeiffer, K. A.,Watkins, K. W., & Saunders, R. B. (2010).
Correlates of availability and accessibility of fruits and vegetables in homes of low-
income hispanic families. Health Education Research, 25(1),97-108. Retrieved
from http://her.oxfordjournals.org/content/25/1/97.full.pdf html
Fryar, C. D., & Ervin, R. B. Centers for Disease Control and Prevention, (2013). Caloric
intake fromfast food among adults: United States, 2007–2010.Retrieved from
website: http://www.cdc.gov/nchs/data/databriefs/db114.htm
Gibson, C. (2010, October 21). At Sugarland Elementary, language lessons are key to all
learning. The Washington Post. Retrieved from
http://www.washingtonpost.com/wp-
dyn/content/article/2010/10/19/AR2010101907121.html
Gibson, C. (2011, February 06). Loudoun county population is the fastest-growing in fast-
growing northern Virginia. The Washington Post.Retrieved from
http://www.washingtonpost.com/wp-
dyn/content/article/2011/02/04/AR2011020406953.html

13. Gwynn, E. R., & Gwynn, D. (n.d.). Food and dietary adaptation among Hispanics in the
United tates. Handbook of Hispanic Cultures in the United States: Anthropology,
Retrieved from http://www.latinoteca.com/latcontent/repository/free-
content/Anthropology/Food and Dietary Adaptation
Loudoun County Free Clinic:Aabout us. (2009). Retrieved from
http://loudounfreeclinic.org/About Us/2545/Section
Loudoun County Government, (2009). Loudoun county, Virginia community health status
assessment. Retrieved from website:
http://www.loudoun.gov/documents/31/3203/Loudoun Community Health Status
Assessment.PDF
Loudoun County Government, Department of Management and Financial Services. (2011).
Loudoun county 2010 census highlights. Retrieved from website: http://va-
loudouncounty.civicplus.com/documents/43/10332/10340/10352/Loudoun County
2010 Census Highligh_1.PDF
Loudoun County Government, Department of Management and Financial Services. (2011).
Loudoun county race and ethnicity maps2010 census. Retrieved from website:
http://va-
loudouncounty.civicplus.com/documents/43/10332/10344/10375/10377/Race and
Ethnicity Maps 2010.PDF
Loudoun County Government, Department of Planning. (2013). Population in loudoun
county. Retrieved from website: http://va-
loudouncounty.civicplus.com/documents/43/10332/10341/10356/Demographic
Forecast Series - Jan17_2013_201301171302227070.pdf
Mansfield, W., Peugh, J.,Torres, J., & Wells, T. (2010). Measuring acculturation in the U.S.
Hispanic population ??wendy mansfield, jordon peugh, jannet torres, and tom wells
knowledge networks. American Statistical Association,Retrieved from
http://www.amstat.org/sections/srms/proceedings/y2010/Files/400127.pdf
Mercado,F., & Fileti, C. (2010). Health implications of dairy intake in us hispanics:
Opportunities for nutrition intervention and education. National Hispanic Medical
Association,Retrieved from
http://www.nationaldairycouncil.org/SiteCollectionDocuments/education_materials/hi
spanic_heath_kit/LAHIDAN_HealthImplications_FinalProof.pdf

14. Perez-Escamilla, R.,& Putnik, P. (2007). The role of acculturation in nutrition, lifestyle, and
incidence of type 2 diabetes among latinos. The Journal of Nutrition,137(4),860-
870. Retrieved from http://hjb.sagepub.com/content/32/1/37.abstract
Plum, K. (2013, June 25). Commentary: Northern virginia’s health. The Connection.
Retrieved from
http://www.connectionnewspapers.com/news/2013/jun/25/commentary-northern-
virginias-health/
U.S. Department of Housing and Urban Development, Office of Policy Development and
Research. (n.d.). Programevaluation and analysis. Retrieved from website:
https://www.bja.gov/evaluation/guide/documents/documentb.html