Effect of Nutrition Education on Perceived Cancer Risk in Rural Texas

The Effect of a Pilot Nutrition Education Intervention on
Perceived Cancer Risk
in a Rural Texas Community
Liliana Correa, MS', Debra B. Reed, PhD, RDN, LD:, Barent N.
McCool, PhD3, Mary Murimi, PhD, RDN, LD2, Conrad
Lyford, PhD4
'Former M.S. Nutritional Sciences Graduate Student, Texas
Tech University, Lubbock, TX
departm ent of Nutritional Sciences, Texas Tech University,
Lubbock, TX
departm ent of Hospitality and Retail Management, Texas Tech
University, Lubbock, TX
departm ent of Agricultural & Applied Economics, Texas Tech
University, Lubbock, TX
Correspondence to:
Debra B. Reed, PhD, RDN, LD
[email protected]
ABSTRACT
Background: A high consumption o f fruits, vegetables, and
whole
grain foods and adequate levels o f physical activity are
associated
with a lower risk o f obesity and lower risk o f lifestyle cancers.
Re-
search suggests that rural communities have a high risk o f
unhealthy
behaviors that may contribute to excessive weight gain and risk
o f
lifestyle related cancers. The purpose o f this pilot study was to
deter-
mine the effect o f an educational intervention in a rural Texas

com-
munity on the intermediate outcomes o f eating behavior
(increasing
the intake o f fruits, vegetables, and whole grain foods) and
physical
activity behavior, and the distal outcome o f body mass index
(BM1).
Methods: The intervention, guided by the Social Cognitive
Theory,
was implemented over a 10-month period and included a variety
o f
community-based education activities related to nutrition,
physical
activity, and cancer in a variety o f settings. The effect o f the
inter-
vention was assessed by analyzing pre- and post-data (N=67)
using
independent and paired samples t-tests and bivariate
correlations.
Results: Participants were mainly Hispanic (53.7%) and White
(44.8%). At pre-intervention, 6% o f participants reported
consuming
>5 servings o f fruits and vegetables daily, 19.4% consumed >3
serv-
ings o f whole grain foods daily, and 85.1% were either
overweight
or obese. Only 31% o f participants were aware that cancer risk
was
related to overweight at pre-intervention. At post-intervention,
His-
panics showed a significant increase in the consumption o f
fruits and
vegetables (p<0.05). Participation in sports or physical activity
pro-
grams showed a significant increase (p<0.05). However, no
signifi-

cant decrease in BM1 was shown.
Conclusion: This intervention had a limited effect in increasing
tar-
geted behaviors and no effect on reducing BMI. More
assessment is
needed in this rural community to identify barriers to healthy
behav-
iors and to improve interventions to increase consumption o f
fruits,
vegetables, and whole grain foods, levels o f physical activity,
and
awareness o f the cancer and obesity relationship.
INTRODUCTION
During the last 20 years, there has been an increase in the rates
o f
excessive weight in the U.S. population with more than 69% o f
the
adult population classified as overweight or obese.1 The
increased
rate o f obesity and other chronic diseases, including cancer, is
influ-
enced by behavioral changes in rural and urban populations.2-4
These
changes include an increased intake o f energy-dense foods that
are
high in saturated fat, trans fat, sugars, and salt, lower
consumption
o f fruits, vegetables, and whole grain foods, and a lack o f
physical
activity.2
Rural populations are at a higher risk o f obesity and chronic
diseases
because they are more affected by unhealthy lifestyles and the
lack

o f access to health care than urban populations.5 The
prevalence o f
unhealthy lifestyles in rural populations is in part due to a lack
o f
health-friendly environments. In health-friendly environments,
per-
sons have access to healthy, affordable food and nutrition
informa-
tion, as well as to facilities, such as walking trails, which
encourage
participation in health activities.6'7 In addition, factors such as
low
educational and socioeconomic levels, low physical activity,
high
prevalence o f obesity, and high smoking rates are associated
with a
negative health status among rural populations.8
Hispanics (42.5%) have the highest age-adjusted rates o f
obesity
compared to non-Hispanic Whites (32.6%) and non-Hispanic
Asians
(10.8%) but are lower than Non-Hispanic Blacks (47.8%).'
Thus,
except for non-Hispanic Blacks, Hispanics may be at greater
risk
for the development o f obesity-related cancers o f the colon,
breast,
kidneys, esophagus, pancreas, prostate, gallbladder, and liver.9
It has
been estimated that up to one-third o f the 589,430 cancer
deaths ex-
pected to occur in 2015 in the U.S. will be related to overweight
or
obesity, physical inactivity and poor nutrition.10 The cancer

incidence
rates for Hispanics in Texas during 2007-2011 were
412/100,000
for males and 325/100,000 for females; for Whites they were
532/100,000 males and 415/100,000 females; and for Blacks
they
were 583/100,000 males and 499/100.000 females." Although
the
cancer incidence rates for Hispanics are actually lower
compared to
other races, Hispanics are an important population to include in
an
educational intervention as they represent 38.6% o f the total
popula-
tion and 31.8% o f the rural population in Texas.12-13 In the
2010 U.S.
Census, 19.3% o f the total U.S. population was classified as
rural,
and in Texas, 15.3% o f the population was considered rural.14
Ap-
proximately 18% o f the rural U.S. population lives in poverty
with
Hispanic, Native American, and African-American populations
hav-
ing the highest percentage o f poverty in both rural and urban
com-
munities.15
Approximately 40% o f the Texas population reported
consuming
fruits less than one time daily, and 21.8% reported consuming
vege-
tables less than one time daily.16 Lutfiyya et al reported that
rural pop-
ulations were less likely than non-rural populations to consume
five

or more daily servings o f fruits and vegetables.6 Specifically,
almost
79% o f the U.S. rural population does not eat the recommended
serv-
ings o f fruits and vegetables. Consumers are eating 6% more
total
grains than recommended but are eating only 34% o f
recommended
amounts o f whole grains.17 Fruits, vegetables, and whole grain
foods
are often not easily accessible and affordable by racial and
ethnic
minority groups in large urban centers or populations in rural
areas.18
While research shows that increasing fruits, vegetables, and
whole
grains may help with weight management and cancer
prevention,2
no rural intervention studies were found that addressed all o f
these
targeted food groups in a single study. Further, while previous
studies
have used smaller rural food stores for the intervention
setting,19'20 no
studies were found that used a full-sized supermarket in
combination
with other settings for intervention within the rural community.
Thus,
a rural community in Texas was chosen for a multi-component
pilot
intervention that was delivered across several settings. It was
hy-
pothesized that participants in the intervention would increase
their
14 TPIIA Journal Volume 68, Issue 1

mailto:[email protected]
intake o f fruits, vegetables, and whole grains and increase
physical
activity levels and that overweight/obesity levels (body mass
index,
BMI) would be reduced,
METHODS
This study was part o f a Cancer Prevention Research Institute o
f
Texas grant-funded project and was approved by the Texas Tech
University Health Sciences Center’s Institutional Review Board
for
the Protection o f Human Subjects. The pre-intervention data
were
collected during summer 2011, and post-intervention data were
col-
lected during spring 2012. The subjects were recruited from
Mule-
shoe, a rural community in West Texas. The population o f
Muleshoe
is estimated to be 5,123 with more than 60% Hispanics.21
Study sample
Participants were recruited using a variety o f methods,
including dis-
tributing flyers at the local supermarket, library, senior center,
and
churches. In addition, presentations about the study were made
to the
Chamber o f Commerce, School Board, and Rotary and Lions
service
organizations. Outdoor electronic message boards at the schools

dis-
played information about the study. Any adult 18 years and
older liv-
ing in Muleshoe and willing to participate in this study was
included,
after they signed a consent form. Individuals who did not meet
these
requirements were excluded; no other screening criteria were
used.
Also, participants who did not participate in both data
collections
(pre- and post-intervention) were excluded from analyses in this
study. Pre-intervention data were collected from 225
participants,
with pre- and post-intervention data available for 67
participants. No
data are available related to reasons for participant drop out.
Intervention
Participants received a 10-month intervention focused on
encourag-
ing participants to increase their consumption o f fruits,
vegetables,
and whole grain foods and to increase their levels o f physical
ac-
tivity. The 10-month intervention period was determined by the
grant schedule and arrangements with the other community
groups/
settings. a b l e 1 shows the specific implementation settings
and de-
tails about the intervention’s content and timeline. This
intervention
differed from others in two aspects: 1) the focus was on a rural
su-
permarket as the primary site for the interventions; and 2)
multiple

“channels” throughout the community were used, with all
interven-
tions coordinated around the monthly themes reflected on the
posters
placed in the supermarket.
The Social Cognitive Theory’s constructs o f behavioral
capability
and self-efficacy were used as the theoretical foundation for this
in-
tervention to change food and physical activity behaviors.
Behav-
ioral capability (knowledge and skill to perform a given
behavior)
was addressed by promoting fruit, vegetable, and whole grain
intake
in nutrition classes; handouts, flyers, and videos; demonstration
o f
new healthy recipes and traditional recipes that had been
modified
with the targeted healthier ingredients; and food tastings.
Self-efficacy (confidence in one’s ability to take action and
overcome
barriers) was addressed in the classes and food preparation
demon-
strations and tastings by emphasizing that healthy, low-cost
food can
be easy to prepare, tasty, and cost less than fast food.
Participants
were presented with healthy options to be able to “make over”
tra-
ditional recipes and encouraged to discuss their ideas in class to
ad-
dress cultural barriers to change. To increase self-efficacy in
making

healthier food choices at the supermarket, classes and store
posters
showed participants how to read food labels and how to use the
su-
permarket’s NuVal™ system for evaluating the nutritional value
o f
foods. As part o f the broader weight management messaging,
foods
low in fat, sugar, and sodium were encouraged in addition to
portion
TPHA Journal Volume 68, Issue 1
control.
Class topics and educational materials related to physical
activity
included recommendations for amounts o f daily physical
activity to
reduce weight (60 minutes) or maintain a healthy weight (30
min-
utes). Low or moderate impact physical activities, such as
walking,
biking, gardening, and stretching were encouraged. The
advantages
to making the desired behavior changes (increase fruit,
vegetable,
and whole grain intake and increase physical activity) and the
health
effects o f not making these changes were discussed in classes.
Most o f the educational materials were obtained from the
Ameri-
can Institute for Cancer Research (AICR) and were available in
both
English and Spanish. Flyers and posters created specifically for

this
project were developed by the Registered Dietitians associated
with
this project and translated into Spanish by bilingual
(English/Span-
ish) graduate students who were familiar with the food and
culture.
However, as the intervention unfolded, less emphasis was
placed on
Spanish written materials as it was determined that while many
o f the
Hispanic participants spoke Spanish and English, they were
unable
to read Spanish and relied on family members who were
bilingual
to interpret for them. The intervention activities were
implemented
by faculty and graduate students with a background in
nutritional
sciences. All classes were taught in English, with the exception
o f
the classes conducted with Head Start parents, which were
taught
in Spanish.
Measures
This study was a pre-and post-intervention design with outcome
measures o f dietary intake, physical activity, and BMI. The
Nutri-
tion and Health Practices Survey included demographic
questions
from the Behavioral Risk Factor Surveillance System (BRFSS)
2010
Survey22 and questions on participants’ eating practices,
attitudes re-
garding cancer risk, and health practices. The survey was

translated
into Spanish by native Spanish speakers who were part o f the
project
staff. It was pretested with 30 participants at a supermarket with
a
primarily Hispanic clientele in a suburban city about 70 miles
from
Muleshoe. In addition, the AIM-HI Fitness Inventory23 created
by
the American Academy o f Family Physicians (AAFP) was used
to
collect data on participants’ dietary intake and physical activity.
It
was selected based on its use in various clinical settings and
demo-
graphic groups,23-24 ease o f administration, face validity, and
Spanish
availability. Height and weight were measured by trained
research
staff and used to determine BMI. Participants received a $25
gift card
from the local supermarket at both pre- and post- data
collection.
Statistical A nalysis
Descriptive statistical analyses were performed to evaluate
partici-
pants’ demographic and physical characteristics at baseline. The
de-
pendent variables included were BMI, physical activity level,
and
intake o f fruits, vegetables, and whole grain foods, while age,
gender,
race, language, marital status, income, education, and beliefs
regard-
ing cancer risk were independent variables. Independent and

paired
sample t-tests were used to compare the pre- and post-
intervention
change score o f the variables tested. Bivariate analyses were
used
to determine the relationship between BMI, age, education,
income,
and physical activity with the participants’ reported
consumption o f
fruits, vegetables, and whole grain foods. A p-value <0.05 was
con-
sidered statistically significant. To perform the statistical
analysis,
IBM SPSS Statistics, version 21 was used.
RESULTS
The majority o f the participants were older than 50 years
(59.7%), fe-
male (70.1 %), married (59.7%), and spoke English as a first
language
(85.1%) (demographic data not shown). Participants were
predomi-
15
Table 1. Implementation of intervention activities
L o c a t i o n I m p l e m e n t a t io n F r e q u e n c y
Supermarket Based
Food Product Tastings
Samples of a variety o f foods (e.g. soups, salads,

casseroles, desserts) prepared with healthy ingredients
were offered to supermarket customers. Nutrition
information and recipes were provided.
2 times per month
for 10 months -
products related
to monthly
themes
Posters
Large posters reflecting healthy eating and healthy
physical activity themes were placed strategically in the
supermarket.
New posters
placed each
month for 10
months
NuVallm a and Healthy
Food Markers
Healthy food markers were placed throughout the
supermarket to supplement the supermarket’s NuValtm
nutrition scoring system.
Markers moved
monthly in
support of poster
themes
Communitv Based
Classes
Community Center

Series of classes held in the evenings included food
demonstrations and tastings and distribution of
educational materials. Examples of class topics included
weight management, recipe modification, portion
distortion, reading food labels, and physical activity
strategies.
Offered monthly
for 10 months; 40
minutes long
Library
Classes held as part of the library’s community education
program - incorporated presentation and discussion;
flyers and materials from American Institute for Cancer
Research were placed in racks for patrons to take.
2 classes during
the 10 month
period
Head Start Center Classes presented to parents of children
enrolled as part of
their parent education program.
2 classes during
the 10 month
period
Health Fairs
High School
Healthy eating and physical activity information provided
at parents’ organization pre-football game dinner. Flyers
promoting classes and events at the supermarket and

community center were distributed.
1 time about mid-
way through 10
month period
Senior Center Healthy eating and physical activity information
provided;
blood pressure, height, and weight measurements taken.
2 times during the
10 month period
Two Local Churches Healthy eating and physical activity
information provided;
blood pressure, height, and weight measurements taken.
1 time each
during the 10
month period
Media
Television Interviews
Project personnel interviewed about the project and the
importance of healthy eating and physical activity by local
TV station.
2 interviews
during the 10
month period
Videos
Videos of project activities prepared by local TV station.
Videos were posted on TV station’s website, and videos
could be viewed at any time during the project.

6 videos posted
during the 10
month period
aNuVallm System summarizes comprehensive nutritional
information in one number between 1 and 100 for each food in
the
supermarket (http://www.nuval.com/How ). The higher the
NuValtm Score, the better the nutritional value. Approximately
30
supermarket chains nationwide use NuVal
(http://www.nuval.com/location).
Table 2. Participants’ beliefs regarding cancer risk at pre- and
post-intervention (N=67)
Pre
A n sw e re d
c o rrectly
%
P ost
A n sw e re d
c o rrectly
%
C h a n g e
%
Pre vs. Post
p -v a lu ea

D rin k in g tap w a terb 62.7 55.2 -7.5 0.058
U sed o f tan n in g beds 65.7 91.0 25.3 0.103
G e ttin g sun b u rn ed 89.6 98.5 8.9 0.568
B ein g o verw eigh t 31.3 52.2 20.9 0.083
D rin k in g excessive
q u a n tities o f alcohol
61.2 61.2 0.0 0.421
C h e w in g tob acco/u sin g
s n u ff
97.0 98.5 1.5 1.000
S m o k in g tob acco p rod ucts 98.5 100.0 1.5 0.321
D rin k in g large q uan tities
o f caffein eb
28.4 32.8 4.4 0.083
a Paired samples t-test.
b Not considered to cause cancer by the American Cancer
Society and National Cancer Institut
nantiy Hispanics (53.7%) and Whites (44.8%), had a high
school
education or less (71.6%) [elementary school 32.8% and high
school
38.8%], and had an annual income o f less than $20,000
(66.1%).
After analyzing by race, it was found that 70.7% o f the
Hispanics had
16
an annual income o f less than $20,000.

In Table 2, participants’ beliefs regarding cancer risk related to
over-
weight and selected behaviors are presented. At pre-
intervention,
there was much more awareness about the cancer risk related to
the
use o f tobacco (97.0-98.5%) and getting sunburned (89.6%)
when
compared to the risk o f being overweight (31.3%). While the
aware-
ness o f cancer risk related to being overweight increased by 21
% at
post-intervention, this increase was not statistically significant
and
was still well below the awareness levels o f other risk factors.
At pre-intervention, participants had a mean BMI o f 30.4±6.97,
and
85.1% were either overweight or obese (37.3% overweight;
47.8%
obese) (data not shown). Only 6% consumed five or more
servings
o f fruits and vegetables daily, and 19.4% consumed three or
more
servings o f whole grain foods daily. There were no statistically
sig-
nificant differences found in fruit, vegetable, and whole grain
food
consumption from pre- to post-intervention. However, after ana-
http://www.nuval.com/How
http://www.nuval.com/location

lyzing data by race, Hispanics showed a significant increase in
the
consumption o f fruits and vegetables at post-intervention
(mean
change 0.30+0.67; p<0.05) (Table 3). Participation in sports or
phys-
ical activity programs showed a significant increase (mean
change
0.21+0.75; p <0.05) from pre- to post-intervention (Table 4). No
change was found in BMI from pre- to post-intervention.
Bivariate correlations between BMI and servings o f fruits, veg-
etables, and whole grain foods did not show significant associa-
tions (data not shown). However, significant positive
associations
(p<0.05) were found among intake o f fruits and vegetables and
edu-
cation level (r =0.26) and fruits and vegetables and income
(r=0.31)
at pre-intervention, but not post-intervention.
In our study, attendance was taken at the classes at the
Community
Center, but unfortunately only 10 o f the 67 participants, for
whom
pre/post test data were available, attended these classes. The
mean
(standard deviation) number o f classes attended by these 10
partici-
pants was 5.10 (+1.97). Participants who attended the most
classes
did not have better outcomes than those who attended fewer
classes
(data not shown).

education intervention in our study would have lower BMI at
post-
intervention; however, this was not found. Similarly, Tussing-
Hum-
phreys et al conducted a multi-component, six-month church-
based
intervention (kickoff celebration followed by monthly, 60-
minute
educational sessions emphasizing increased intake o f fruits,
vege-
tables, whole grains, and low fat dairy foods; a didactic
physical ac-
tivity session, and a self-directed physical activity component)
with
rural, lower Mississippi Delta African-American adults, and did
not
find a significant reduction in BMI.29 However, successful
weight
loss was reported for rural African-American women
participating in
a community-based intervention program conducted in churches
in
South Carolina.30 Since Muleshoe churches were receptive to
one in-
tervention session, they may be a good avenue for a continued
higher
dose o f intervention.
From pre- to post-intervention, the percentage o f participants
who
were aware that overweight is related to cancer risk increased
from
31% to 52%; however, this increase was not statistically
significant
and shows the need for additional education efforts related to
over-

weight as a factor that may increase cancer risk. A 2007
national
cross-sectional study (n = 7452) found that 82-89% o f
respondents
Table 3. Fruits and vegetables intake by race at pre- and post-
intervention (N=66)
Race
W hite (n=30) C hange W hite H ispanic (n=36) C hange H
ispanic W vs.
(W) (H) H
Pre Post P re vs. Pre Post P re vs. C hange
Post Post P-
p-valuea p-valuea valueb
* mean ± standard deviation * < mean ± standard deviation- *'
F ru its and 1.80+0.61 1.70+0.70 - 0.522 1.33+0.53 1.63+0.68
0.30+0.67 0.010* 0.033*
Vegetables9 0.10+0.84
n (%)
5 o r more 3 (10.0) 4(1 3 .3 ) 1 (3.3) 1 (2.8) 4(11.1) 3 (8.3)
3 to 4 18(60.0) 13 (43.3) -5 (-16.7) 10(27.8) 15 (41.7) 5(13.9)
2 o r less 9 (30.0) 13 (43.3) 4 (13.3) 25 (69.4) 17(47.2) -8 (-
22.2)
‘ W h ite (pre vs. p o st) an d H isp an ic (pre vs. p o st) p valu
es w ere calcu lated using p aired sam ples t-test, *p <0.05.
b W h ite vs. H isp an ic in d ep en d en t sam ples t-test.
c Serv in g s eaten a day; 1= 2 o r less; 2 = 3 to 4; 3 = 5 o r m
ore
DISCUSSION

This study examined the effect o f a nutrition intervention on
improv-
ing eating behaviors, specifically those related to the intake o f
fruits,
vegetables, and whole grains, and increasing physical activity in
a ru-
ral community o f West Texas. These health behaviors are
important
in the prevention o f obesity, cancer, and other chronic
diseases.2,25
The 2010 Census found that Hispanics (31.8%) and Whites
(58.4%)
were the most predominant races in rural Texas.13 In Muleshoe,
per-
centages were higher for Hispanics (53.7%) and lower for
Whites
(44.8%). Rural populations are more likely to live in poverty
than
urban populations, and Hispanics have the highest prevalence o
f
poverty.14 Our findings indicated that a majority o f
Muleshoe’s par
ticipants, especially Hispanic participants, were living below
the
poverty level. Limited income has been shown to affect a house-
hold’s ability to purchase healthy foods.26
The prevalence o f obesity is higher in rural populations who
are more
vulnerable to unhealthy lifestyles.27 Data from the 2005-2008
Na-
tional Health and Nutrition Examination Survey (NHANES)
showed
that the prevalence o f obesity was 39.6% among rural adults
com-

pared to 33.4% among urban adults.28 Rural populations’
increased
likelihood to be obese was reflected in this study as 47.8% o f
Mule-
shoe participants were obese, compared to 34.9% in the total
U.S.
population.1 It was hypothesized that participants who received
the
across all races said they had never looked for information
related to
cancer prevention.31
In our study, it was hypothesized that participants who received
the
nutrition education intervention would have a significantly
higher
mean intake o f fruits, vegetables, and whole grains after the
inter-
vention. Most o f the participants in. Muleshoe reported a low
con-
sumption o f fruits, vegetables, and whole grains at pre- and
post-
intervention. Although the consumption o f fruits and
vegetables
was still low at post-intervention in the total sample, we found
that
Hispanics, not Whites, significantly increased their
consumption
o f fruits and vegetables. This racial difference was found also
in a
Table 4. Physical activity at pre- and post-intervention (N=67)
C h aracteristics

Times a week o f physical
activity3
Pre P ost C han ge Pre vs. Post
p -valu eb
mean ± standard deviation- *
Yard or housew ork 2.36±0.7 2.34±0.6 0.01±0.8
0.8853 6 4
W alk >10 m inutes 2.01±0.8 2.07±0.7 0.06±0.9 0.609
6 8 5
S ports or p hysical activity 1.40±0.6 1.61±0.8 0.21±0.7
0.026*program 5 3 5
al= less than 1; 2= 1 -3; 3= 4 or more.
b Paired samples t-test.
*p<0.05.
TPHA Journal Volume 68, Issue 1 17
study that analyzed fruits and vegetables dietary behavior to
assess
the effects o f a low-intensity, physician-endorsed intervention
in a
rural population, where the majority o f participants were
Whites or
African-Americans. The authors found that for Whites there was
not
a significant effect, but African-Americans increased their
intentions
compared to controls, at one and six months.32 In a systematic
review

o f interventions designed to increase fruit and vegetable intake,
the
authors found that the largest effects o f these interventions
were ob-
served among sub-groups o f participants who were at a higher
risk o f
disease, implying that these participants had increased
motivation to
improve their eating behaviors.33 In our study, Hispanics
comprised
54% o f the total participants, and 61% were considered obese
at pre-
intervention. Therefore, it is possible that participants perceived
the
need to lose weight, and thus they were motivated to increase
their
intake o f fruits and vegetables. However, the motivation or
strategies
used by those who increased fruits and vegetables was not
deter-
mined.
In comparing our results related to changes in fruit, vegetable,
and
whole grain intake to other studies, similar findings were
reported for
different intervention methods. A six-week community-based
partic-
ipatory research intervention to make the home environment
more
supportive o f healthy eating and physical activity for rural
adults o f
Southwest Georgia consisted o f a tailored home environment
pro-
file, goal-setting, and behavioral contracting delivered through
two

home visits and two telephone calls.34 While intervention
households
reported significant improvements in purchasing o f fruit and
vegeta-
bles and family support for healthy eating and increased
purchasing
o f exercise equipment and family support for physical activity
rela-
tive to comparison households, no significant changes were
observed
for fruit and vegetable intake, physical activity, or weight
between
intervention and comparison households.
Tussing-Humphreys et al reported in their study with lower
Missis-
sippi Delta African-American adults that fruit, vegetable, and
whole
grain intake for both the intervention and control groups
increased,
but there were no significant differences.29 However, they did
find
that the high participation intervention group had significant
increas-
es in these dietary outcome variables compared to the control
group.
They also found a positive effect o f vehicle ownership on study
com-
pletion and attendance at intervention activities. Given the
limited
attendance at classes in our study, transportation and other
barriers to
classes should be explored in future work with the Muleshoe
com-
munity.

Additionally, it was hypothesized that the intervention would
in-
crease physical activity levels. A significant increase in
engagement
in a sport or physical activity program on a regular basis was
found
and may indicate a socially acceptable way o f increasing
physical
activity in this community. However, participants did not report
significant increases in yard or housework or walking from pre-
to
post-intervention. Previous research using a community-based
ap-
proach to promote walking in rural Missouri Caucasian and
Black
participants also did not find a statistically significant
intervention ef-
fect, although a positive net change in rates o f seven-day total
walk-
ing in two subgroups (persons with a high school degree or less
and
persons living in households with annual incomes o f <$20,000)
was
reported.35 Even so, walking has been determined as the most
com-
mon physical activity, especially in overweight, low income,
and low
education populations.36,37 Thus, it would be helpful to
determine
barriers to walking in this rural community.
Study Limitations
One limitation was the lack o f a comparable control group, and
therefore the positive changes seen may not be totally
attributable

to the intervention. Also, while there were 225 participants at
pre-
intervention, only 67 provided survey data and anthropometries
at
post-intervention, which limits the generalizability to all
Muleshoe
residents. Further, the small number o f participants decreased
the
ability to detect changes in outcomes. Another limitation is that
self-
reported data were used to assess food intake and physical
activity
levels. In self-reported measures, participants have the tendency
to
under-report normal daily food intake and under- or over-
estimate
physical activity levels. This could be due to inaccurate
memory,
social desirability, or their inability to capture accurately their
physi-
cal activity and food intake.38,39 Additionally, although the
Aim-Hi
Fitness Inventory has been used in a number o f settings
nationally,
it was not validated or tested for reliability in this study
population.
Another limitation was that only individual factors were
assessed
and not environmental factors such as access to walking trails,
qual-
ity o f food (food portions and nutritional value) sold in the
com-
munity venues other than the intervention supermarket, and
food af-
fordability, which could contribute to unhealthy behaviors.
Although

low-cost, healthy foods were promoted by the intervention, food
insecurity was not assessed or addressed directly through
activities
or referrals.
Study Strengths
This study has several strengths. First, limited data are
available on
rural interventions that include multiple components (diet and
physi-
cal activity) in a bi-racial rural population. Second, assessment
tools
and most educational materials were available both in English
and
Spanish, and recipes used in classes and materials reflected the
com-
munity’s cultural groups. Third, height and weight were
measured by
trained staff, rather than using self-reported data, to increase
validity.
In addition, the data collected in this study helped to assess the
BMI,
eating habits, and physical activity status in this rural
community that
had not been studied before. .
CONCLUSIONS
It is encouraging that Hispanics improved their intake o f fruits
and
vegetables and that participation in physical activity programs
in-
creased in the total sample in this rural community. The
interven-
tion did not have a significant effect in helping participants to
reduce
their BMI or increase intake o f whole grain foods. The 21 %

increase
in participants who were aware o f the relationship between
over-
weight and cancer at post-intervention was a positive finding,
but
much improvement is still needed in knowledge and behavior.
This
study showed that the rural community o f Muleshoe is at high
risk of
continued obesity and chronic diseases due to unhealthy
behaviors
and knowledge gaps. There is a need for additional assessment
in
this rural community to identify other possible barriers to
healthy
behaviors and to improve interventions to make them more
success-
ful. Focus group discussions or other forms o f community
partici-
patory research could help further assess needs and promote
more
community ownership. Also, the sport and group activities
results are
promising and should be explored further.7
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H o s t e d b y t h e G a l v e s t o n C o u n t y
H e a l t h D i s t r i c t
A t t h e S a n L u i s R e s o r t S p a &
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A p r i l 1 1 - 1 3 , 2 0 1 6
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A E C - G A L V E S T O N - T e x a s
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u b le .
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Id e n t if y y o u r s e lv e s a s b e in g w i t h T e x a s P u
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S e e E x h ib it o r In fo r m a t io n on p a g e 2 6
19

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Educational Interventions to Promote Healthy
Nutrition and Physical Activity Among Older
Chinese Americans: A Cluster-Randomized Trial
Jane Jih, MD, MPH, MAS, Gem Le, PhD, MHS, Kent Woo,
MSW, Janice Y. Tsoh, PhD, Susan Stewart, PhD, Ginny
Gildengorin, PhD, Adam
Burke, PhD, MPH, Ching Wong, BS, Elaine Chan, BA, Lei-
Chun Fung, MPH, MSW, Filmer Yu, MPH, Rena Pasick, DrPH,
Stephen J. McPhee,
MD, and Tung T. Nguyen, MD

Objectives. To evaluate the efficacy of an in-language
intervention of 2 lectures plus
printed materials versus printed materials alone on knowledge
and adherence to
nutrition and physical activity guidelines among older Chinese
Americans in San
Francisco, California.
Methods. From August 2010 to September 2013, we randomized
756 Chinese
Americans aged 50 to 75 years to either lectures plus print (n =
361) or print (n = 357).
Clusters were the participants recruited by each lay health
worker. Intervention out-
comes were changes in knowledge of recommended vegetable
intake, fruit intake, and
physical activity level and adherence to those recommendations
from pre- to 6 months
postintervention.
Results. The retention rate was 99%. At baseline, knowledge
and adherence to
recommendations were low. Print yielded increases in
knowledge of recommended
vegetable intake and physical activity level and adherence to
fruit intake and physical

activity recommendations. Lectures plus print had significant
increases in all 6
outcomes. In multivariable models, lectures plus print was
superior to print for
knowledge of vegetable (adjusted odds ratio [AOR] = 12.61;
95% confidence interval
[CI] = 6.50, 24.45) and fruit (AOR = 16.16; 95% CI = 5.61,
46.51) intake recommenda-
tions and adherence to vegetable intake recommendations (AOR
= 5.53; 95% CI = 1.96,
15.58).
Conclusions. In-language print materials, alone and combined
with lectures, increased
nutrition and physical activity knowledge and behaviors among
older Chinese Americans.
(Am J Public Health. 2016;106:1092–1098.
doi:10.2105/AJPH.2016.303111)
Asian Americans constitute the fastestgrowing racial/ethnic
group in the
United States.1 The largest group is Chinese,
69% of whom are immigrants and 46% of
whom have limited English proficiency
(LEP).2 Chinese Americans have low physical
activity levels3,4 and eat less than the rec-
ommended amounts of vegetables and fruits.5

Thus, they may have an increased risk of
chronic diseases, such as obesity, cancer, di-
abetes mellitus, and cardiovascular disease.6–11
Improving healthy nutrition and physical
activity (NPA) is a public health priority in
this rapidly growing population.
Culturally relevant and linguistically ap-
propriate interventions targeting Chinese
Americans are needed because many have
LEP and low levels of health literacy,12–14 but
there is a lack of rigorous research on in-
terventions to address NPA among Asian
Americans in general and Chinese Americans
in particular. A systematic review of lifestyle
interventions for Asian Americans found
only 7 randomized control trials (RCTs), only
2 of which had a sample size of more than
100.14 Previous NPA interventions in
Asian Americans have focused on print-15
or lecture-based education alone.16,17 There
has been no RCT that compared an NPA
lecture–based intervention to NPA printed
materials among Asian Americans.
Through a community-based participa-
tory research partnership formed by an
academic medical center, an undergraduate
university, and a Chinese community–based
organization in San Francisco, California, we
developed a lecture-based intervention and
print materials to deliver culturally relevant,

in-language NPA messages. Using a cluster
RCT design, we aimed to compare the effects
of this lecture-based intervention combined
with Chinese-language written materials
with those of Chinese-language written
materials only in a sample of older Chinese
American immigrants.
METHODS
We used a parallel group cluster RCT de-
sign with a 1-to-1 allocation ratio to test the
effectiveness of an intervention consisting of
2 Chinese-language NPA lectures combined
with Chinese-language print materials (lectures
ABOUT THE AUTHORS
Jane Jih, Gem Le, Ginny Gildengorin, Ching Wong, Filmer Yu,
Rena Pasick, Stephen J. McPhee, and Tung T. Nguyen
are with the Division of General Internal Medicine, University
of California, San Francisco. Kent Woo and Elaine Chan are
with the NICOS Chinese Health Coalition, San Francisco, CA.
Janice Y. Tsoh is with the Department of Psychiatry,
University of California, San Francisco. Susan Stewart is with
the Department of Public Health Sciences, University of
California, Davis. Adam Burke is with the Department of Health
Education, San Francisco State University, San Francisco.
Lei-Chun Fung is with the Chinatown Public Health Center, San
Francisco.Department of Public Health, San Francisco.
Correspondence should be sent to Jane Jih, 1545 Divisadero St,
Box 0230, San Francisco, CA 94115 (e-mail: [email protected]
edu). Reprints can be ordered at http://www.ajph.org by
clicking the “Reprints” link.
This article was accepted February 2, 2016.

doi: 10.2105/AJPH.2016.303111
1092 Research Peer Reviewed Jih et al. AJPH June 2016, Vol
106, No. 6
AJPH RESEARCH
http://www.ajph.org
plus print or intervention group) compared
with the effectiveness of the same print ma-
terials only (print or comparison group; Figure
A, available as a supplement to the online
version of this article at http://www.ajph.org).
This study was registered in the ClinicalTrials.
gov registry(NCTNCT00947206). The study
period was from October 2010 to April 2014.
The study’s educational materials are available
for download at www.asianarch.org.
From2010to2013,theChinesecommunity–
based organization recruited 58 lay health
workers (LHWs), each of whom in turn
recruited approximately 15 participants. LHWs
were community members trained by the re-
search team to recruit research participants and
maintain contact with them to maximize re-
tention in the study. Eligibility criteria for
LHWs included self-identifying as Chinese or
Chinese American; being aged 35 years or
older; being a Cantonese, Mandarin,or English
speaker; being able to read Chinese; and
intending to live and stay in San Francisco for at

least 12 months. Median age of LHWs was 50
years old and 79% were women. LHWs were
given sample scripts that included a description
of the study and health topics to use in
recruiting potential participants.
LHWssubmittedalistofeligibleparticipants
to the community-based organization project
coordinator, who then confirmed participant
eligibility according to the following criteria:
1. self-identifying as Chinese or Chinese
American;
2. being aged 50 to 75 years;
3. being a Cantonese, Mandarin, or English
speaker;
4. intending to live and stay in San Francisco
for at least 6 months;
5. there being no other participants in their
household; and
6. having no personal history of colorectal
cancer (because it was the focus of
a parallel RCT).
LHWs received a stipend of $1000 for
their 8- to 10-month studyinvolvement.Study
participants received $20 after completing the
preintervention survey and $30 after complet-
ing the postintervention survey 6 months later.
We recruited LHWs and participants in 4

waves between August 2010 and September
2013. The biostatistician used SAS version 9.3
(SAS Institute, Cary, NC) to randomize the
LHWs 1 to 1 to the lectures plus print or
print-only intervention in blocks of variable
size. Within each wave, we stratified LHWs
by gender and then randomly assigned them
to the lectures plus print group or the print
group. We cluster randomized the partici-
pants along with their LHW. To reduce bias,
research staff and LHWs learned study arm
assignments only after the LHW completed
participant recruitment.
Lectures Plus Print Intervention
and Print Comparison Groups
The lectures plus print group received (1)
two 60–90-minute lectures delivered by an
instructor in the participants’ preferred lan-
guage (Cantonese, Mandarin, or English)
about 2 months apart, (2) 2 cohort mainte-
nance telephone calls from their LHWs about
1 month after each lecture, and (3) printed
lecture handouts and a nutrition brochure.
The community–academic research team de-
veloped the NPA lectures, and a community
advisory board reviewed them for cultural and
linguistic appropriateness; they were tested in
focus groups with community participants who
were not enrolled in the study.
The first lecture, titled “How to Eat Smart
and Be Active,” focused on basic NPA edu-
cation that was tailored to older Chinese

Americans and used culturally appropriate
examples for food and physical activity. For
example, along with pictures of common
fruits and vegetables in the American diet,
there were also pictures of fruits such as
mango and papaya and vegetables such as bok
choy. A rice bowl was used to illustrate
serving size measurement for some foods.
Tai Chi was included among the recom-
mended physical activities. Tips for cooking
included how to minimize some commonly
used ingredients in Chinese cooking such
as soy sauce, salted fish, and organ meats.
We designed the curriculum to be simple
and engaging, with culturally appropriate
mnemonic techniques to help participants
remember the basic recommendations re-
garding maintaining a healthy diet and an
optimal aerobic physical activity level (which
we adapted from the national 2005 Dietary
Guidelines of Americans and the 2008
Physical Activity Guidelines, which were the
accepted standards at the initiation of the
trial).18,19 For example, lecturers used simple
hand gestures with a Chinese poem as
a learning aid to help participants recall the
recommended number of servings of the basic
food groups and recommended number of
minutes of aerobic physical activity.
One month after the first lecture, the
LHWs called their participants to ask them
about their impressions and recall of the
first lecture and to remind them to attend the

next lecture. The second lecture, titled
“Disease Prevention and Health Promotion,”
included general information on hyperten-
sion, hypercholesterolemia, and diabetes
mellitus; how they affected Chinese
Americans; and how healthy NPA reduced
the risks of those conditions. One month
after that, LHWs called participants, thanked
them for participating, and reminded them
that research staff would contact them about
the postintervention survey.
The print comparison group received the
same print NPA materials. As part of the
parallel RCT and forattentioncontrol,LHWs
delivered 2 small group education sessions on
colorectal cancer to participants in this arm
(with approximately 5–8 participants in each)
about 2 months apart; they made 2 follow-up
telephone calls about colorectal cancer about
1 month after each small group session.
Data Collection
The preintervention survey was self-
administered in a written format at a com-
munity center before the first NPA lecture or
first comparison group meeting. About 6
months later, the postintervention survey was
self-administered in a written format at the
community center. Both surveys required
approximately 30 to 45 minutes to complete.
The trilingual community–academic research
team developed the survey instruments in
English and cognitive tested, revised, and then
translated them into Chinese.

The survey instrument included socio-
demographic characteristics of age, gender,
educational attainment, marital status, num-
ber of years in the United States, employment
status, annual household income, spoken
English proficiency, self-rated health,
comorbidities, height, weight, and whether
they had made any visit to a Western health
care provider in the last 12 months. We used 3
items to assess NPA knowledge: (1) knowing
that5 servingsofvegetables was recommended
AJPH RESEARCH
June 2016, Vol 106, No. 6 AJPH Jih et al. Peer Reviewed
Research 1093
http://www.ajph.org
http://ClinicalTrials.gov
http://ClinicalTrials.gov
http://www.asianarch.org
daily, (2) knowing that 4 servings of fruit
was recommended daily, and (3) knowing that
150 minutes of at least moderate intensity
physical activity was recommended weekly.
We used 3 items to assess self-reported
NPA behaviors: (1) the number of servings of
vegetables eaten during the previous day, (2)
the number of servings of fruit eaten during
the previous day, and (3) the duration of at
least moderate intensity physical activity
during the previous week.

Analysis
We computed descriptive statistics
(frequency distributions or means 6SDs, as
appropriate) for each independent variable
by study arm. We analyzed the data using
SAS version 9.3, and we used P = .05 as the
cutoff level for statistical significance. We
compared the study arms with respect to these
variables using generalized estimating equa-
tions to account for clustering by LHWs
(Table 1). We computed each participant’s
body mass index (BMI; defined as weight in
kilograms divided by the square of height
in meters) from self-reported weight and
height and entered BMI as a continuous
variable in models.
On the basis of guidelines from the World
Health Organization,20 we used Asian BMI
criteria: overweight was a BMI of 23.00 to
27.49, and obesity was a BMI of 27.50 or
greater. To quantify NPA knowledge and
behavior outcomes, we computed the per-
centage of participants who knew the correct
answer and the percentage who reported
meeting the guidelines at pre- and post-
intervention in each group.
We computed intraclass correlations
for the NPA knowledge and behavior
outcomes from variance components esti-
mated using SAS PROC GLM with study
arm, time, and their interaction as fixed effects
and LHW as a random effect. We tested

the primary hypotheses of the NPA in-
tervention effects using generalized estimat-
ing equations models to assess outcome
changes from pre- to postintervention within
and between groups, accounting for clus-
tering by LHW (Tables 2 and 3).
We used multivariable logistic regression
models for the outcomes to account for
within-LHW clustering with generalized es-
timating equations, and we adjusted them for
TABLE 1—Sociodemographic and Health Characteristics of
Chinese American Participants by
Study Group at Enrollment: San Francisco, CA, August 2010
and September 2013
Characteristic
Lectures and Print Materials
Intervention Group (n = 365),
% or Mean 6SD
Print Materials Only
Comparison Group (n = 360),
% or Mean 6SD P a
Female 79.2 83.1 .30
Age, y 61.7 67.0 62.8 66.8 .11
Years in the United States 16.9 611.7 17.8 612.8 .56
Married 77.0 70.8 .12

Education .70
< high school diploma
or equivalent
69.7 71.4
‡ high school diploma
or equivalent
30.3 28.6
Employment .10
Employed 31.8 22.5
Retired 29.9 38.3
Otherb 38.4 39.2
Self-reported spoken English
proficiency
.58
Fluent like native speaker 1.4 2.2
Well 2.8 2.2
So-so 29.5 27.5
Poor 40.8 36.9
Not at all 25.6 31.1

Annual household income, $ .44
< 5000 14.3 12.1
5000 to < 10 000 19.7 17.7
10 000 to < 20 000 26.3 28.4
20 000 to < 30 000 11.0 8.4
30 000 to < 40 000 6.9 5.1
40 000 to < 50 000 3.0 2.5
‡ 50 000 4.7 3.1
Don’t know 14.3 22.8
Saw Western health care provider
in last 12 mo
79.7 80.8 .70
Self-reported health status .89
Excellent 2.2 1.4
Very good 5.2 6.1
Good 27.9 27.2
Fair 56.2 58.9
Poor 8.5 6.4
BMI 23.3 64.0 24.2 63.4 .002
Asian BMI cutpoints,c kg/m2 .009
Underweight, < 18.5 5.5 3.1
Normal weight, 18.5–22.9 43.7 34.7

Overweight, 23.0–27.49 40.9 46.7
Obese, ‡ 27.5 9.9 15.6
Continued
AJPH RESEARCH
106, No. 6
potential confounders, age, gender, education,
marital status, number of years in the United
States, employment status, income, English
proficiency, self-rated health, number of car-
diovascular conditions, BMI, and whether
they had made any visit to a Western
health care provider in the last 12 months
(Table 4).
RESULTS
Each of the 58 LHWs recruited on average
15 participants, for a total of 756 enrolled
participants. The mean age of the LHWs was
50.6 years (SD=9.3), and 79.3% were women.
All LHWs spoke Cantonese and read Chinese.
We ended recruitment when the goal sample
size was attained. The overall 6-month re-
tentionrateforthestudywas99.0%.Participants
lost to follow-up (n=7) did not complete the
postintervention survey (Figure A, available as

a supplement to the online version of this article
at http://www.ajph.org). On review of pre-
intervention surveys, we excluded randomized
participants who did not meet the inclusion age
criterion from the analysis (n=30). The final
analysis included 718 eligible participants.
Table 1 shows the participant characteristics
of both groups, which were similar except that
lectures plus print participants had a slightly lower
mean BMI than did those in the print group
(23.3 kg/m2 vs 24.2 kg/m2, respectively;
P=.002). We used Asian BMI cutpoints20 and
found that the proportion of participants who
were overweight or obese was lower in the
lectures plus print group (50.8%) than in the print
group (62.3%; P=.009). More than 60.0% ofthe
sample reported at least 1 comorbidity, such as
heart disease, diabetes, or hypertension. At
baseline, the median number of servings of
vegetables and fruits eaten during the pre-
vious day was 2 per person.
Knowledge and Behavior Changes
Within Groups
Table 2 shows pre–post changes in the
knowledge of NPA recommended guidelines
by study group. Knowledge of the recom-
mended vegetable intake (at least 5 servings
daily) increased significantly from 2.8% to
35.7%(P £ .001)inthelecturesplusprintgroup
(n =361) and from 5.0% to 8.4% (P = .003) in
the print group (n=357). Knowledge of the
fruit intake recommendation (at least 4 servings

daily) increased from 2.8% to 36.3% (P £ .001)
in the intervention group versus a non-
significant change from 3.1% to 3.9% (P = .51)
in the comparison group.
Knowledge of the physical activity rec-
ommendation (at least 150 minutes weekly)
increased from 1.1% to 20.2% (P £ .001) in the
intervention group versus an increase from
0.3% to 2.5% (P < .02) in the comparison
group.Theintraclasscorrelations were0.05for
knowledge of daily vegetable servings, 0.04 for
daily fruit servings, and 0.01 for weekly du-
ration of at least moderate physical activity.
Self-reported consumption of at least 5
servings of vegetables daily increased signifi-
cantly in the lectures plus print group
(from 2.2% to 15.2%; P £ .001) but not in
the print group (from 3.4% to 4.8%; P = .31;
Table 3). Both groups reported significant
increases for daily consumption of at least 4
servings of fruits daily (9.1% to 22.4%; P £ .001
for the intervention group and 7.3% to
11.5%; P < .03 for the comparison group).
TABLE 1—Continued
Characteristic
Lectures and Print Materials
Intervention Group (n = 365),
% or Mean 6SD
Print Materials Only

Comparison Group (n = 360),
% or Mean 6SD P a
Self-reported cardiovascular
disease
Heart disease 3.0 5.0 .16
Stroke 1.9 2.5 .59
Diabetes 15.6 15.1 .84
Hypertension 32.9 39.8 .09
Hyperlipidemia 34.8 35.3 .89
None of the above 35.6 31.9 .43
Note. BMI = body mass index. The sample size was n = 725.
aAccounting for lay health worker clustering.
bIncludes unemployed, students, and homemakers.
cAccording to recommendations by the World Health
Organization.20
TABLE 2—Knowledge of Nutrition and Physical Activity
Guidelines at Pre- and Postintervention by Study Group Among
Older Chinese
Americans: San Francisco, CA, August 2010 and September
2013
Intervention Group, Lectures and
Print Materials, n = 361,
Knowledge of Guidelines, %

Comparison Group, Print
Materials Only, n = 357,
Knowledge of Guidelines, %
Guideline Pre Post P Pre Post P Pre–Post Differences Between
Group P
Daily vegetable servings, 5 2.8 35.7 £ .001 5.0 8.4 .003 £ .001
Daily fruit servings, 4 2.8 36.3 £ .001 3.1 3.9 .51 £ .001
Weekly duration of at least moderate physical
activity, 150 min
1.1 20.2 £ .001 0.3 2.5 .02 £ .001
Note. Percentages took into account lay health worker
clustering. Vegetable and fruit intake guidelines were adapted
from the 2005 Dietary Guidelines for
Americans of the US Department of Health and Human Services
and US Department of Agriculture.18 Physical activity
guidelines were adapted from the 2008
Physical Activity Guidelines for Americans of the US
Department of Health and Human Services.19 The sample size
was n = 718.
AJPH RESEARCH
Research 1095
http://www.ajph.org

Similarly, both groups had significant in-
creases in the proportion of those reporting
at least 150 minutes of moderate physical
activity weekly (54.9% to 69.5%; P £ .001 for
the intervention group and 54.9% to 64.7%;
P = .001 for the comparison group). The
intraclass correlations were 0.03 for self-
reported daily vegetable intake, 0.03 for
daily fruit intake, and 0.06 for weekly
physical activity.
Knowledge and Behavior Changes
Between Groups
Tables 2 and 3 also show the statistical
significance of between-group differences for
NPA outcomes (pre–post differences be-
tween group P values).
The lectures plus print group had signifi-
cantlygreaterincreasesthandidtheprintgroup
in knowledge of recommended vegetable
intake, fruit intake, and physical activity (all
P £ .001). For self-reported behaviors, the
lectures plus print group had significantly
greater increases than did the print group in
meeting recommendations for vegetable in-
take (P £ .001) and fruit intake (P = .003) but
not in physical activity level (P = .20).
Multivariable Models of
Intervention Effects
Table 4 shows the multivariable models for

all 6 outcomes of NPA knowledge and be-
haviors. After adjusting for sociodemographic
and health characteristics, participants in the
lectures plus print group had a greater increase
than did those in the print group in the odds of
knowing the daily vegetable intake recom-
mendation(adjustedoddsratio[AOR]=12.61;
95% confidence interval [CI] = 6.50, 24.45)
and the daily fruit intake recommendation
(AOR = 16.16; 95% CI = 5.61, 46.51).
Similarly, the lectures plus print group had
a greater increase than did the print group in
the odds of meeting the vegetable intake
recommendation (AOR = 5.53; 95%
CI = 1.96, 15.58). Significant covariates in the
multivariable models for each outcome are
shown in Table A (available as a supplement
to the online version of this article at http://
www.ajph.org).
DISCUSSION
To our knowledge, this study is the first
RCT of behavioral NPA interventions
among Asian Americans and the first RCT
that compared the efficacy of 2 such
TABLE 3—Self-Reported Behavior Meeting Nutrition and
Physical Activity Guidelines at Pre- and Postintervention by
Study Group Among
Older Chinese Americans: San Francisco, CA, August 2010 and
September 2013
Intervention, Group

Lectures and Print
Materials, n = 361, Self-
Reported Behavior Meeting
Guidelines, %
Comparison Group, Print
Materials Only, n = 357,
Self-Reported Behavior
Meeting Guidelines, %
Guideline Pre Post P Pre Post P Pre–Post Differences Between
Group P
Vegetable intake on previous d of ‡ 5 servings 2.2 15.2 £ .001
3.4 4.8 .31 £ .001
Fruit intake on previous d of ‡ 4 servings 9.1 22.4 £ .001 7.3
11.5 .03 .003
Duration of at least moderate physical activity in the last week
of
‡ 150 min
54.9 69.5 £ .001 54.9 64.7 .001 .20
Note. Percentages took into account lay health worker
clustering.Vegetable and fruit intake guidelines adapted from
the 2005 Dietary Guidelines for Americans
of the US Department of Health and Human Services and US
Department of Agriculture.18 Physical activity guidelines
adapted from the 2008 Physical Activity
Guidelines for Americans of the US Department of Health and
Human Services.19 The sample size was n = 718.

TABLE 4—Adjusted Intervention Effects on Knowledge of and
Self-Reported Behavior Meeting Nutrition and Physical Activity
Guidelines
Among Older Chinese Americans: San Francisco, CA, August
2010 and September 2013
Knowledge of Guidelines, AOR (95% CI) Meeting Behavioral
Guidelines, AOR (95% CI)
Guideline
Daily Vegetable
Intake
Daily Fruit
Intake Weekly Physical Activity
Self-Reported Daily
Vegetable Intake
Self-Reported
Daily Fruit Intake
Self-Reported Weekly
Physical Activity
Intervention effecta 12.61 (6.50, 24.45) 16.16 (5.61, 46.51) 2.70
(0.31, 23.15) 5.53 (1.96, 15.58) 1.77 (0.99, 3.15) 1.27 (0.89,
1.80)
Post vs pre effect in print
comparison groupb
1.79 (1.20, 2.66) 1.29 (0.60, 2.77) 8.19 (1.18, 56.92) 1.45 (0.72,
2.89) 1.62 (1.02, 2.57) 1.52 (1.16, 1.99)
Post vs pre effect in lectures

plus print intervention groupb
22.50 (13.24, 38.22) 20.80 (9.93, 43.57) 22.08 (8.86, 55.03)
8.00 (3.70, 17.29) 2.86 (2.00, 4.08) 1.93 (1.54, 2.42)
Note. AOR = adjusted odds ratio; CI = confidence interval.
Models accounted for lay health worker clustering and were
adjusted for additional covariates: years
in the United States, self-reported spoken English proficiency,
highest education level, and visit to a Western health care
provider in last 12 mo. The sample
size was n = 700.
aThe increase in the odds of knowing the guideline or in
meeting the guideline for participants in the lectures plus print
group compared with those in the print
group.
bThe increase in the odds of knowing the guideline or in
meeting the guideline for participants within the same group
pre- and postintervention.
AJPH RESEARCH
106, No. 6
http://www.ajph.org
http://www.ajph.org
interventions in Chinese Americans. In this
sample of older Chinese Americans with LEP,
those who received Chinese-language prin-
ted materials had significant increases in both
knowledge of NPA recommendations and
self-reported behaviors that met those rec-
ommendations at postintervention. Those

who received 2 Chinese-language lectures in
addition to the print materials also had in-
creases in NPA knowledge and behavior. The
combination of lectures plus print materials
was superior to print materials alone for
knowledge of nutrition guidelines and for
behavior meeting such guidelines, although
not for knowledge of the physical activity
recommendation or for behavior meeting
that recommendation.
Baseline rates of knowledge and behavior
related to vegetable and fruit intake guidelines
(adapted from the 2005 Dietary Guidelines
of Americans)18 were low among the older
Chinese Americans, which is consistent with
published studies in other racial/ethnic
groups.21,22 Before intervention, our study
participants reported eating a median 2
servings of vegetables and 2 servings of fruits
during the previous day. This level is slightly
higher than that noted among Vietnamese
Americans surveyed in California in the mid-
1990s23 and national data reporting that
Americans in general have a median intake
of vegetables of 1.6 times daily and of fruit
of 1.1timesdaily.24 Thesefindingsunderscore
the need for designing and testing in-
terventions that can improve healthy nutri-
tion among Asian Americans.
Printed materials led to small but statisti-
cally significant increases of 3.4% in the
proportion knowing the vegetable intake
recommendation and 1.4% and 4.2%, re-
spectively, in the proportion of those meeting

the vegetable and fruit intake recommenda-
tions. Adding 2 Chinese-language lectures
to our lectures plus print intervention led
to substantially larger increases of 32.9%
and 33.5%, respectively, in the proportion
knowing the vegetable and fruit intake
recommendations and 13.0% and 13.3%,
respectively, in the proportion meeting
vegetable and fruit intake recommendations.
Similarly, other studies evaluating the effect
of interactive nutrition lectures in different
at-risk adult populations have also shown
increases in measures of nutrition knowledge
and behavior.25,26
Our findings indicate that optimal nutri-
tion health promotion programs for Chinese
Americans need to include both print and
interactive educational methods. These re-
sults are consistent with published studies
evaluating similar print or instructional in-
terventions promoting healthy NPA in other
Asian and non-Asian populations.27,28 Future
research could examine the training of the
person delivering the oral information (e.g.,
a LHW, certified health educator, registered
dietitian, or physician), the best education
format (e.g., large lectures, small group ses-
sions, or individual instruction), and the
educational content (e.g., MyPlate recom-
mendations, which do not focus on daily
serving intake).
At preintervention, although almost
none of the Chinese Americans in our study
knew the recommended minimum level of

physical activity, about 55% reported
physical activity that met this recommended
level; this baseline level is comparable to
a study reporting that 51.6% of all US adults
met this level.29 Knowledge of the rec-
ommended level of physical activity in-
creased by 2% in the group receiving
Chinese-language print materials compared
with a 19% increase in the group receiving
the print materials and 2 lectures. Behaviors
meeting the recommended level increased
significantly by 10% with the print in-
tervention; adding 2 Chinese-language
lectures in the lectures plus print in-
tervention led to a significant increase
of 15%.
Unlike the findings for nutrition, we
found no difference in effect on self-reported
physical activity between the print and the
lectures plus print interventions. This finding
could be owing to a lack of power in the study
to detect a small difference between the 2
interventions. A second possible explanation
may be that teaching individuals about the
benefits and the recommended level of
physical activity may increase their level of
physical activity to a small degree regardless
of the mode of delivery, but greater increases
may require other intervention methods
in this population. Further research can
explore the effect of alternative educational
methods such as using LHWs who can
provide social support and mobile technol-
ogies that can provide regular reminders
and feedback.

Limitations and Strengths
This study had several important limita-
tions. We used self-reported data, which may
be subject to inflation because of a desire to
meet perceived guidelines.30,31 BMI may be
underestimated because participants may
have underreported their weight and over-
reported their height, a bias that may have
varied by age and gender.32 Furthermore, like
other Asian Americans, Chinese Americans
may have challenges in accurately estimating
serving sizes of vegetables and fruits eaten
because of their preference for “family-style”
eating.33 The findings from this sample of
older Chinese Americans with LEP living
in San Francisco may not be generalizable
to other Chinese American groups or
communities.
In addition, with changes in national di-
etary recommendations,34,35 the nutrition
guidelines we used are no longer the norm.
Because we did not have a no-intervention
control, the modest increases found in the
print-only intervention may have been ow-
ing to increased exposure to the information
through repeated surveys or to secular trends.
The methodological strengths of this study
include the RCT design with strong com-
munity engagement and a large sample size in
an understudied population with a very high
retention rate.
Public Health Implications

Both dietary behaviors and physical ac-
tivity levels are critical, modifiable factors in
the development and subsequent manage-
ment of cardiovascular disease risk factors,
such as hypertension and diabetes. In our
study, two thirds of the participants reported
having at least 1 cardiovascular disease risk
factor (e.g., 15% had diabetes, and > 50% were
overweight or obese). Asian Americans in
particular are at risk because they tend to
develop diabetes at lower BMIs.8,9 Clearly,
interventions are needed to address the po-
tential morbidity and mortality resulting from
poor nutrition and inadequate physical ac-
tivity in this rapidly growing population.
In our cluster RCT, we found that
in-language print materials led to modest
increases in knowledge about nutrition and
improvements in eating behavior and that
adding lectures led to much larger effects.
Print materials alone led to moderate increases
AJPH RESEARCH
Research 1097
in the proportion of participants reporting
adherence to the recommended physical
activity level; adding lectures did not signif-
icantly increase adherence compared with
print materials alone. These findings can

help health promotion programs to design
effective and relevant interventions for
Chinese and other Asian American
communities.
CONTRIBUTORS
J. Jih and G. Le led in writing the content. All authors
contributed substantially to the conceptualization, design,
analysis, and interpretation of data and participated in
revising the content and approving the final version of the
article.
ACKNOWLEDGMENTS
This study was funded by the National Institutes of
Health, National Cancer Institute (grant 1R01CA138778).
Additional support was provided by the National Cancer
Institute,CentertoReduceCancerHealthDisparities(grant
U54 CA153499).
Study results were presented at the 2014 American
Public Health Association Annual Meeting in New
Orleans, LA.
Note. The funders had no role in study design, data
collection and analysis, or preparation of the article.
HUMAN PARTICIPANT PROTECTION
Study protocols were approved by the University of
California, San Francisco and San Francisco State Uni-
versity institutional research boards.
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RESEARCH ARTICLE Open Access
Nutrient intake, serum lipids and iron status of
colligiate rugby players
Hiroyuki Imamura1*, Kazuhide Iide2, Yoshitaka Yoshimura3,
Kenya Kumagai4, Reika Oshikata5, Keiko Miyahara1,
Kazuto Oda1, Noriko Miyamoto6 and Anthony Nakazawa7
Abstract
Background: There are two main playing positions in rugby
(backs and forwards), which demonstrate different

exercise patterns, roles, and physical characteristics. The
purpose of this study was: 1) to collect baseline data on
nutrient intake in order to advise the athletes about nutrition
practices that might enhance performance, and 2) to
compare serum lipids, lipoproteins, apolipoproteins (apo),
lecithin:cholesterol acyltransferase (LCAT) activity, and iron
status of forwards and backs.
Methods: The sporting group was divided into 18 forwards and
16 backs and were compared with 26 sedentary
controls. Dietary information was obtained with a food
frequency questionnaire.
Results: There were significant differences among the three
groups. The forwards had the highest body weight,
body mass index, percentage of body fat (calculated by sum of
four skinfold thicknesses), as well as the highest
lean body mass, followed by the backs and the control group.
The mean carbohydrate intake was marginal and
protein intake was lower than the respective recommended
targets in all three groups. The mean intakes of
calcium, magnesium, and vitamins A, B1, B2, and C were lower
than the respective Japanese recommended dietary
allowances or adequate dietary intakes for the rugby players.
The forwards had significantly lower high-density
lipoprotein cholesterol (HDL-C) and HDL2-C than the backs
and had significantly higher apo B and LCAT activity
than the controls. The backs showed significantly higher HDL-
C, HDL3-C, low-density lipoprotein cholesterol, and
apo A-I, and LCAT activity than the controls. Four forwards
(22%), five backs (31%), and three controls (12%) had
hemolysis. None of the rugby players had anemia or iron
depletion.
Conclusion: The findings of our study indicate that as the
athletes increased their carbohydrate and protein intake,

their performance and lean body mass increased. Further, to
increase mineral and vitamin intakes, we
recommended athletes increase their consumption of green and
other vegetables, milk and dairy products, and
fruits. The forwards showed more atherogenic lipid profiles
than the backs, whereas the backs showed not only
anti-atherogenic lipid profile, but also showed more atherogenic
lipid profile relative to the control group.
Additionally, our study showed none of the rugby players
experienced anemia and/or iron depletion.
Keywords: Athlete, Lipoprotein cholesterol, Apolipoprotein,
Physical activity, Anemia, Iron depletion
* Correspondence: [email protected]
1Faculty of Health Management, Department of Health and
Nutrition,
Nagasaki International University, 2825-7 Huis Ten Bosch,
Sasebo-shi,
Nagasaki 859-3298, Japan
Full list of author information is available at the end of the
article
© 2013 Imamura et al.; licensee BioMed Central Ltd. This is an
Open Access article distributed under the terms of the Creative
Commons Attribution License
(http://creativecommons.org/licenses/by/2.0), which permits
unrestricted use, distribution, and
reproduction in any medium, provided the original work is
properly cited.
Imamura et al. Journal of the International Society of Sports
Nutrition 2013, 10:9
http://www.jissn.com/content/10/1/9

http://creativecommons.org/licenses/by/2.0
Background
Rugby is a popular sport globally, with the International
Rugby Board encompassing 92 national unions. Playing
positions in rugby may be broadly classified as forwards
and backs, which demonstrate different exercise patterns
and roles. The forwards take part in scrums that involve
physical impact and muscular performance, in addition
to running and tackling. The backs display an exercise
pattern focused on running and speed, in addition to
some tackling [1].
Given the different demands placed on forwards and
backs, physical characteristics differ between these posi-
tions. Generally the forwards have higher body fat than
the backs, which may serve as a protective buffer in con-
tact situations. The backs have lower body fat than the
forwards, which may reflect the higher speed require-
ments for these players [1]. Lean subjects, in comparison
with their counterparts, tend to show higher high-
density-lipoprotein cholesterol (HDL-C) and lower low-
density-lipoprotein cholesterol (LDL-C) [2,3]. It has been
shown that low HDL-C concentrations and high LDL-C
concentrations are associated with increased risk of cor-
onary heart disease [4-6]. High physical activity is one of
the factors shown to be associated with high HDL-C
concentrations [7], which may explain, in part, the
decreased risk of coronary heart disease in physically ac-
tive people [8]. A 2002 study reported the lipid profile of
rugby players [9] showed paradoxical decreases in HDL-
C and apolipoprotein (apo) A-I in rugby players com-
pared with those in control groups. However, this study
only compared rugby players as a single group with a
control group.

Because running and physical contact (such as tackling
and scrumming) play an essential role in rugby training
and matches, participating players have risk factors for
iron depletion, which include hemolysis caused by
repeated foot strikes and physical contact, as well as iron
loss through gastrointestinal and urinary tracts, and
sweating [10]. Regarding the occurrence of hemolysis,
one study [11] reported on the iron status of rugby
players. The results of the study showed continuous oc-
currence of hemolysis in the players. However, this study
only compared rugby players as a single group with a
control group.
Many of the studies on the lipid [6,12,13] and iron
[14,15] status of athletes primarily examine their relative
endurance activities, whereas the lipid and iron status of
rugby players is less known. The purpose of this study
of rugby players was: 1) to collect baseline data on nu-
trient intake in order to advise athletes about nutrition
practices that might enhance performance, and 2) to
compare serum lipids, lipoproteins, lecithin:cholesterol
acyltransferase (LCAT) activity, and iron status of the
forwards and backs.
Methods
Subjects
The sporting group consisted of 34 male rugby players
who competed in the All Japan Collegiate Champion-
ship. They were divided into two groups, 18 forwards
and 16 backs, and were compared with 26 sedentary
controls. The players had maintained their training
schedule, which consisted of aerobic and anaerobic exer-
cises all year round (at least six days/week, two train-
ings/day, and two hours/day), and had played one match
a week for more than 4 years. The mean (± SD) experi-

ences of the forwards and backs were 5.6 ± 3.8 years and
6.5 ± 3.3 years, respectively. Because almost all partici-
pating university students belonged to sport clubs at
their respective university, collegiate controls from three
other universities were solicited for participation. They
had been sedentary, except when taking a physical edu-
cation class once a week, for at least 1 year. All data
were obtained in June, which was considered representa-
tive of athletes’ physiological status during pre-season
training. The subjects were all non-smokers and were
not taking any drugs known to affect lipid and lipopro-
tein metabolism. The study protocol was approved by
the ethics committee of the participating universities.
Informed consent was obtained from each participant of
this study.
Measurements and dietary information
Body weight and height were measured with the subjects
in underwear to the nearest 0.1 kg and 0.1 cm, respect-
ively. The body mass index (BMI) was determined as
weight/height2 (kg/m2). The biceps brachii, triceps bra-
chii, subscapular, and suprailiac skinfold thicknesses
were measured with a Harpenden caliper on the right
side of the body with the subject in a standing position
and are expressed as the mean of three consecutive mea-
surements. The average of three measurements at each
site was used to calculate the body density [16], percent-
age of body fat (%Fat), and lean body mass (LBM) [17].
All subjects were interviewed by experienced dietitians
using a food frequency questionnaire (FFQ), which is
based on 29 food groups and 10 types of cooking, for es-
timating the energy and nutrient intakes of each subject
during the past one to two months [18]. From FFQ’s, the
selected mean daily dietary and nutrient intakes were
calculated according to the Tables of Japanese Foodstuff

Composition [19]. Information on nutrient supplements
and/or on diet was obtained via a self-administered
questionnaire. The accuracy of the questionnaire was
checked through individual interviews.
Blood analysis
Physical exercise and beverages other than water were
not allowed 36 h prior to the blood sampling. Subjects
Nutrition 2013, 10:9 Page 2 of 9
http://www.jissn.com/content/10/1/9
arrived at the laboratory by 0800 h. The temperature of
the laboratory was set at 25�C. Fasting (12 h) blood sam-
ples were drawn from the antecubital vein after each
subject had been seated quietly for at least 30 min. The
samples were immediately stored in a cooler box, which
was kept at 4�C until centrifugation was done in a refri-
gerated centrifuge at 4�C. Samples were analyzed by a
local commercial laboratory (SRL Inc., Tokyo, Japan). All
measurements were duplicated, and the results were
reported within 2 weeks. Total cholesterol and triglycer-
ides (TG) were analyzed by enzymatic methods. HDL-C
was analyzed by direct assay with a selective inhibition
method. HDL2-C and HDL3-C were analyzed by an
ultracentrifugation method. LDL-C was analyzed by hep-
arin and citrate precipitation method. LCAT activity was
analyzed by a dipalmitoyl lecithin substrate method. Apo
A-I and B were analyzed by a turbidimetric immuno-
assay method. Details of these methods and intra-assay
and inter-assay coefficients of variation have been pre-
sented prior [20,21].
Red blood cells (RBC), hemoglobin (Hb), and hematocrit

(Ht) were measured using an automated blood cell
analyzer. Mean corpuscular volume (MCV) was calculated
by Ht/RBC×10. Mean corpuscular hemoglobin (MCH) was
calculated by Hb/RBC×10. Mean corpuscular hemoglobin
concentration (MCHC) was calculated by Hb/Ht×100.
Serum ferritin was measured by chemiluminescent enzyme
immunoassay. Serum iron, total iron-binding capacity
(TIBC), and unsaturated iron binding capacity were mea-
sured by a Nitroso-PSAP method. Serum transferrin was
measured by a turbidimetric immunoassay method. Serum
haptoglobin was measured by a nephelometry method. Per-
centage of saturated transferrin was calculated by serum
iron/TIBC×100. Details of these methods for iron-related
parameters have been presented elsewhere [22]. Anemia
was defined as Hb level below 13 g/dl. Iron depletion was
defined as ferritin level below 20 μg/L [23]. Hemolysis was
defined as serum haptoglobin lower than the standard
values reported by the commercial laboratory (SRL Inc.,
Tokyo, Japan).
Statistical analysis
The SPSS statistical software 17.0J (Chicago, IL) was
used to analyze the data. Descriptive statistics included
means and SD. One-sample Kolmogorov-Smirnov test
was performed to examine whether or not each param-
eter was normally distributed. Logarithmic transform-
ation of TG was used to normalize the grossly skewed
(p<0.05) distribution of this parameter. The mean differ-
ences among the three groups were determined by one-
way analysis of variance. Scheffe’s test was used to identify
specific significant differences when significant F values
were identified. Two-sided p<0.05 was considered to be
statistically significant.
Results

The mean characteristics of the subjects are shown in
Table 1. The forwards had significantly higher body
weight, BMI, waist circumference, biceps brachii, sub-
scapular, and suprailiac skinfold thicknesses, sum of 4
skinfold thicknesses, % fat, and LBM than the backs and
control group. The backs had significantly higher body
weight, BMI, triceps brachii, sum of 4 skinfold thick-
nesses, % fat, and LBM than the control group
The mean daily nutrient intakes are shown in Table 2.
Among the rugby players, nine were occasionally tak-
ing protein and/or multi-vitamin and mineral supple-
ments. Because the inclusion of supplements did not
alter the results, the results are presented without the
supplements. The forwards had significantly higher
mean intakes of energy, fat, carbohydrate, saturated
fat, polyunsaturated fat, potassium, calcium, magne-
sium, phosphorus, iron, vitamins B1 and B2 than the
controls. The backs had significantly higher energy,
carbohydrate, and magnesium intakes than the control
group.
The micronutrient intakes expressed as percentages of
the Japanese dietary allowances (RDAs) or adequate diet-
ary intakes (ADIs) are shown in Table 3. The mean
intakes of calcium, magnesium, and vitamins A, B1, B2,
and C were lower than the respective Japanese RDAs or
ADIs in the rugby players. The mean intake of iron was
above RDA in the forwards, whereas it was below in the
backs. All micronutrient intakes were lower than the re-
spective RDAs or ADIs in the control group.
Table 1 Anthropometric characterics of rugby players
and controls
Forward Backs Controls

(n=18) (n=16) (n=26)
Age (yrs) 19.5 ± 0.9 19.5 ± 1.0 19.5 ± 1.1
Height (cm) 173.7 ± 5.9 † 171.2 ± 4.3 168.8 ± 6.9
Weight (kg) 87.3 ± 8.9 * † 72.6 ± 7.4 † 58.5 ± 6.1
BMI (kg/m 28.9 ± 2.5 * † 24.8 ± 2.0 † 20.5 ± 1.8
Waist (cm) 89.5 ± 9.5 * † 78.7 ± 5.9 72.2 ± 5.3
Biceps brachii (mm) 8.9 ± 3.2 * † 6.5 ± 3.6 4.6 ± 0.7
Triceps brachii (mm) 17.0 ± 4.0 † 13.7 ± 4.5 † 9.7 ± 3.6
Subscapular (mm) 19.3 ± 6.1 * † 14.4 ± 5.1 11.0 ± 2.7
Suprailiac (mm) 20.9 ± 7.0 * † 11.6 ± 6.1 8.3 ± 2.2
4 skin in fold (mm) 66.1 ± 18.0 * † 46.3 ± 16.5 † 26.2 ± 8.1
% Fat 22.9 ± 4.1 * † 18.8 ± 4.5 † 14.8 ± 2.4
LBM (kg) 68.3 ± 5.1 * † 59.7 ± 5.1 † 50.4 ± 5.2
Values are the mean ± SD.
Abbreviations; BMI, body mass index; % Fat, Percentage of
body fat; LBM, lean
body mass.
*p < 0.05 vs Backs.
†p < 0.05 vs Controls.
Nutrition 2013, 10:9 Page 3 of 9

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