A physically active lifestyle is important for many aspects of health (9). Studies have shown that people who are more physically active have reduced risk of heart disease (21,30,35), colon and breast cancer (15,33,38), diabetes (11,19,26), depression (12,20,28), and increased longevity (23,37). Despite the widely held belief that physical activity has many health benefits, many Americans do not achieve the target of ≥30 min of moderate to vigorous activity on most days of the week (9). It has been estimated that in 2000, roughly 45% of Americans engaged in activities consistent with the physical activity recommendation (27).
Coupled with the problem of achieving a physically active lifestyle is the problem of increasing obesity. Like physical inactivity, obesity contributes to many health conditions and is now considered a public health epidemic (31). In the United States, the prevalence of obesity is higher in certain ethnic groups, including African-American, Hispanic, and Native American populations, and is most likely linked to activity patterns in these populations (8).
Data from migrant studies suggest that as people move from areas of low disease rates to high disease rates, they adopt the disease rates in the host country (18). It has been suggested that in migrant populations, a major contribution to changing disease rates is acculturation, where migrant populations take on diet and lifestyle characteristics of the dominant group in the host country. However, acculturation is a complex concept, and although no single factor is an adequate measure, language preference has been used frequently (25). Our existing knowledge of activity patterns in minority groups suggests that they engage in lower amounts of recreational activities than non-Hispanic white populations (6,22). However, less is known about the influence of acculturation on activity patterns in U.S. ethnic minority populations. Outside the arena of screening, acculturation has been examined in only a few studies as a moderator of obesity, diet, and cigarette smoking (7,29,32).
In the southwestern United States, the effects of changing lifestyle patterns among Hispanic populations may contribute to increasing obesity and other diseases associated with these changes. According to the 2000 U.S. Census, in the four-corner states of Arizona, Colorado, New Mexico, and Utah, 22% of the total population are of Hispanic or Latino ethnicity. This Hispanic population includes families who are long-term residents of the region, as well as immigrants from Spanish-speaking countries. Significant numbers of both U.S.-born and foreign-born respondents to the 2000 U.S. Census in the southwest reported that Spanish is spoken in the home. Health behaviors, including physical activity, may differ depending on the extent to which individuals have retained the traditional Hispanic culture or have adopted the cultural characteristics of non-Hispanic white populations.
In this paper, we describe activity patterns of Hispanic and non-Hispanic white women living in the southwestern United States, using data from controls participating in the 4 Corner’s Study of breast cancer. The purpose of the larger study is to evaluate differences in breast cancer risk factors between Hispanic and non-Hispanic white women, with a focus on nutrition, exercise, hormones, and insulin. In these analyses, we used information obtained from approximately 2000 women interviewed as controls to describe activity patterns and obesity among Hispanic women in this region, compare them with non-Hispanic white women, and evaluate the effects of language acculturation on activity patterns and obesity among Hispanic women. We use language preference as an indicator of acculturation.
Participants were women between 25 and 79 yr of age living in Arizona, Colorado, New Mexico, and Utah and selected as controls for a large case-control study of breast cancer. In Arizona and Colorado, participants younger than age 65 were randomly selected from a commercial mailing list; in New Mexico and Utah, they were randomly selected from driver’s license lists. In all states, women 65 yr and older were randomly selected from CMS (social security lists). In all states, controls were frequency matched by 5-yr age groups to breast cancer cases. All participants signed informed written consent; the study was approved by the institutional review board for human subjects in each study center.
Diet and lifestyle data were collected by trained and certified interviewers using a computerized questionnaire. Respondents were given the option of having the interview administered in either English or Spanish. Questionnaires were translated into Spanish by two individuals with a third person arbitrating for differences in translation. Interviewers reported the language of the interview as English only, mixed-mostly English, mixed-mostly Spanish, and only Spanish. Participants were asked to self-report race or ethnic background by selecting one or more of the following groups: Hispanic/Latina, white or Anglo not of Hispanic origin, Native American or Alaska Native, or other. Additionally, respondents were asked to describe both their mother’s and father’s race or ethnic background using the same categories. Self-reported ethnicity was used to classify women as either Hispanic or non-Hispanic white.
To help determine language acculturation, questions were asked regarding preference for speaking and reading Spanish. Participants were asked whether they spoke/read Spanish only, Spanish better than English, both English and Spanish equally well, English better than Spanish, and only English. Language acculturation was used as an indicator of acculturation and was based on a combination of these questions.
A detailed physical activity questionnaire was developed to capture activity performed at various levels of intensity, including activities performed at leisure, work, and around the home. The physical activity questionnaire was adapted from the Cross-Cultural Activity Participation Study (CAPS) questionnaire that has been used to estimate activity of minority women (3). The CAPS questionnaire was modified to obtain more information on reported intensity of physical activities, to include more activities that were common in the study population, and to change the referent period from 1 month to 1 yr. Additionally, questions about physical activity over one’s lifetime were asked that included the amount of moderate and intense activities performed at ages 50, 30, and 15. The following physical activities were ascertained: activity performed at home (light effort household chores, heavy effort household chores, and lawn, yard and farm chores of light and intense nature); caring for dependent children and dependent adults (activities requiring light and intense effort during care providing); walking (both leisurely pace and at a moderate to brisk pace as for walking for exercise or to get places); sports and conditioning activities (dancing, golfing, softball, volleyball, basketball, tennis or other racquet sports, backpacking, skiing, biking, stretching and yoga, lifting weights, jogging, running, swimming, rowing or canoeing, exercise machines, and any other sports or conditioning); work (time spent sitting or standing and walking); and volunteering (by level of intensity). Women were asked to report the amount, intensity, and duration of activities they performed. MET values were assigned based on the compendium of physical activities that was updated in 2000 (2). To obtain an activity variable that was more representative of lifetime activity, we averaged the activity reported at ages 15, 30, and 50 and during the referent period.
Weight was measured at the time of interview to the nearest 0.50 lb. Height was measured to the nearest 0.25 inch. Body mass index was calculated using the formula of weight (kg) divided by height (m) squared (kg·m−2). Other questionnaire data included reproductive history, use of hormone replacement therapy, history of aspirin and nonsteroidal antiinflammatory drug use, and cigarette smoking history. Dietary intake was obtained from a detailed diet history questionnaire that was used to estimate dietary intake during the referent year. The questionnaire obtains information on over 300 possible foods eaten, amount eaten, and frequency of consumption; it is based on the validated CARDIA diet history questionnaire (24,34).
Characteristics of the population were summarized for non-Hispanic white women, all Hispanic women, and Hispanic women by level of language acculturation. The population was described in terms of numbers, percentages, differences in mean levels of reported activity and body mass index (BMI), and differences in proportions of non-Hispanic white to Hispanic, by level of language acculturation, and by comparing Hispanic women with the highest level of language acculturation to non-Hispanic white women. Differences in the distributions of the populations and the differences in proportions across populations were assessed using the chi-square test; Student’s t-tests were used when evaluating mean differences in activity levels. Age-adjusted means of physical activity variables were predicted from a generalized linear model. Values of both written and spoken language range from 1 to 5 (1 = “Spanish only” to 5 = “English only”), and the average of these two values was used to measure language acculturation that was used as a surrogate for acculturation. Low language acculturation was given to individuals who had a score of ≤2 and high was given to women with a score of ≥4. This generally resulted in those who could only read and speak Spanish or read and speak Spanish better than English as having low language acculturation. Hispanic women classified as being highly linguistically acculturated generally only read and speak English or read and speak English better than Spanish. To compare the effects of language acculturation on activity and obesity, we compared non-Hispanic white women with Hispanic women, Hispanic women across levels of language acculturation, and highly linguistically acculturated Hispanic women with non-Hispanic white women.
Physical activity was assessed by individual activities within activity domains; activity at ages 15, 30, and 50; lifetime activity; and activity factor scores that were generated from factor analyses in an attempt to look at broader activity patterns. Activities were grouped into various domains of activity as well as lifetime measures of activity such as activity around the house, at work, during dependent care, sports, and specific types of sports.
Physical activity patterns were determined from the individual activity variables using factor analysis. Factors were extracted using the principal components method, and factors with eigenvalues >1.0 were retained. The factors were then rotated using the varimax rotation and factor scores were calculated for each study participant for each factor that was retained. Within a factor, a negative loading indicates that they are inversely associated with the factor, while those with a positive loading indicate a direct association with the factor. Each factor is uncorrelated with each other factor, with the first factor accounting for as much of the variability in the data as possible. Each subsequent factor is orthogonal to the previous factors and accounts for as much of the remaining variability in the data as possible. Rotation of the factors enabled us to minimize the number of variables correlated with a given factor while maximizing the intercorrelation of the variables within that factor. The magnitude of the absolute value of the factor loading of a variable indicates the strength of the contribution of that variable to a specific factor. The value for meaningful factor loading is arbitrary; we considered factors with values of ≥0.2 as contributing significantly to the activity factors. Labeling of activity patterns was arbitrary and based on our interpretation of the data and does not represent a priori assumptions. Individual factor scores were used in analyses. Physical activities can be in more than one factor, with varying degree of loading into the various factors.
Associations between language acculturation, obesity, and physical activity were estimated using logistic regression models; odds ratios (OR) and 95% confidence intervals (CI) are reported. In these models, adjustment variables were treated as continuous variables, except for education and center that was categorical. In these analyses, non-Hispanic white women are the referent group. To further evaluate the public health implications of acculturation on activity patterns, we report the prevalence of meeting various physical activity recommendations across race and acculturation levels as described by Brownson and colleagues (6). All statistical analysis were performed using SAS 8.2 (SAS Institute, Cary, NC).
The majority of the women participating were between 40 and 69 yr of age (Table 1). Approximately 22% of Hispanic women reported speaking Spanish better than English or Spanish only, and 18.9% reported reading Spanish better than English or Spanish only. Over 19% of Hispanic women completed the interview entirely or mostly in Spanish. Of Hispanic women, 18.5% were classified as low language acculturation. Significantly more Hispanic women than non-Hispanic white women had a BMI of ≥30. Significantly more non-Hispanic white women reported physical activity at moderate and vigorous levels of intensity than Hispanic women. Education was significantly associated with ethnic group. Further evaluation showed strong inverse associations between education achieved and level of language acculturation (data not shown in table).
Types of activities reported by non-Hispanic white women and Hispanic women differed (Table 2). Hispanic women reported more housework, dependent caregiving, dancing, and jobs involving standing and vigorous activity than non-Hispanic white women. As Hispanic women became more acculturated to the English language, they were more involved in moderate-intensity sports and reported less job activity. Vigorous activity performed at ages 15 and 30 were similar for non-Hispanic white women and Hispanic women; however, at age 50, non-Hispanic white women reported significantly more activity than Hispanic women. Lower physical activity levels at age 50 among Hispanic women contributed to their lower total lifetime activity levels than was observed for non-Hispanic white women. However, Hispanic women with high language acculturation still differed from non-Hispanic women in several domains, including housework, dependent care, and dancing. The mean MET-minutes of total and vigorous activity was higher among non-Hispanic white women than Hispanic women (Table 2). The differences were significant when assessed by language acculturation, with Hispanic women with lower language acculturation having significantly lower MET-hours of total and vigorous physical activity compared with Hispanic women with higher language acculturation.
Achievement of various physical activity milestones was evaluated by race and language acculturation (Table 3). Approximately 35% of non-Hispanic white women reported obtaining regular moderate- to intense-level activity 30 min·d−1, 5 d·wk−1, whereas 25% of Hispanic women reported meeting this goal. These differences were statistically significant after adjusting for age and education level. Considerably fewer women reported vigorous activity for at least 20 min, three times per week. Significantly more Hispanic women, regardless of level of language acculturation, reported no leisure time or any regular activity. Involvement in regular and vigorous activity increased with increasing levels of language acculturation, while occupational and household activity decreased.
To describe physical activity patterns, we evaluated six different physical activity factors that explain 43.7% of the total variation (Table 4). Factor 1, Fitness Club, consisted of activities often done at fitness clubs and included strength training, aerobics, exercise machines as well as biking, jogging, and walking. Factor 2, Sports, included all types of leisure time sports including tennis, hiking, skiing, swimming, rowing, and other sports. Factor 3, Home and Yard, loaded heavily on housework, yard work, dependent care, and walking. Factor 4, Group Sports, included softball, basketball, and bowling as the major contributors to the factors. Factor 5, Club Activities, was restricted to golfing, tennis, skiing, and bowling and inversely related to performance of other activities. Dancing, aerobics and swimming were the main contributors to the sixth factor, Dance/Aerobics, with lower levels of loading by strength training, dependent care, and bowling. The factor scores for Hispanic and non-Hispanic white women showed a predominance of different activity patterns for the two groups. The major differences were observed in factors 2, 3, and 5, with being Hispanic having inverse association with factors that revolved around sports and being Hispanic having direct associations with factors involving house, yard, dependent care, and walking.
Physical activity was strongly inversely associated with BMI (Table 5). Both non-Hispanic white women and Hispanic women were significantly less likely to be overweight or obese if they had high levels of physical activity. These associations were similar for all ages and levels of language acculturation (age and language acculturation data not shown in table).
Further evaluation of the association of ethnicity and language acculturation on body weight showed that Hispanic ethnicity overall was associated with being overweight and obese after adjusting for age, physical activity, education, and energy intake (Table 6). Those considered to have an intermediate level of language acculturation compared with non-Hispanic white women were roughly three times more likely to be overweight (OR = 3.24, 95% CI = 2.16–4.87) and obese (OR = 2.79, 95% CI = 1.85–4.20); this difference across categories was statistically significant at the 0.01 level. Hispanic women with the highest level of language acculturation were more likely to be overweight (OR = 1.57, 95% CI = 1.12–2.21) and obese (OR = 1.78, 95% CI = 1.28–2.47) than non-Hispanic white women after adjusting for energy intake, physical activity, center, and education level.
This study indicates that there are differences in both type and intensity of activities performed by Hispanic and non-Hispanic women; differences further exist by level of language acculturation among Hispanic women. Less than 25% of all women reported doing ≥20 min of vigorous activity on ≥3 d·wk−1. The majority of both Hispanic and non-Hispanic white women also were involved in <30 min of leisure activity ≥5 d·wk−1, although among Hispanic women, a greater percentage of women meet the goal if they reported higher levels of acculturation. Results from this study indicate that Hispanic and non-Hispanic white women in the southwest differ in the type of physical activities that they participate in and that the type of physical activity differs by level of language acculturation. The effect of these differences is lower MET-hours of total and vigorous physical activity among women with lower levels of language acculturation.
We evaluated activity patterns in Hispanic and non-Hispanic white women by looking at various activity domains as well as activity factors. Our results suggest that activities and patterns of activities performed by these women living in the southwest differ by ethnic group. Hispanic women are more likely to report activities that are performed around the house and of dependent care, while non-Hispanic white are more likely to report activities that are sport based. These differences may contribute to differences in activity levels of women at different ages.
In this study, we evaluated differences in physical activity patterns and obesity by ethnic group and language acculturation. Acculturation is complex and difficult to measure because it encompasses many aspects of individual’s lives. The indicator of acculturation we used in this study was restricted to language acculturation as indicated by preferred language to speak and to read. Language use has been identified by others as an easily measured indicator of cultural change (25). Similar acculturation scores to the one used here have been developed by taking into consideration the preferred language to speak, read, think, and speak with friends (10). The results from the study by Evenson and colleagues (13) evaluating language acculturation and physical activity support our findings on language acculturation and physical activity. They observed that Latino women with lower levels of language acculturation had lower levels of physical activity. We add to the work by Evenson and colleagues by looking at types of activities and patterns of activities that may be associated with language acculturation.
There are several limitations in studies of acculturation. First, acculturation is highly correlated with education level. Ability to accurately estimate types, frequency, and duration of activities may vary directly with education level. Thus, differences in activity levels may reflect ability to accurately complete the questionnaire and recall activities. However, we observed differences in types of activities between Hispanic women and non-Hispanic white women regardless of language acculturation level, although we also observed dose-response changes in activity levels and types of activities with increasing language acculturation. In an effort to compare differences across level of acculturation as well as by ethnic group, many comparisons were made. Thus, the chance of spurious findings exists, although most P values were <0.01. Evaluation of physical activity using standard MET values could introduce errors in estimating physical activity levels because significant differences in body size exist between Hispanic and non-Hispanic white women. Study participants were matched by 5-yr age groups to breast cancer cases in the target populations and therefore are not truly a random sample of all Hispanic women. Height and weight were measured in the participant’s home; thus, we were able to avoid potential recall bias of these variables that were used to calculate BMI.
In this study, we showed that Hispanic women reported less total and vigorous physical activity, particularly at age 50, than non-Hispanic white women. This was especially true when looking at MET-hours of activity, with significant increases in MET-hours of activity as language acculturation increased. Types of activities reported also varied by language acculturation. While non-Hispanic white women reported more activities involving leisure and sports; Hispanic white women more often reported activities that involved providing dependent care, housework, and occupational activity. These differences in types of activities could account for the differences in physical activity levels in Hispanic women at age 50. While there were no differences in overall activity levels at ages 15 and 30 for non-Hispanic white women and Hispanic women by level of acculturation, at age 50, significant differences in activity patterns were observed between non-Hispanic white and Hispanic women. Others have examined different components of acculturation such as the age at which one moves to the United States and activity. Evenson and colleagues (13) found that women with higher language acculturation were more likely to be active and that moving to the United States when younger rather than older also was associated with greater activity levels. Unfortunately, we do not know length of time spent in the United States, although data from the U.S. Census shows that 12.8% of the population in Arizona, 8.6% of the population in Colorado, 8.2% of the population in New Mexico, and 7.1% of the population in Utah are foreign born. Others have reported that in children, acculturation to the United States was associated with lower physical activity and higher consumption of fast foods, behaviors that increase the risk of obesity (36). A study by Gordon-Larsen et al. (17) also considered proportion of foreign-born neighbors as an indicator of acculturation. In that study, rapid acculturation was associated with overweight-related behaviors such as physical inactivity, with the first generation experiencing the greatest lifestyle differences that influenced obesity and activity patterns. In our study, those with intermediate language acculturation had the greatest percentage of women who were both overweight and obese. It is possible that women with low levels of language acculturation may be less likely to adapt to changes in diet that influence obesity, those in the intermediate level adapting a Western-style diet but not increasing activity patterns to compensate for the increased energy intake, and those at the highest level changing activity patterns and possibly healthier dietary patterns.
Regardless of ethnic group and level of language acculturation, the majority of women did not meet the recommended levels of regular or vigorous activity. Our results on the prevalence of activity in the population are similar to what is reported in other studies. In a study of acculturation and physical activity in North Carolina Latina women, 37.4% met recommendations for physical activity and 20.7% reported no moderate to vigorous activity (13). Others report lower physical activity for Hispanic than non-Hispanic white populations at all age and education groups (1,5,14,16).
Obesity is a major public health problem, and this problem is accentuated among Hispanic women. Reports show that among Hispanic populations, obesity is a major contributor to insulin-resistance syndrome and type 2 diabetes (8). The prevalence of obesity has been shown in one study of Hispanic women to be 39.7 and 41% in another study (4); the prevalence of obesity, or a BMI of ≥30, in our study was 42% among Hispanic women (8). Another study suggested that more highly acculturated Mexican-American women were more likely to have more education, higher income, and fewer barriers to a healthy diet compared with more traditional Mexican women; all these factors were associated with obesity (4). Our data would support this observation. The study of Gordon-Larsen et al. (17) suggested that length of time in the United States influenced obesity level and that people who moved more recently and were in a rapid acculturation stage were most likely to experience weight gain. Our data suggest that those in the intermediate acculturation group were most likely to be obese and overweight. This could possibly be explained by the degree of acculturation, similar to that observed by Gordon-Larsen and colleagues. Those with lowest level of acculturation may be less likely to have acquired dietary and other lifestyle habits that would contribute to greater obesity, while those at the highest level of acculturation have the resources to achieve better diet and activity patterns, and those at intermediate levels of acculturation are most at risk of becoming obese. However, in all groups of Hispanic women, we observed significant increases in risk of being overweight and obese compared with non-Hispanic white women after adjustment for education level, energy intake, and physical activity. It is possible that this is indicative of greater genetic susceptibility to obesity among Hispanic women.
In summary, these data show differences in activity patterns between Hispanic and non-Hispanic white women, some of which are influenced by level of acculturation. These differences were greatest as women aged, with significant differences in activity reported at age 50, although not when younger. Overall, more non-Hispanic white women and Hispanic women with higher levels of language acculturation reported meeting physical activity goals more frequently. However, all Hispanic women were at increased risk of being overweight and obese after adjusting for age, education level, energy intake, and physical activity patterns. Promotion of physical activity in Hispanic women is needed, given the increased risk of obesity; focusing on activities that are culturally accepted should be an important component of these health promotion efforts. Further assessment of how these differences in behavior translate to differences in disease rates is important. Likewise, it is important to identify possible differences in genetic susceptibility that may put these women at higher risk of obesity. As Hispanic populations are becoming more acculturated, targeted promotion of physically active lifestyles is needed.
1. Ahmed, N. U., G. L. Smith, A. M. Flores, et al. Racial/ethnic disparity and predictors of leisure-time physical activity among U.S. men. Ethn. Dis.
2. Ainsworth, B. E., W. L. Haskell, M. C. Whitt, et al. Compendium of physical activities: an update of activity codes and MET intensities. Med. Sci. Sports Exerc.
3. Ainsworth, B. E., M. L. Irwin, C. L. Addy, M. C. Whitt, and L. M. Stolarczyk. Moderate physical activity patterns of minority women: the Cross-Cultural Activity Participation Study. J. Womens Health Gend. Based Med.
4. Ayala, G. X., J. P. Elder, N. R. Campbell, et al. Correlates of body mass index and waist-to-hip ratio among Mexican women in the United States: implications for intervention development. Womens Health Issues
5. Brownson, R. C., E. A. Baker, R. A. Housemann, L. K. Brennan, and S. J. Bacak. Environmental and policy determinants of physical activity in the United States. Am. J. Public Health
6. Brownson, R. C., A. A. Eyler, A. C. King, D. R. Brown, Y. L. Shyu, and J. F. Sallis. Patterns and correlates of physical activity among US women 40 years and older. Am. J. Public Health
7. Cantero, P. J., J. L. Richardson, L. Baezconde-Garbanati, and G. Marks. The association between acculturation and health practices among middle-aged and elderly Latinas. Ethn. Dis.
8. Cossrow, N., and B. Falkner. Race/ethnic issues in obesity and obesity-related comorbidities. J. Clin. Endocrinol. Metab.
9. Department of Health and Human Services, U. S. Physical activity and health: a report of the Surgeon General.
Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996.
10. Deyo, R. A., A. K. Diehl, H. Hazuda, and M. P. Stern. A simple language-based acculturation scale for Mexican Americans: validation and application to health care research. Am. J. Public Health
11. Di Loreto, C., C. Fanelli, P. Lucidi, et al. Make your diabetic patients walk: long-term impact of different amounts of physical activity on type 2 diabetes. Diabetes Care
12. Dunn, A. L., M. H. Trivedi, J. B. Kampert, C. G. Clark, and H. O. Chambliss. Exercise treatment for depression: efficacy and dose response. Am. J. Prev. Med.
13. Evenson, K. R., O. L. Sarmiento, and G. X. Ayala. Acculturation and physical activity among North Carolina Latina immigrants. Soc. Sci. Med.
14. Evenson, K. R., S. Wilcox, M. Pettinger, R. Brunner, A. C. King, and A. McTiernan. Vigorous leisure activity through women’s adult life: the Women’s Health Initiative Observational Cohort Study. Am. J. Epidemiol.
15. Friedenreich, C. M., and T. E. Rohan. A review of physical activity and breast cancer. Epidemiology
16. Gordon-Larsen, P., L. S. Adair, and B. M. Popkin. Ethnic differences in physical activity and inactivity patterns and overweight status. Obes. Res.
17. Gordon-Larsen, P., K. M. Harris, D. S. Ward, and B. M. Popkin. Acculturation and overweight-related behaviors among Hispanic immigrants to the US: the National Longitudinal Study of Adolescent Health. Soc. Sci. Med.
18. Haenszel, W., and M. Kurihara. Studies of Japanese migrants. I. Mortality from cancer and other diseases among Japanese in the United States. J. Natl. Cancer Inst.
19. Hu, F. B. Sedentary lifestyle and risk of obesity and type 2 diabetes. Lipids
20. Iverson, G. L., and D. S. Thordarson. Women with low activity are at increased risk for depression. Psychol. Rep.
21. Karmisholt, K., and P. C. Gotzsche. Physical activity for secondary prevention of disease. Systematic reviews of randomised clinical trials. Dan. Med. Bull.
22. Kriska, A. M., and A. R. Rexroad. The role of physical activity in minority populations. Womens Health Issues
23. Lee, I. M., R. S. Paffenbarger, Jr., and C. H. Hennekens. Physical activity, physical fitness and longevity. Aging (Milano)
24. Liu, K., M. Slattery, D. Jacobs, Jr., et al. A study of the reliability and comparative validity of the cardia dietary history. Ethn. Dis.
25. Marin, G. A. M., and B. Van Oss. Research with Hispanic Populations.
Newbury Park, CA: Sage Publications, 1991, p. 123.
26. Meigs, J. B. Prevention of coronary heart disease in diabetes. Curr. Treat. Options Cardiovasc. Med.
27. MMWR. Prevalence of Physical Activity, Including Lifestyle Activities among Adults—United States, 2000–2001
, 2003, pp. 764–769.
28. Morgan, W. P. Physical activity, fitness, and depression. In: Physical Activity, Fitness, and Health. International Proceedings and Consensus Statement.
C. Bouchard, R. J. Shephard, and T. Stephens (Eds.). Champaign, IL: Human Kinetics Publishers, 1994, pp. 851–868.
29. Neuhouser, M. L., B. Thompson, G. D. Coronado, and C. C. Solomon. Higher fat intake and lower fruit and vegetables intakes are associated with greater acculturation among Mexicans living in Washington State. J. Am. Diet. Assoc.
30. Powell, K. E., P. D. Thompson, C. J. Caspersen, and J. S. Kendrick. Physical activity and the incidence of coronary heart disease. Annu. Rev. Public Health.
31. Rigby, N. J., S. Kumanyika, and W. P. James. Confronting the epidemic: the need for global solutions. J. Public Health Policy.
32. Samet, J. M., C. A. Howard, D. B. Coultas, and B. E. Skipper. Acculturation, education, and income as determinants of cigarette smoking in New Mexico Hispanics. Cancer Epidemiol. Biomarkers Prev.
33. Slattery, M. L. Physical activity and colorectal cancer. Sports Med.
34. Slattery, M. L., B. J. Caan, D. Duncan, T. D. Berry, A. Coates, and R. Kerber. A computerized diet history questionnaire for epidemiologic studies. J. Am. Diet. Assoc.
35. Sundquist, K., J. Qvist, S. E. Johansson, and J. Sundquist. The long-term effect of physical activity on incidence of coronary heart disease: a 12-year follow-up study. Prev. Med.
36. Unger, J. B., K. Reynolds, S. Shakib, D. Spruijt-Metz, P. Sun, and C. A. Johnson. Acculturation, physical activity, and fast-food consumption among Asian-American and Hispanic adolescents. J. Community Health
37. Walker, A. R., B. F. Walker, and F. Adam. Nutrition, diet, physical activity, smoking, and longevity: from primitive hunter-gatherer to present passive consumer—how far can we go? Nutrition
38. WHO, IARC. Weight Control and Physical Activity.
Lyon, France: IARC Press, 2002, pp. 83–199.