Factors Influencing the Accumulation of Recommended Physical Activity among Latinos in the Deep South of the United States

Less than 40% of the U.S. population achieves the recommended amount of leisure-time physical activity (LTPA) recommended by the American College of Sports Medicine [ACSM (>150 minutes/week of moderate-intensity or equivalent vigorous-intensity LTPA)]. The number of Hispanic/Latino men and women who report being physically inactive is disproportionately higher than non-Hispanic/Latinos. The purpose of this investigation is to evaluate factors which influence the achievement of meeting ACSM recommendations for LTPA among adults with Hispanic/Latino ethnicity and whites (non-Hispanic/Latino) in the southern United States. Self-reported data collected as part of the Behavioral Risk Factor Surveillance System (BRFSS) was analyzed in male and female Hispanic/Latinos and non-Hispanic/Latino whites using the Andersen Model and Chi Square Analysis to examine the association between variables. Hispanic/Latino men/women were significantly less likely to meet the ACSM recommendations (> 150 minutes/week) compared to non-Hispanic/Latinos. Lower amounts of income, education, and access to health care were all significant factors of whether Hispanic/Latinos in the Deep South achieved the ACSM recommendations for LTPA. Although the percentage of overweight Hispanic/ Latinos was considerably higher than White (non-Hispanic/Latino), reported obesity was highest among Whites (non-Hispanic/Latino). LTPA between the two groups differed significantly, suggesting that not achieving the physical activity recommendations is associated with being overweight, but other factors may also contribute to being overweight and obesity.


Introduction
Following years of multiple and conflicting reports on the recommended amount of physical activity needed for healthy adults, the American College of Sports Medicine (ACSM) set forth a clear and concise recommendation to diminish public misperception.In its 2011 Position Stand, ACSM recommends that healthy individuals, 18-65 years, accumulate > 30 minutes of moderate-intensity physical activity > 5 days/week (> 150 min/week) or > 20 minutes of vigorous-intensity physical activity > 3 days a week (> 75 min/week) (Garber et al., 2011).The recommended volume of physical activity represents the minimum quantity and quality of leisure-time physical activity (LTPA) needed to maintain and improve good health, prevent disease, and reduce the risk of early mortality in adults.
Numerous studies provide evidence that LTPA offers benefits to those who transition from a sedentary lifestyle to one that meets or exceeds the minimum requirements set forth from ACSM (Plaisance, Grandjean, & Mahurin, 2009).Performing the recommended 150 minutes of moderate LTPA per week has been shown to reduce blood pressure, risk of coronary heart disease, stroke, type 2 diabetes, and breast cancer in women and colorectal cancer in men (Plaisance et al., 2009).In addition to the physiological benefits, there are specific psychological benefits that have also been observed in those who meet the ACSM guidelines for LTPA.Studies have shown that LTPA can deter and possibly prevent the effects of mild and moderate depression and increase vigor (Bartholomew, Morrison, & Ciccolo, 2005;Puetz, 2006).In older adults, LTPA reduces the risk of falls and slows the deterioration of bone mass (Nelson et al., 2007) while increasing quality of life (QOL) (Conn, Hafdahl, & Brown, 2009).
While organizations, such as ACSM, have set forth a clear recommendation for weekly physical activity in healthy adults, recent studies have found that most Americans fail to achieve these guidelines.For example, approximately 33% of the American population in 2008 reported not engaging in any form of LTPA.Furthermore, significant disparities exist in the accumulation of LTPA among different race/ ethnic groups, such as Hispanics (Latinos) and African Americans, compared to non-Hispanic whites.Indeed, 37% of the U.S. Latino population was considered physically inactive as compared to 33% of the African American population and 22% of the non-Hispanic white population (Ickes & Sharma, 2012).While Latinos and African Americans seem to accumulate lower levels of physical activity compared to non-Hispanic whites, research has also shown that Latino women are the most inactive (Larsen, Pekmezi, Marquez, Benitez, & Marcus, 2013).The authors reported that approximately 48% of Latino women do not participate in LTPA as compared to 29% of non-Hispanic white women.These results highlight the trend that a large majority of Americans are exposed to risks that accompany a sedentary lifestyle and that certain cultural or environmental factors are responsible for the physical activity related disparities that exist between ethnic groups.
The likelihood that an individual will meet the physical activity recommendations set forth by ACSM and pursue a healthy lifestyle may be determined by their health behaviors.Health behaviors include actions such as smoking and utilization of available health care facilities which may be influenced by ethnicity and cultural background.Margerison-Zilko and Cubbin found that non-Hispanic Whites had higher smoking rates than Hispanic/Latinos, although Hispanic/Latinos tend to initiate the habit of smoking at a much earlier age (Margerison-Zilko & Cubbin, 2013).Others have shown disparities in healthcare coverage and routine healthcare among Hispanics compared to non-Hispanic Whites (Villa, Wallace, Bagdasaryan, & Aranda, 2012).Since Hispanics typically experience a greater incidence of obesity and diabetes compared to non-Hispanic whites («Health disparities experienced by Hispanics-United States,» 2004), the role of physical activity and factors which increase the adoption of physical activity as part of a healthy lifestyle are crucial to reduce the disparities in health in this population.Therefore, the purpose of this investigation was to explore factors associated with the accumulation of LTPA between Hispanic/ Latinos and non-Hispanic whites in the Deep South of the United States (U.S.) through the 2011 administration of the Behavioral Risk Factor Surveillance System (BRFSS).

Methods and Materials
The BRFSS is a collaborative project of the Centers for Disease Control and Prevention (CDC) and U.S. states and territories.The objective of the BRFSS is to collect uniform, state-specific data on preventive health practices and risk behaviors that are linked to chronic diseases, injuries, and preventable infectious diseases that affect the adult population (CDC, 2012c).This study used publicly available data from the 2011 survey administration of the BRFSS from 4 of the 6 Deep South states: Alabama, Georgia, Mississippi, and South Carolina.Response rates ranged from 24.39% to 45.72% (CDC, 2012b).

Theoretical Model
The Behavioral Model of Health Services Use by Ronald Andersen suggests that health outcomes are affected by health services use and social and individual determinants of health (Andersen, 2008;Gelberg, Andersen, & Leake, 2000).In the Andersen model, predisposing, enabling, and need characteristics predict personal health practices, including the use of health services, and, ultimately, health status.Predisposing characteristics such as gender, age, race/ethnicity, marital status, education, and employment describe the propensity of an individual to use health services such as routine medical checkups or explain personal health practices such as substance use (Anderson, 2008).Enabling characteristics refer to the individual's ability to gain access to needed health services.Potential health care access issues are related to family resources such as insufficient household income, lack of adequate health insurance coverage, not having a regular source of medical care, and lacking the financial means to pay for health care when needed (Anderson, 2008).Perceived need for care is also a component of this model.Need includes both self-perception of health status and clinically diagnosed chronic conditions such as asthma, cardiovascular disease, and diabetes (Anderson, 2008).Self-perception of good health may decrease perceived need for subsequent use of health services or to improve health practices, while individuals with actual health needs are likely to have more health care encounters that may result in more opportunities to discuss other preventive health services with their health care provider (Gelberg et al., 2000).
For this study, there were two main variables of interest: ethnicity [report being Hispanic/Latino or White (non-Hispanic/Latino)] and participating in 150 minutes or more of physical activity outside of work, or LTPA.Ethnicity was ascertained by the variable «RACE2», calculated to derive categories White only, non-Hispanic; Black only, non-Hispanic; Asian only, non-Hispanic; Native Hawaiian or other Pacific Islander only, Non-Hispanic; American Indian or Alaskan Native only, Non-Hispanic; Other race only, non-Hispanic, Multiracial, non-Hispanic; Hispanic; Don't know/Not sure/Refused; and Missing.In this study, White only, non-Hispanic and Hispanic/Latino were retained for analysis (CDC, 2012a) $50,000 -$74,999, and $75,000 or more) and access to health care through factors such as having health insurance (Yes/No), having a personal health provider (Yes/No), not seeking health care when needed due to cost (Yes/No), and receiving last medical check-up (within 12 months, 1 -2 years, 3 -4 years, 5 or more years).Factors included in the study demonstrating need for physical activity included self-perception of health status (Excellent, Very Good, Good, Fair, Poor), Body Mass Index (Underweight, Normal Weight, Overweight, and Obese), selfreported chronic conditions such as hypertension (Yes, Borderline, High) and high cholesterol (Yes/No).Personal health practices were included in the model.Behaviors included as personal health practices were smoking (Everyday, Some Days, and Non-smoker) and heavy drinking.Heavy drinking for women is described as 1 or more drinks per day and 2 or more drinks per day for men.SAS v.9.4 was used to perform count and weighted frequency analysis.× 2 tests were performed on the sample data to obtain descriptive characteristics of the sample and to assess the significance of bivariate relationships between the outcomes of interest (i.e., ethnicity and ACSM guidelines).Analysis was limited to survey participants living in the four southern states: Alabama, Georgia, Mississippi, and South Carolina.Additionally, individuals who self-reported Hispanic/Latino ethnicity and individuals self-reporting White (non-Hispanic/Latino) race were included in the analysis.All other ethnic/racial groups and all other state/territory data were excluded from analysis.Other exclusions were made for missing data and participants reporting «I don't know» to variables included in the study.

Results
Among those included in our sample from the 2011 administration of the BRFSS living in the Deep South; approximately 38% were male and over 96% of study participants were White (Non-Hispanic/Latino).Significant differences were observed between men and women by age.For example, greater proportions of men were observed in age categories below age 65 (Table 1).Differences also existed by education status with greater proportions of women completing high school (31.24%) when compared to men, but men reported receiving greater than high school education in larger proportions (60.52%).Additionally, men reported greater proportions of higher household income and greater proportions of being married (Table 1).
Regarding health indices, greater proportions of men reported better health and lesser proportions of men reported smoking «everyday» or «some days» out of the past 30 days (Table 1).However, men reported greater proportions of heavy drinking when compared to women.Men also reported being overweight (43.70%) and obese (29.69%) in greater proportions than women (Table 1).Furthermore, men in the sample reported having a medical checkup in the past 12 months in lower proportions when compared to women (70.92% vs. 77.21%),while women reported greater proportions of not seeing a doctor due to medical costs during the past year (15.11%) (Table 1).Additionally, men reported being covered by health insurance and having a personal doctor in lower proportions when compared to women.In contrast, men reported greater proportions of the accumulation of at least 150 minutes of physical activity when compared to women (Table 1).
Differences in respondent characteristics were observed among participants who accumulated 150 minutes or more LTPA when compared to respondents who did not meet ACSM guidelines.Weighted estimates detail greater proportions of women (58.46%) not meeting the threshold of 150 minutes or more of LTPA within the study sample (Table 2).Significant differences were also observed between the proportions of Hispanic/Latino survey respondents meeting ACSM guidelines (5.23%) and Hispanic/Latino not meeting guidelines (6.95%) (Table 2).Examining socioeconomic status (SES), 65.29% of persons with greater than high school education reported accumulating 150 minutes or more of LTPA per week compared to 52.99% with similar education not meeting ACSM guidelines.Similar trends of accumulating 150 or more minutes of LTPA were observed for the highest level of income (27.71% vs. 19.50)when comparing meeting ACSM guidelines versus not meeting guidelines.Likewise, a greater proportion of those not meeting ACSM guidelines were observed among those with income levels less than $25,000.00(37.8%) (Table 2).
Regarding health indices, weighted estimates illustrate greater proportions of lower (fair 16.46%) (poor 9.59%) levels of perceived health, reporting high blood pressure (39.25%), reporting high cholesterol (47.65%), smoking everyday (38.35%), last having a checkup five or more years ago (11.14%), not seeing a doctor due to medical costs (21.57%), not having a personal doctor (23.10%), and not having health coverage (21.40%); was observed among those accumulating less than 150 minutes of LTPA per week when compared to survey respondents who did meet ACSM guidelines (Table 2).Additionally, survey participants who met ACSM guidelines regarding LTPA reported greater proportions of normal weight (39.81%) and lesser proportions of obesity (21.33%), when compared to participants with less than 150 minutes of LTPA per week ( meet the ACSM recommendations or not.An interesting finding from this study was that Hispanic/Latinos had a greater proportion of overweightness compared to Whites (non-Hispanic/Latino) suggesting that not achieving the physical activity recommendations is linked with the likelihood of being overweight or that being overweight increases the burden of performing LTPA, thereby reducing the propensity to achieve the ACSM recommendations.Future studies are required to determine the magnitude of the association between race/ethnicity and physical activity guidelines, and the influence of related factors on the association of ethnicity and LTPA.Additionally, prospective studies should be considered to help determine causal relationships with regards to these findings since previous studies show that exercise improves mechanical efficiency for a given task, thereby increasing the likelihood that an individual will expend a greater amount of activity and non-activity related energy expenditure which would be expected to produce beneficial effects on weight loss and maintenance (Hunter, Bickel, Fisher, Neumeier, & McCarthy, 2013).One of the primary limitations of this study is that over 96% of the study participants within the BRFSS dataset were White (non-Hispanic/ Latino).However, weighted and unweighted measures for each parameter suggest that the interpretation of our data and inference to the larger population of the U.S. Deep South is valid.Another limitation was that we were unable to incorporate any measures of dietary quantity or quality and their influence on the overall prediction of achieving the recommendations.Additionally, due to the cross-sectional nature of the study, we are unable to determine temporal sequence to ascertain causality.Longitudinal studies are required to more thoroughly evaluate the contribution of each of the predictor variables on the achievement of the ACSM recommendations.Finally, we are limited by selection bias and recall bias.Although many persons were asked to be interviewed for the BRFSS, participants self-selected to participate.In addition, participants were asked a series of questions related to different time periods during the past 30 days, past year, and past 5 years.Thus, participants may have recalled events in error, resulting in bias by the respondent.Still, strengths of the study include an exploratory examination of the «Deep South» population regarding physical activity and factors influencing the achievement of ACSM guidelines among a specific minority.Moreover, this study illustrates the importance of individual, contextual, and behavioral factors in influencing physical activity accumulation.
In conclusion, the results of the current investigation indicate that Hispanic/Latino men/women are significantly less likely to meet the ACSM recommendations (> 150 minutes/week) compared to non-Latino/Hispanics. Lower amounts of income, education, and access to health care are all important determinants of whether Hispanic/Latinos in the Deep South achieved the ACSM recommendations.

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. Physical activity was calculated from previous survey measures to estimate if adults participated in 150 minutes (or vigorous equivalent minutes) of physical activity per week.The variable «_PA150R1» was dichotomized to having met the ACSM guidelines versus having not met the guidelines (150 minutes or more of LTPA).

Table 1 .
Chi-square analysis of the characteristics of Deep South participan ts bygender, Behavioral Risk Factor  Surveillance System, 2011.

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Table 2).

Table 2 .
Chi-square analysis of the characteris tics of Deep South par ticipants by meeting ACSM guidelines for Ph ysicalActivity, Beha viora l Risk Factor Surveillance System, 2011.