**1. Introduction**

Among men, overweight (BMI ≥ 25) and obesity (BMI ≥ 30) are serious health issues that are associated with numerous health problems, including cardiometabolic diseases [1–4]. Latino men, in particular, have concerningly high rates of overweight or obesity. In fact, Hispanic/Latino men have the highest prevalence (41.2%) of obesity or severe obesity compared to non-Hispanic Black (37.5%), non-Hispanic White (36.9%), and Asian (11.7%) men [5]. Moreover, there are marked differences in overweight and obesity rates between Latino men of different backgrounds. In the *Hispanic Community Health Study/Study of Latinos* (HCHS/SOL), a landmark epidemiologic study of Hispanics/Latinos, men of Puerto Rican (40.9%) and Mexican (36.8%) descent—the two largest Hispanic/Latino subgroups in the U.S. [6]—had the highest rates compared to men of other Hispanic/Latino backgrounds [7]. The differences in the prevalence of overweight and obesity between Hispanics/Latinos and other racial/ethnic groups and between different Hispanic/Latino ethnic groups are attributable to behavioral and environmental factors in addition to genetic

**Citation:** Sanchez-Johnsen, L.; Dykema-Engblade, A.; Rosas, C.E.; Calderon, L.; Rademaker, A.; Nava, M.; Hassan, C. Mexican and Puerto Rican Men's Preferences Regarding a Healthy Eating, Physical Activity and Body Image Intervention. *Nutrients* **2022**, *14*, 4634. https://doi.org/10.3390/ nu14214634

Academic Editors: Silvia V. Conde and Alessandro Sartorio

Received: 30 August 2022 Accepted: 26 October 2022 Published: 3 November 2022

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

influences [8,9]. Given the influential role of obesity in development of cardiometabolic diseases [3], addressing these disparities is critical. Behavioral weight loss interventions are the preferred method for treating overweight and obesity; however, few weight loss interventions have been developed specifically for Latino men [10,11] and fewer, if any, have focused on specific subgroups of Latinxs.

The majority of diet and physical activity interventions conducted with Hispanic/Latinos have primarily targeted women, e.g., [12–16]; and only a few, to our knowledge, have focused exclusively on Hispanic/Latino men [17,18]. Indeed, the dearth of physical activity interventions for Hispanic/Latino men has been noted in two recent systematic reviews [10,11]. The low number of Hispanic/Latino men in weight-loss interventions is surprising given that studies indicate that, in general, men are interested in interventions that address overweight and obesity [19].

Despite this interest, men tend to enroll less frequently in behavioral weight loss interventions than women [20], and this disparity is exacerbated among Hispanic/Latino men [21,22]. Lack of enrollment of Latino men in weight loss interventions is two-sided. On one hand, Latino men face logistical (e.g., limited off-work time) and sociocultural (e.g., lack of control of diet due to gender roles) barriers that make it difficult to adopt healthy lifestyle behaviors [21,22]. For example, in a study among 14 Latino men with overweight, Garcia et al. [21] found that some of the barriers to healthy eating and physical activity included dietary norms and familial influence, long work hours, and fatigue. On the other hand, there is a lack of interventions that are designed to address the specific preferences and needs of Latino men [23]. While some reasons for the lack of enrollment—such as limited off-work time—among men are similar across racial/ethnic groups, others are specific to Hispanic/Latino men (e.g., spoken language, living environment, social, cultural, and familial influences) [21,23]. Factors that may be important to address these needs and overcome some barriers include the language of the intervention and program materials, the characteristics of the intervention leader, and the location and type of physical activity [21,24], and the integration of cultural elements into the intervention.

Moreover, interventions that focus on Latino men are important due to their patterns of diet and physical activity. For example, in the HCHS/SOL, individuals of Puerto Rican descent had the lowest estimated intake of fruits and vegetables compared to other Hispanic/Latino groups [25]. Further, a large proportion of Hispanic/Latino men (>73%) do not engage in regular physical activity [26]. Data from a recent study revealed that number of hours watching television per day was higher among Puerto Rican than Mexican men [27]. In another study, 47.5% of Mexican men and 56.9% of Puerto Rican men reported no leisure-time physical activity [28].

According to recent U.S. Census data, 67.6% of Hispanics/Latinos speak Spanish at home, and of those, 22.8% do not speak English well [29]. Language preference, however, varies by nativity and Hispanic/Latino background, with U.S.-born and Puerto Ricans more likely to speak English only than foreign-born and other Hispanics/Latinos [30]. Thus, an English- or Spanish-only intervention may not be appropriate for all Hispanic/Latino groups. Moreover, some Latinx groups (e.g., less acculturated groups) may prefer a Latinx intervention leader whereas others may not have a specific preference for the ethnicity of the leader. In a past qualitative study, a sample of 39 Mexican American women and men expressed that the ideal physical intervention would be led by a bilingual instructor [31]. However, no study, to our knowledge, has examined the preferences regarding the ethnicity of intervention leaders among Latinx men.

Another important consideration for interventions is the location of the intervention. Indeed, inadequate access to or lack of safe spaces for physical activity has been identified as a major barrier among Hispanic men [18,23,31]. Hispanic men report that their neighborhoods may be unsafe (e.g., gang activity) or inadequate (e.g., lack sidewalks and/or streetlights) for exercise, but, at the same time, transportation to and from facilities outside of their communities may be time-consuming [18,23,31]. While past studies have

assessed Latinx men's perceived barriers, few, if any, have inquired about their preferences. Relatedly, preferences for specific types of physical activity reported in previous studies are mixed, with some Latino men preferring team sports [18,32] and others walking [31]. Despite that dancing-based aerobic exercises are easier to implement (e.g., can be performed in- or out-doors, requires less space) than other forms of physical activity and are popular among Latinx men [33], little is known about Latinx men's preferences regarding aerobics-based interventions.

Culture-specific content are also important to include in interventions that address diet and physical activity among culturally and linguistically diverse populations [34]. One type of cultural-specific content is *dichos*, or Latino sayings or proverbs. Although *dichos* have not been used in a combined diet, physical activity and body image intervention for Latino men, they have been used in counseling [35,36], educational or health literacy programs [37,38], and in other interventions among Latinos [39–41]. For instance, *dichos* have previously been used in the development of an intervention focused on nutrition for Latinas and their families [42], and in another one focused on diet, physical activity, body image, and secondhand smoke intervention with Latina women [43]. Specifically, *dichos* can be validating to a person, can communicate openness to a person's Latino culture, and can be used to build rapport and trust [35]. Thus, *dichos* may be a culturally appropriate strategy to recruit, improve communication, and encourage healthy lifestyle behaviors among Latinos [38]. It is unknown, however, whether including *dichos* in an intervention would make it more appealing for Latino men. Similarly, the use of *cuentos*—folktales or stories/storytelling in Spanish—has yet to be examined in a health intervention with Latino men. Although not used extensively, *cuentos* have also been used in therapy and interventions to promote personal and social development and healthy behaviors [44–46]. If *dichos* and *cuentos* are important for Latino men, then such cultural components may be used to guide the development of a diet, physical activity and body image intervention for Latino men.

Latino men have been largely absent from interventions seeking to promote healthy lifestyles, and it is possible that this omission is due to the lack of tailoring interventions to their specific needs and preferences. Moreover, few studies, if any, have assessed differences in needs and preferences among different Latinx groups. To this end, the present study aimed to examine the preferences of Mexican and Puerto Rican men regarding the design and development of a healthy eating, physical activity and body image intervention. Specifically, the following were examined: Preferences regarding the language of the intervention and intervention materials, the importance of the intervention leader's language and Hispanic or Latino background; preferences regarding the frequency, duration, and location of the intervention; preferences regarding the type of exercise program; and questions regarding the use of various cultural elements such as *dichos* and *cuentos* during the intervention.
