Abstract
The prevalence of overweight in Mexican American children has been increasing at a steady rate over the past few years. People of Mexican origin make up the largest proportion of the Hispanic population, which has been reported by the U.S. Census Bureau to be the fastest growing ethnic group in the United States. The purpose of this integrative review was to examine and summarize the current research on parental perceptions of childhood overweight in the Mexican American population. Four main themes evolved as a result of the data analysis: parental perception of overweight, parental practices, household food security status, and acculturation. School nurses are in a position to influence children in improving their nutritional status and increasing their physical activity. Understanding cultural values and beliefs regarding health status and overweight of Mexican American families should be a priority for school nurses. Identifying food-related parenting styles and the concept of acculturation should also be considered prior to incorporating relevant interventions in the school setting.
Keywords
The prevalence of childhood overweight in the United States has been steadily rising over the past two decades. Ogden and colleagues (2006) reported that the prevalence of overweight in the United States is 13.9% among 2- through 5-year-olds, 18.8% among 6- through 11-year-olds, and 17.4% among 12- through 19-year-olds based on the most recent examination data from the 2003–2004 National Health and Nutrition Examination Survey (NHANES). These data were obtained using complex, multistage probability samples of the civilian, noninstitutionalized U.S. population and consist of an interview and physical examination for each survey participant. Mexican American children are exhibiting similar trends in overweight and obesity over time as other portions of the U.S. population (Flegal, Ogden, & Carroll, 2004).
It has been reported by the U.S. Census Bureau (2006) that between 2000 and 2006, the Hispanic population was the fastest growing ethnic group and accounted for one half of the nation’s growth. People of Mexican origin constitute the largest proportion of that population, which increases the significance of studying overweight issues of Mexican American children. The U.S. Census Bureau describes the Hispanic or Latino population of the United States as individuals who trace their origin or descent to Mexico, Puerto Rico, Cuba, Spanish-speaking Central and South American countries, and other Spanish cultures. On the Census 2000 and American Community Survey (ACS), respondents to the questionnaire classified themselves as Mexican, Mexican American, Chicano, Puerto Rican, or Cuban. It also included the category of “other Spanish/Hispanic/Latino.”
For children and adolescents aged 2 to 19 years of age, overweight is defined as body mass index (BMI) for age at or above the sex-appropriate 95th percentile of the Centers for Disease Control and Prevention (CDC) growth charts (Ogden et al., 2006). Over the past few years, a greater number of Mexican American children and adolescents ages 2 to 19 years have been identified as being overweight based on the 2000 CDC BMI-for age-growth chart criteria (National Center for Health Statistics, 2007). Data from the NHANES 2003–2004 revealed that the prevalence of overweight has increased for all children and adolescents over time but that there are disparities among racial and ethnic populations. For Mexican American boys ages 2 to 19 years, the prevalence of overweight was greater (22.0%) than for non-Hispanic Black (16.4%) or non-Hispanic White (17.8%) boys. The prevalence for overweight among Mexican American girls ages 2 to 19 years (16.2%) was greater than non-Hispanic White girls (14.8%) but less than non-Hispanic Black girls (23.8%).
Overweight is a significant health issue for children and adolescents. Healthy People 2010 (U.S. Department of Health and Human Services [USDHHS], 2000) identified overweight and obesity as 1 of the 10 leading health indicators in the United States. Objective 19-3 called for a reduction in the proportion of children and adolescents who are overweight or obese, but data indicating trends in childhood overweight reveals that progress toward this Healthy People 2010 target goal has not been made.
Obesity is associated with significant health problems and is a substantial early risk factor for many chronic diseases such as type 2 diabetes, renal disease, sleep apnea, hypertension, and hyper-cholesterolemia (Freedman, Dietz, Srinivasan, & Berenson, 1999; Institute of Medicine, 2004; Tarlton, 2007; Urrutia-Rojas & Menchaca, 2006). Freedman and others (1999) examined samples of children derived from the landmark Bogalusa Heart Study, the longest and most detailed study of biracial population of children in the world. The focus of the Bogalusa Heart Study is on understanding the early natural history of coronary artery disease and essential hypertension. They concluded that overweight is consistently related to several cardiovascular disease risk factors. Childhood obesity is also a risk factor for adulthood obesity. The obesity epidemic may decrease overall life expectancy because it raises lifetime risk for type 2 diabetes, cardiovascular disease, and other chronic disease health problems (Carrera, Gao, & Tucker, 2007; Myers & Vargas, 2000).
The purpose of this integrative review was to examine and summarize the current research on parental perceptions of childhood obesity in the Mexican American population. The implications for school nurses will then be discussed.
METHOD OF REVIEW
An integrative review of the literature was conducted using Cooper’s (1998) framework of research synthesis. This method was selected because it provided a structured, feasible approach to reviewing research studies relevant to a particular focus of research while providing a comprehensive summary of the current position of existing evidence on the specific topic of childhood overweight in the Mexican American population. The integrative review takes into account the inclusion of experimental and nonexperimental research, which allows for a greater perception of the subject matter under review (Whittemore & Knafl, 2005).
Cooper (1998) recognized five stages of a research synthesis methodology: (a) problem formation, (b) data collection, (c) data evaluation, (d) analysis and interpretation, and (f) presentation of findings. This article discusses systematically reviewed publications using Cooper’s stages of research analysis to identify parental perceptions of childhood overweight and health status, culturally related parenting styles, factors that affect healthy dietary intake and physical activity, and dietary practices in the Mexican American population.
DATA COLLECTION
Sampling Method
Research studies were identified through systematic searches of relevant computer databases. The Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed (U.S. National Institutes of Health), and Medline databases were reviewed. A current report on findings of randomized controlled trials pertaining to interventions for preventing obesity in children in general was retrieved from the Cochrane Database Systematic Reviews. The keywords used in the database search included “childhood overweight,” “Mexican American children,” “ Hispanic children,” “parental perceptions,” “perceived health,” “dietary habits and obesity,” and “physical activity and obesity.” The reference lists from the journal articles retrieved were also reviewed to provide additional articles or sources that were not identified in the original review of literature. Fifty-six peer-reviewed journal articles were identified and examined for data collection.
Inclusion Criteria
Only journal articles and studies found in the comprehensive computer-assisted search that were published between 2000 and 2007 and published in English were included in the integrative review.
Exclusion Criteria
Journal articles and studies that did not describe original research were excluded from the integrative review. Study reports that did not represent Mexican American children and the issue of overweight as the focus of the article were excluded except for two reports on general parental perceptions of overweight (Baughcum et al., 2000; Rhee, DeLago, Arscott-Mills, Mehta, & Davis, 2005), which were not specifically related to Mexican American children. Unpublished manuscripts were not included in the review.
DATA EVALUATION
Evidence Hierarchy
Evidence hierarchies have been developed to rank evidence sources according to the validity and strength of their findings. This integrative review uses Polit and Beck’s (2008) evidence hierarchy of seven levels of evidence as a guide for evaluating studies regarding parental perceptions, cultural beliefs, and effectiveness of healthcare interventions relating to childhood overweight and the Mexican American community. It should be noted that an evidence hierarchy is a framework to determine the strength of available evidence and recognizes that a variety of research methods can offer valid evidence (Evans, 2003).
Polit and Beck (2008) described Level I a, systematic review of randomized clinical trials (RCTs), as the strongest level of research. Level I b consists of a systematic review of nonrandomized trials; Level II a indicates one single RCT, whereas Level II b describes the use of one single nonrandomized trial. Level III includes a systematic review of correlational/observational studies, and a single correlational/observational study is classified as Level IV. Level V provides a systematic review of descriptive/qualitative/physiologic studies, and Level VI includes a single descriptive/qualitative/physiologic study. The final level of the hierarchy is Level VII, which contains opinions of authorities or expert committees.
Of the 56 research articles retrieved and reviewed, it was determined that 19 studies met the criteria for inclusion in the integrative review. Twelve of those studies qualified as Level IV research, whereas the remaining 7 studies were Level VI research. During the literature review process, it was noted that although there were a variety of studies published about childhood overweight and potential effective interventions, the number of studies involving overweight Mexican American children was limited. Each study identified in the review is listed in Table 1, including a description of the sample, purpose of the study, a summary of the findings, and level of evidence hierarchy.
[A]lthough there were a variety of studies published about childhood overweight and potential effective interventions, the number of studies involving overweight Mexican American children was limited.
RESULTS
The purpose of this integrative review is to provide a summary of the implications of overweight and obesity trends that have been occurring in Mexican American children. A thorough interpretation and synthesis of the research evidence are the goals of data analysis (Cooper, 1998). Strategies to complete this analysis included categorizing, summarizing, and identifying themes that evolved while reviewing the research articles.
Parental Perception of Overweight
A majority of studies regarding parental perception of overweight reveal that a large percentage of parents do not perceive their children to be overweight and are not concerned about health risks (Baughcum et al., 2000; Eckstein, Mikhail, Ariza, Thomson, & Binns, 2006). Three studies that specifically investigated Hispanic/Latina mothers’ perception of their children’s body size and health beliefs and attitudes toward overweight reported failure of the mother to perceive her child was overweight (Crawford et al., 2004; Killion, Hughes, Wendt, Pease, & Nicklas, 2006; Myers & Vargus, 2000).
[S]tudies that specifically investigated Hispanic/Latina mothers’ perception of their children’s body size and health beliefs and attitudes toward overweight reported failure of the mother to perceive her child was overweight.
Crawford and colleagues (2004) explored the cultural context of Latina mothers’ perceptions about children’s weight issues and recognized beliefs that moderate overweight when a child was young was perceived as being healthy and happy. Many of these mothers also believed that young children will grow out of being overweight or that the child’s weight is determined by genetics. A child who was thin was considered to be in poor health, especially among Latinas who came to the United States from a country with a high incidence of malnutrition and intestinal infections or parasites. Tyler (2004) suggested that among Mexican Americans the perception of good health status for children is related to the absence of health issues that restrict functional ability to perform normal activities on a daily basis.
Parenting Practices
It has been suggested that food-related parenting styles may influence a child’s risk for being overweight. Two studies reported that in Mexican American and Latino families, mothers’ parenting attitudes surrounding food were associated with their children’s dietary weight and intake (Arredondo et al., 2006; Matheson, Robinson, Varady, & Killen, 2006). A study by Arredondo and others (2006) in which parental practices of discipline were examined found that parental monitoring and use of reinforcement were positively related to children’s healthy eating habits. Use of a controlling parenting style regarding children’s eating was shown to be positively related to children’s unhealthy eating practices. Parenting styles vary, but many Mexican American parents’ discipline techniques have been described as authoritarian, with many strict rules and stressing respect for authority. Examples of other food-related parenting styles identified by Matheson and colleagues (2006) included pressuring children to eat by controlling food intake and limiting or restricting available foods. The pressure to eat by mothers of Mexican American fifth-grade children in California was inversely correlated with their children’s BMI (Matheson et al., 2006).
Household Food Security Status
Three studies identify the need for more research in the area of food insecurity and its relationship to nutritional status in Mexican American children (Kaiser et al., 2003; Matheson, Varady, Varady, & Killen, 2002; Melgar-Quinonez & Kaiser, 2004). Food insecurity has been defined as the “limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways” (Anderson, 1990, p. 1560). According to Kaiser and colleagues (2003), food-insecure households report they rely on a limited assortment of foods, including various customary Mexican staples such as corn or flour tortillas, frijoles (beans), rice, chilies, fruits, and vegetables. Matheson and others (2002) found food insecurity was negatively related to the children’s BMIs and available food supplies, but not with their food intake. A later study by Matheson and others (2006) indicated that the level of food security may determine associations between food-related parenting behaviors and children’s food intake.
Acculturation
Acculturation refers to the modification of an individual by adapting the attributes of another culture as a result of exposure to this culture. Two studies reported their findings on acculturation and potential implications on the nutritional status of Mexican American children. Kaiser and colleagues (2001) concluded that less acculturated mothers were more likely to provide alternate food choices when a child would not eat and use child-feeding strategies that may contribute to childhood overweight, such as bribes, threats, and punishment. Ariza, Chen, Binns, and Christoffel (2004) conducted a study to test their hypothesis that overweight was more prevalent in highly acculturated Mexican American children aged 5 to 6 years; however, the results did not substantiate an association between overweight and acculturation in this population.
Duerksen and colleagues (2007) reported that increased levels of acculturation may lead to higher rates of overweight among Mexican American families if they were eating more meals at fast-food and buffet-style restaurants rather than selecting traditional, authentic Mexican restaurants. Carrera, Gao, and Tucker (2007) did not find any significant differences in overweight in Mexican American adults who ate a traditional Mexican diet, including tacos, tortillas, and legumes, versus three other American dietary patterns consisting mainly of either poultry, milk or baked products, or meat. Overweight was common in all four groups, leading the researchers to conclude that a better understanding of the food choices made by this population is needed to determine the relationship between dietary patterns and overweight.
The level of acculturation and television viewing patterns was investigated by Pinzon-Perez and Soto (2006). Their results indicated a significant association between the length of time living in the United States, (which was identified as less than 5 years, 5 to 10 years, and more than 10 years) and the number of hours spent watching television by a group of Latina mothers and their children in rural California. Not only was it determined that 32.8% of the mothers watched television with their children for at 3 least or more hours a day, but there was a connection between watching television and the mothers’ food-purchasing behavior. Children often requested to eat foods that were advertised during television commercials.
Limitations
Research on childhood overweight specifically focused on Mexican American children is limited. Many studies have small sample sizes (Crawford et al., 2004; Pinzon-Perez & Soto, 2006; Snethen, Hewitt, & Petering, 2007; Tyler, 2004). Convenience sampling limited the ability of a number of studies to generalize the findings to other Mexican American populations (Kaiser et al., 2003; Matheson et al., 2006; Melgar-Quinonez & Kaiser, 2004; Tyler, 2004). Methodological issues in various studies made it difficult to generalize findings and determine applicability to other Mexican American communities (Arrendondo et al., 2006; Baughcum et al., 2000; Carrera et al., 2007; Kaiser et al., 2001; Matheson et al., 2002).
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
Throughout the United States, school settings are experiencing a growth in the population of Mexican American children. School nurses are in a unique position to influence these children to improve their nutritional status and increase their physical activity. School nurses can help reduce and prevent childhood overweight as part of their nursing practice and health education.
Understanding Mexican American cultural values and beliefs regarding health status and overweight must be taken into account before developing prevention and intervention strategies for weight management. According to the limited research available, many Hispanic/Latina mothers failed to perceive that their child was overweight. The cultural framework of these perceptions about weight should be explored in an attempt to more fully comprehend the mother’s belief systems.
School nurses should identify prevalent food-related parenting styles and their relationship to children’s dietary food intake and weight. Diverse cultural values and socioeconomic challenges influence Mexican American parenting styles. Further knowledge about parenting practices could guide the development of culturally relevant educational interventions in reference to issues of overweight.
It is important that school nurses have an awareness of the concept of acculturation and its potential implications on the nutritional status of Mexican American children. There is a wide variation in the level of acculturation among families. Research has indicated that dietary and lifestyle changes associated with acculturation may increase the risk for overweight. Pinzon-Perez and Soto (2006) identified a significant association between the length of time spent living in the United States and the number of hours daily spent watching television. School nurses are in a position to educate parents about the importance of decreasing television watching and strategies to introduce alternative activities.
It is important that school nurses have an awareness of the concept of acculturation and its potential implications on the nutritional status of Mexican American children.
By gaining a greater understanding of parental cultural beliefs and values, parenting styles, and acculturation in the Mexican American community, the school nurse will be able to develop culturally relevant interventions for nutrition education in the school setting. Health programs in the school can include educational approaches targeting factors that affect dietary intake and physical activity. Tyler (2004) explored the interest of overweight Hispanic children in making lifestyle changes to promote a healthy weight and found the children were interested in family-based interventions, such as playing sports or learning about healthy eating together as a family. School nurses should include family participation in many different school-based nutrition education programs.
CONCLUSION
Childhood obesity is increasing in the Mexican American population. This integrative review summarized the implications of overweight and obesity trends that are occurring in this group of children. The effectiveness of weight management interventions are influenced by parental perceptions of overweight, cultural beliefs and values, parenting styles, and levels of acculturation. Future research focused on Mexican American parental misconception of overweight and how these views influence the risk of overweight is needed. It should be determined how parenting practices relate to healthy eating behaviors and physical activity. The relationship between food insecurity in the home and nutritional status in children needs further exploration. School nurses are in a unique position to help identify factors that affect dietary intake and physical activity because they see children on a daily basis and can have an impact on the entire family. They can develop interventions directed toward alleviating overweight and obesity in Mexican American children and incorporate culturally relevant interventions in the school setting.
Footnotes
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