Childhood Obesity Prevention in Mexican American School Age Children

Childhood Obesity

One of the most significant health problems seen in the United States is obesity. Within this dynamic there are particular issues of special concern for the health care industry and society in general, most notably the exponential increase in obesity found among children. (Strauss, Pollack, 2001, pgs. 2845-2848) and (Troiano, Flegel, 1998, pgs. 497-504) "Childhood obesity has more than doubled over the past 20 years, and it represents the most prevalent nutritional disease among youth in the United States." (Lowry, Wechsler, Galuska, Fulton, & Kann, 2002, pg. 1)

Though there are many other problems faced by the youth of America today the press on violence and relatively rare though increasing incidences of it far outweighs the press on the issue of childhood obesity, a much more widespread and deadly problem. Obesity is discussed through the overzealous and unrealistic body images of adults and young adults, as represented by the racially biased television and other media or through crazed and frenetic diet options offered as if doctrine to countless seekers of unrealistic goals. What children and adults alike learn from these views is decreased self-esteem and possibly after enough tries at unrealistic dieting, learned helplessness. (Davison & Birch, 2001, pg. 159)

Though historically defining obesity among children has been a challenge, using growth charts and mean body fat density ratios has been a tool. For this work the definition will be governed by a general percentage rule. "A weight that exceeds ideal body weight by 20% defines childhood obesity. More than one fourth of children in the United States are considered clinically obese." (Sothern, Hunter, Suskind, Brown, Udall, Blecker, 1999, pg. 577) Factors associated with risk for obesity are many, among them, dietary intake, level of sedentary behavior vs. high physical activity, self-esteem, socioeconomic status, gender, insurance status and last but certainly not least race and ethnicity.

This study will focus on the problems and solutions as they associate to issue of obesity in children with specific emphasis on the growing Hispanic ethnic minority population. With increased risk based solely on the isolated issue of ethnicity and the growth rate of this ethnic minority, (mostly Latinos of Mexican decent) especially in California race must be considered as one of the most important of all factors associated with risk for obesity and all its health consequences. One cultural aspect, being the overall acceptance or the perception by certain cultures of overweight as healthy. (Maynard, Galuska, Blanck, Serdula, 2003, pgs 1-17)

Though race can certainly not be altered, factors especially significant to racial minorities must be addressed carefully and solutions must include interventions that are navigable for those at greatest risk. Be it physical or environmental the challenges faced by Latino-American youth are many but obesity is clearly more prevalent, dangerous and deadly than gang violence. "Obesity is the most widespread and severe nutritional problem of children in the United States, with prevalence rates that vary greatly by ethnic group. Rates are generally highest for Hispanic...children." (Crawdford, Story, Wang, Ritchie, Sabry, 2001, pg. 855)

Special care must be taken to ground the society in changes that can assist all children at risk for obesity, yet the focus on alternatives, especially within schools on increased physical activity must have considerations for challenges of the growing ethnic minority population. Additionally, though the significance of the problem greatly impacts the individual and the family the outcome of widespread obesity among children and adults, in a population also at high risk for lower socioeconomic status and therefore greater need for publicly funded healthcare access demonstrates an extreme social and economic problem that can only be successfully combated through prevention.

Statement of Problem

One danger in our society is resting on the idea that this is something we can solve later with better adult offerings and behavior, or that children who are obese will likely grow out of the condition. Not, only is this not true, evidence suggests that the problem of obesity follows children into adulthood and significantly impacts their future health and even mortality rate. (MacKenzie, 2000, pgs. 527-530)

It is observed that many of the negative and even deadly health outcomes of obesity that are seen among obese and overweight adults (Reilly, Methven, McDowell, hacking, Alexander, Stewart, Kelnar, 2003, pgs. 748-752) are also seen in the very young. The seriousness of the problem just seems to be growing without any sign of slow down.

More than 60% of overweight children have at least one additional factor for cardiovascular disease, such as elevated blood pressure, hyperlipidemia, or hyperinsulinemia." (Lowry, Wechsler, Galuska, Fulton, & Kann, 2002, pg. 2) The challenges to society in general and specifically to individuals are complex but the health outcomes are directly associated with increases cost and decreased quality and length of life. (Pi-Sunyer, 1993, pgs. 655-660)

Challenges are many and complicated and the solutions to this particular growing health threat have been divided for the last twenty years but the impact of the number of hours children spend in school demonstrates an opportunity for intervention that has been largely ignored in the last twenty years. Most research has addressed factors such as environment, socioeconomic level, activity level and family history as important facets of the problem. Some would even lay blame upon the television as a serious factor for the development of obesity in children. (Lowry, Wechsler, Galuska, Fulton, & Kann, 2002, pgs. 1-23) Many blame nutritional changes that have taken place within the United States as a whole, regarding the amount of fast food we eat because of its easy availability and the reduction of fresh fruit and vegetables being replaced by the bulk high fat, high carbohydrate low nutrition foods available in the everyday marketplace.

As schools become more and are focused on the academic success of children and outcomes-based testing, and the disproportionate level of school funding in association with increases in cost of living there has been a reduction of extracurricular activities. One of the most foundational aspects of those cost cutting standards is the loss of physical education time and funding. "The National Children and Youth Fitness Study and other investigations indicate that at least half of today's; youth do not engage in physical activity appropriate to long-term health promotion and that less than 36% of elementary and secondary schools offer daily physical education classes. " (Sothern, Hunter, Suskind, Brown, Udall, Blecker, 1999, pg. 577)

Additionally, the growing trend has been to address physical education as an extracurricular activity that children must go out of their way to engage in and is not funded through schools. Making the real desire to involve oneself in physical education a competitive demonstration of far more than a desire to be involved in physical activity. Often those most in need of the opportunity to get up and move are barred from extracurricular activities by the competitive nature of the offerings and the time/resources needed to compete. Many would like to individualize the problem by addressing the children's behavior or lack of desire to engage in physical activity,

Recently the idea of learned helplessness has been suggested as a probable reason for lack of motivation... With learned helplessness, children justify the causes of bad events in their lives as stable in time, global in effect, and internal to themselves. Such children have a cluster of helplessness deficiencies, including (1) passivity/non-assertiveness, (2) cognitive flaws and inability to recognize existing opportunities to control outcomes, (e.g., being unable to see alternatives, (3) sadness, (4) lowered self-esteem, (5) lowered competitiveness / achievement-oriented behavior, and (6) lack of motivation, initiative and persistence. (Sothern, Hunter, Suskind, Brown, Udall, Blecker, 1999, pg. 577)

One problem with this view of the situation, though is that it does offer promising ways to combat the problem at a base level, rather than just attempting to remove negative environmental conditions, it also implies that the competitive offerings of our society are a viable and realistic availability for children regardless of their personal like or dislike of competitiveness and/or avoidance of popularity issues. It would seem that one possible intervention would be to increase offerings, both during the school day and outside it of non-competitive alternatives to organized sports as well as increasing physical education activity offerings and requirements in school.

One issue that is absolutely imperative to discuss is race as the problem is unquestionably more concentrated among racial minorities, than among white children. Challenges to the individual students are compounded by many factors but one factor of particular importance is associated with ethnicity. In a study attempting to isolate risk factors among both young students and adolescents a group of experts uses race, socioeconomic status, and health insurance status as points of study findings associated with race were most significant. " In the younger group, both Black and Latino children had a greater likelihood of being overweight compared with white children. Among the adolescent group, Latinos and Asian/Pacific Islanders were more likely to be overweight." (Haas, Lee, Kaplan, Sonneborn, Phillips, Liang, 2003, pg. 1)

It seems that the growth of obesity in ethnic minority children is even greater than in the general population, particularly for African-American and Hispanic-American children. As is widely known, in the state of California the largest ethnic minority is Hispanic, and mostly Mexican-American. It is for this reason that the particular population of Hispanic-American youth in the San Francisco School District will be the focus of this work. "Hispanics now account for one in three of the state's population, due largely to an increase in Hispanic births that is exceeding the Hispanic death rate.' (Primedia, 2004, "Shifting Sands" website (http://racerelations.about.com/library/weekly/aa040301a.htm)

The population of the greater San Francisco Unified School District, though it includes many other racial minorities, has an overall representation of 21.4% latino students with an even higher concentration found in grades one through six. (SFUSD web site: (http://orb.sfusd.edu/profile/prfl-100.htm) This demographic demonstrates both an obstacle and an opportunity for the development of a program or plan that will assist this generation and those to come in their attempts to reduce the number of Hispanic youths with this serious problem. Yet, more importantly without a global intervention within this and other populations the problem will likely continue to skyrocket. Most importantly without sustainable solutions to this problem, which clearly consider and respond to individual identity, be it racial or otherwise there will be no long-term change in either habit or health of children.

Review of Literature

Within the literature associated with the growing problem of obesity among American children there is a seminal understanding of several key factors the greatest being the demonstrative, some would say exponential, growth of unhealthy body weights at younger and younger ages. Children of all races are at risk as we have said before, and the challenges are great. The initial studies that will be examined here are both general and specific to factor isolation.

In Race/Ethnicity, Social Class and Their Relation to Physical Inactivity During Leisure Time, Results from Third National Health and Nutrition Examination Survey conducted between the years 1988 and1994 are analysed and the findings isolate the factors of race and social class as issues that in part influence the demonstration of active physical leisure activity. The findings demonstrate that there is a strong correlation between both race and social class, with regard to the level of inactive activities that people engage in during their leisure time. The findings suggest that the highest risk group would be those who are at socioeconomic lows and also are of ethnic minority backgrounds. "Ample evidence has shown that racial and ethnic minorities engage in less leisure time physical activities than Non-Hispanic whites." (Crespo, Smit, Anderson, Carter-Pokras, Ainsworth, 2000, pg. 46)

Yet the researchers also make clear that the factor of ethnicity cannot be separated from age and social class. (pg. 46)

The study surveyed both adults and children through the statistics of the NHANES III conducted as a home questionnaire survey between 1988 and 1994. This work is an interpretive analysis of these statistics, using a sample of non-institutionalized individuals in the U.S. beginning at age 2 months with no end age.

The challenge of the statistical analysis was to attempt to isolate ethnicity and social class but the variety of ages surveyed also led to interesting results with regard to the samples.

The data consists of both a physical assessment and a social class assessments.

The results as stated by the work demonstrates that both men and women of the Mexican-American ethnicity showed a significantly higher tendency to exhibit the highest levels of leisure time inactivity, and that gender mattered with regard to education level, as Mexican-American men who had completed 12 years of education tended to have a slightly lower level of leisure time inactivity. (pg. 48)

The greatest importance of this work, as it mainly analyses adults, is the significant impact of the parent child relationship within Mexican-American households. The challenges associated with this issue, as parents and adult role models in the high-risk groups, Mexican-American households with lower social class are demonstrating leisure inactivity as a standard for their children. The authors do also point out that the level of inactivity exhibited by these adults may be influenced by the relative physical nature of their employment, (pg. 49) yet this does little to create an example for their children as the children do not benefit from the physical activity of their parents labour, nor do they often spend much time with parents when they are at work, therefore the example is set in the home and can not be beneficial to the child. Though this is clearly only one influential factor, it is a significant one and would lead many to believe the situation can only be combated through change within or additional strong influences without, such as in school programs.

Another factor of great importance in this question is the association, not of modeling but actual physical attributes of ethnicity as a factor for obesity. In Ethnic Issues in the Epidemiology of Childhood Obesity a prominent group of health researchers discuss some of the historical aspects of the issue of ethnicity and health problems, mainly here obesity. (Crawford, Story, Wang, Ritchie, Sabry, 2001, pgs. 855-873) One interesting fact included in this work demonstrates that the modeling of parents cannot be an isolated factor for blame as many preschool aged children are obese almost from birth. "Reports from PedNSS show that the prevalence of obesity for Mexican-American preschoolers, aged 4-5 years, increased from 10.6% (1982-1984) to 13.2% (1988-1994) for girls, and from 4.9% to 12.0% for boys." This is also a significantly higher rate of preschool obesity than in either the White or African-American populations, according to Crawford and colleagues. (pg. 858-859) Another study, addresses the challenges of prevention and treatment of obese children among which the most significant are mothers who: 1. focused on surviving daily life stress. 2. used food to cope with stress and as a tool in parenting 3. had difficulty setting limits with children 4. lacked knowledge about normal child development and eating behavior 5. were not committed to sustained behavioral change and 6. did not believe their overweight children where overweight. (Chamberlin, Sherman, Jain, Powers, Whitaker, 2002, pg. 1) The last issue, mothers perceptions or misperceptions of the degree of the problem a preschool child may have with their health also spurned other research on the subject and found it to be a significant obstacle to change. (Baughcum, Chamberlin, Deeks, Powers, Whitaker, 2000, pgs. 1380-1381)

Though modeling can not be removed from the mix when speaking of the older children, "Data from NHANES-III showed that male Mexican-American children aged 6-11 years and adolescents, aged 12-17 years, experienced higher rates of obesity, 18.8% and 14.% respectively, than African-Americans (14.7%, 12.5%) and whites (13.1%, 11.8%)." (pgs. 859-860) Similar reflective percentages are true of female Mexican-Americans, with the exception that African-American females obesity rates exceed those of Mexican-American females in this age group. (pg. 860) Though the gender difference in these two sets of numbers would indicate a genetic connection an additional and noteworthy finding by these researchers more strongly points towards ethnicity, combined with environemtn as a strong causal factors. "It is noteworthy that generational differences were observed-only 26% of first generation Hispanic adolescents were obese compared to 33% of second and third generation Hispanics." (pg. 860)

Within this work adaptive mechanisms were discussed as more and more substantiation is associated with ethnicity as a strong indicator of risk. Two significant theories are detailed,

According to the thrifty gene theory, certain populations that have migrated to affluent industrialized societies are predisposed to obesity because harsh conditions, such as famine, experienced by previous generations resulted in genetic selection for populations with highly efficient (thrifty) metabolisms and, therefore, low metabolic rates. (pg. 862)

An additional theory along these same lines is a significant answer to the increased rates of obesity and type II diabetes among some ethnic minorities.

The thrifty phenotype hypothesis suggests that insulin-producing cells of the pancreas and insulin-sensitive tissues in the body adapt in response to poor nutrition during fetal and infant life, resulting in decreased growth in early life at the cost of increased risk for obesity and type 2 diabetes in later childhood and adulthood. (pg. 682)

The study also mentioned the possibility of a bell curve statistic associated with a higher level of obesity in youth and adulthood as associated with both low and high birth weight, a demonstrative aspect of many at risk populations. (Hediger, Overpeck, McGlynn, Kuczmarski, Maurer, Davis, 1999, pg. e33) In another study ther ewas a link found between prolonged bottle use and overweight (Bonuck, & Kahn, 2002, pgs. 1-9) and yet another determined that one of the most significant periods of development than can effect obese or overweight outcome is prenatal. (Dietz, 1997, pgs. 1884S-1885S)

These bits of information clearly demonstrate additional need for early intervention for at risk populations. The work goes on to further outline some of the major issues also associated with high rates of obesity, more traditionally linked to its causes, socioeconomic status, physical activity, dietary patterns (in which at risk populations esp. Latinos) have a lower intake of calories from fresh fruits and vegetables and a higher BMI (Body Mass Index) than their white counterparts. And maternal factors, where higher BMI among mothers was associated with higher BMI among children and an overall difference in perceptions about ideal body size and health. (pg. 865) This work, comprising a rather holistic review of the issue goes on to discuss possible interventions, which will be further discussed within the solutions section of this work.

In a third article for review there is address for a common popular belief that new technology associated with inactive leisure activities such as television, computer and video games is a very strong cause for the demonstration of increased obesity among children of all races. In Television Vieing and its Associations with Overweight Sedentary Lifestyle, and Insufficient Consumption of Fruits and Vegitalbes among U.S. High School Students, Differences by Race, Ethnicity and Gender, (2002), Lowry, Wechester, Galuska, Fulton and Kann, set the standard for a greater understanding between the interplay of sedentary popular behavior and also poor nutrition associated with media influence. Though the researchers are quick to point out that these factors are not alone in the causation of obesity they are significant as more and more people become prey to relaxation that does not exercise the body and, some would say only marginally engages the mind. According to the authors, "Other than sleep, time spent watching TV represents the single greatest source of physical inactivity among American children." (pg. 2)

The survey questionnaire given by this group of researchers to high school aged children assessed both the number of hours per school day they watched television and also the number of servings of fruits and vegetables they ate, this was further broken down by three classifications for race, White, Hispanic, and Black and also by gender. (pg. 4)

The results indicate that Hispanic children range in the middle for excessive TV viewing (more than 2 hours per school day). (Blacks (73.7%) Hispanics (52.2%) than White (34.2%)). It is clear that the overall rate of excessive TV viewing was alarming but it is even more telling to look at the rates as they increase among younger school aged children, those significant in this study. Additionally one in 10 was overweight and 30.5% had a sedentary lifestyle. (pgs. 4-5) Strangely, insufficient consumption of fruits and vegetables, a relatively high rate in general did not vary by gender age or ethnicity. (pg. 5) The most important factor in this assessment is the fact that the number of hours children view television is a modifiable factor associated with unhealthy lifestyle choices and can be addressed through means such as offering alternatives that include gender, ethnicity and age identity issues as factors for program development.

In Overweight Children and Adolescents: Description, Epidemiology, and Demographics, (1998) Troiano and Flegal break down the issues at hand, through a comprehensive method including epidemiology and demographics.

The most striking aspect of this work is the demonstrative manner in which it breaks down the relative growth of obesity among children during a target number of years (1988-1994).

Though the study does disagree in that it does not find significant differences between the races in the number of cases of obesity. Yet, it must be noted that this study is limited to the view of attempting to stress the overall extremity of the problem among all children. Additionally the study stresses the importance of the recognition for the need of serious and rapid intervention as the problem is likely to get much, much worse in the next few years. The article also does a significant job assessing and outlining possible causes for this problem's growth. The number one problem found, as the study found no statistical change in the caloric intake of children was the reduced level of physical activity. Though the study did not particularly address elementary aged children it found fault in the extreme reduction in physical education among older children. (pg. 16)

In a Journal of American Medicine article associated with the relatively recent increase in relative body weight among children in the U.S. The authors call the changes epidemic, in the manner in which they will effect the future for children, adults and society in general, rather obese or average. Strauss and Pollack in Epidemic Increase in Childhood Overweight, 1986-1998 look not specifically at obesity but at overweight demographics, and in disagreement with the previous article found significant differences between the races as the increases in overweight youth developed over the years of the study. The difference is probably a direct result of the statistics, which were analyzed.

Additionally the distinct although sometimes vague difference between obesity and overweight in children could provide other clues to the differences between these two findings. (Molnar & Livingstone, 2000, pgs. S45-S55) The results of the work also make clear the importance of defining, developing and implementing what Strauss and Pollack call "culturally competent treatment strategies." (2001, pg. 1)

In summary the defining research on the subjects of obesity in children agree on many issues, the greatest being the extreme nature of the problem. A second important agreement of most of the research is that those at greatest risk for obesity, as children and for life are ethnic minorities. Yet the research also contends that the hours of physical education offered by schools continues to decrease and sedentary technology continues to command a unrealistic portion of our children's time.

Additional research on long-term health effects and experimental implementation of culturally conscious programs to increase physical activity among children are both called for.

Proposal for Intervention

Logical culturally sound interventions include options such as an increase in physical education requirements in schools, especially within schools that have a large percentage of high-risk students. Within the San Francisco Unified School District, as has been stated previously there is a high percentage of Latino students, disproportionately high in the lower grades. An intervention is most likely to succeed if it is implemented within the hours that children are in school and additionally the changes that can be made within the early mind of a student, with regard to a life long desire to be involved in physical rather than sedentary leisure activities.

One culturally sensitive aspect of daily physical education would be to provide physical education curriculum that is less likely to make an individual student feel early pressures of popularity and possible rejection. This implementation must occur very early in the grade levels, as students who are already at risk or who may already be above average weight, prior to entering school will need special attention with regard to their potential physical fitness even as early as pre-K. Nutrition, although a foundationally important aspect of overall health, and culture is addressed continually within the school systems at the same time that physical education is loosing substantially in the war for healthier children.

The need to implement diverse curriculum with mildly competitive and creative aspects is imperative. One example of such a program would be multi-cultural dance and games that require more movement than skill with low levels of direct competition. As, self-esteem is such a large part of body image and health the trap of associating physical education with humiliation and rejection must be avoided, as the cyclical effect of overweight image-decreased self-esteem-decreased physical activity must be avoided at all cost, especially with regard to ethnic minorities, who may already feel marginalized by greater society. (Strauss, 2000, pgs. 1-5)