Childhood Obesity and Hispanic Youth: Causes and Interventions

Introduction

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 healthcare industry and society in general, most notably the exponential increase in obesity found among children (Strauss & Pollack, 2001, pp. 2845–2848; Troiano & Flegal, 1998, pp. 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, p. 1).

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

Though historically defining obesity among children has been a challenge, using growth charts and mean body fat density ratios has served as a useful tool. For this paper, 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, p. 577). Factors associated with risk for obesity are many, among them dietary intake, level of sedentary behavior versus physical activity, self-esteem, socioeconomic status, gender, insurance status, and race and ethnicity.

This paper focuses on the problems and solutions associated with obesity in children, with specific emphasis on the growing Hispanic ethnic minority population. With increased risk based even on the isolated factor of ethnicity—and given the growth rate of this ethnic minority, mostly Latinos of Mexican descent, especially in California—race must be considered one of the most important factors associated with risk for obesity and all its health consequences. One cultural aspect of particular note is the overall acceptance, or perception in certain cultures, of overweight as healthy (Maynard, Galuska, Blanck, & Serdula, 2003, pp. 1–17).

Though race cannot 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. Whether 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" (Crawford, Story, Wang, Ritchie, & Sabry, 2001, p. 855).

Special care must be taken to ground society in changes that can assist all children at risk for obesity, yet the focus on alternatives—especially increased physical activity within schools—must account for the particular challenges of the growing ethnic minority population. Additionally, though the problem greatly impacts the individual and the family, the widespread prevalence of obesity among children and adults in a population also at high risk for lower socioeconomic status, and therefore greater need for publicly funded healthcare, 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 behavioral change, or that children who are obese will likely grow out of the condition. Not only is this untrue, but evidence suggests that the problem of obesity follows children into adulthood and significantly impacts their future health and even mortality rate (MacKenzie, 2000, pp. 527–530).

It is well observed that many of the negative and even deadly health outcomes of obesity seen among obese and overweight adults (Reilly, Methven, McDowell, Hacking, Alexander, Stewart, & Kelnar, 2003, pp. 748–752) are also seen in the very young. The seriousness of the problem appears to be growing without any sign of slowing down.

"More than 60% of overweight children have at least one additional risk factor for cardiovascular disease, such as elevated blood pressure, hyperlipidemia, or hyperinsulinemia" (Lowry et al., 2002, p. 2). The challenges to society in general, and specifically to individuals, are complex, but the health outcomes are directly associated with increased costs and decreased quality and length of life (Pi-Sunyer, 1993, pp. 655–660).

Solutions to this growing health threat have been debated for the last twenty years, but the number of hours children spend in school represents an opportunity for intervention that has been largely ignored. Most research has addressed factors such as environment, socioeconomic level, activity level, and family history as important facets of the problem. Some researchers point to television as a serious factor in the development of obesity in children (Lowry et al., 2002, pp. 1–23). Many blame nutritional changes within the United States as a whole—the amount of fast food consumed due to easy availability, and the replacement of fresh fruits and vegetables with high-fat, high-carbohydrate, low-nutrition foods in the everyday marketplace.

As schools have become increasingly focused on academic success and outcomes-based testing, and as the disproportionate relationship between school funding and cost of living has led to the reduction of extracurricular activities, physical education has suffered. "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 et al., 1999, p. 577).

Additionally, the growing trend has been to treat physical education as an extracurricular activity that children must seek out on their own, rather than one funded through schools. This makes participation in physical activity a competitive endeavor requiring more than simple desire. Often those most in need of the opportunity to move are barred from extracurricular activities by their competitive nature and by the time and resources required to participate. Many would like to individualize the problem by addressing 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, (3) sadness, (4) lowered self-esteem, (5) lowered competitiveness/achievement-oriented behavior, and (6) lack of motivation, initiative, and persistence" (Sothern et al., 1999, p. 577).

One problem with this view, however, is that while it does offer promising ways to combat the problem at a base level—rather than simply attempting to remove negative environmental conditions—it also implies that the competitive offerings of our society are a viable and realistic option for children regardless of their personal preference for or avoidance of competition. 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 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. In a study attempting to isolate risk factors among both younger students and adolescents, researchers used race, socioeconomic status, and health insurance status as variables, and 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, p. 1).

The growth of obesity in ethnic minority children appears to be even greater than in the general population, particularly for African-American and Hispanic-American children. In the state of California, the largest ethnic minority is Hispanic, and mostly Mexican-American. For this reason, the particular population of Hispanic-American youth in a target school district serves as the focus of this work. The demographic data demonstrates both an obstacle and an opportunity for the development of a program that will assist this generation and those to come in reducing the number of Hispanic youth affected by this serious problem. Without a global intervention within this and other populations, the problem will likely continue to skyrocket. Most importantly, without sustainable solutions that clearly consider and respond to individual identity—whether racial or otherwise—there will be no long-term change in either the habits or the health of children.

Review of Literature

Within the literature associated with the growing problem of obesity among American children, there is a foundational understanding of several key factors, the greatest being the demonstrably exponential growth of unhealthy body weights at younger and younger ages. Children of all races are at risk, and the challenges are significant. The studies examined here are both general and specific in their factor isolation.

In Race/Ethnicity, Social Class and Their Relation to Physical Inactivity During Leisure Time, results from the Third National Health and Nutrition Examination Survey (NHANES III), conducted between 1988 and 1994, are analyzed, and the findings isolate the factors of race and social class as influences on the demonstration of active physical leisure activity. The findings demonstrate a strong correlation between both race and social class and the level of inactive activities that people engage in during their leisure time. The highest-risk group would be those at socioeconomic lows who are also of ethnic minority backgrounds. "Ample evidence has shown that racial and ethnic minorities engage in less leisure-time physical activity than non-Hispanic whites" (Crespo, Smit, Anderson, Carter-Pokras, & Ainsworth, 2000, p. 46). Yet the researchers also make clear that the factor of ethnicity cannot be separated from age and social class.

The study surveyed both adults and children through the statistics of the NHANES III, conducted as a home questionnaire survey between 1988 and 1994, using a sample of non-institutionalized individuals in the U.S. beginning at age two months, with no upper age limit. 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 across the samples.

The results demonstrate that both men and women of Mexican-American ethnicity showed a significantly higher tendency to exhibit the highest levels of leisure-time inactivity, and that gender interacted with education level: Mexican-American men who had completed 12 years of education tended to have a slightly lower level of leisure-time inactivity (Crespo et al., 2000, p. 48). The greatest importance of this work—since it mainly analyzes adults—is in highlighting the significant impact of the parent-child relationship within Mexican-American households. Adults in high-risk groups, particularly Mexican-American households with lower social class, are modeling leisure inactivity as a standard for their children. The authors note that the level of inactivity exhibited by these adults may be influenced by the physical nature of their employment (p. 49), yet this does little to create a positive example for their children, as children do not benefit from the physical labor of their parents' work. The example set in the home cannot be assumed beneficial, and this leads many to believe the situation can only be combated through change within the home or through strong external influences such as school programs.

Another factor of great importance is the association of actual physical attributes of ethnicity as a risk 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 obesity (Crawford, Story, Wang, Ritchie, & Sabry, 2001, pp. 855–873). One significant finding demonstrates that parental modeling 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" (Crawford et al., 2001, pp. 858–859). This represents a significantly higher rate of preschool obesity than in either the white or African-American populations.

Another study addresses the challenges of prevention and treatment of obese children, among which the most significant involve 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 were overweight (Chamberlin, Sherman, Jain, Powers, & Whitaker, 2002, p. 1). The last issue—mothers' misperceptions of the degree of the problem—also prompted other research, which found it to be a significant obstacle to change (Baughcum, Chamberlin, Deeks, Powers, & Whitaker, 2000, pp. 1380–1381).

Though modeling cannot be removed from the discussion when speaking of 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 14.1% respectively, than African-Americans (14.7%, 12.5%) and whites (13.1%, 11.8%)" (Crawford et al., 2001, pp. 859–860). Similar 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. Though the gender differences in these numbers would indicate a genetic connection, an additional finding more strongly points toward ethnicity combined with environment as 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" (p. 860).

Within this work, two adaptive mechanisms are discussed as additional substantiation for ethnicity as a strong indicator of risk. 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" (Crawford et al., 2001, p. 862). An additional theory along these same lines provides a significant explanation for the increased rates of obesity and type 2 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" (p. 862).

The study also mentions the possibility of a bell-curve statistic associated with higher levels of obesity in youth and adulthood related to both low and high birth weight, a demonstrative aspect of many at-risk populations (Hediger, Overpeck, McGlynn, Kuczmarski, Maurer, & Davis, 1999, p. e33). Another study found a link between prolonged bottle use and overweight (Bonuck & Kahn, 2002, pp. 1–9), and yet another determined that one of the most significant periods of development that can affect obese or overweight outcomes is prenatal (Dietz, 1997, pp. 1884S–1885S). These findings clearly demonstrate additional need for early intervention for at-risk populations.

Crawford and colleagues go on to further outline major issues associated with high rates of obesity, including socioeconomic status, physical activity, and dietary patterns—in which at-risk populations, especially Latinos, have a lower intake of calories from fresh fruits and vegetables and a higher BMI than their white counterparts—as well as maternal factors, where higher BMI among mothers is associated with higher BMI among children and overall differences in perceptions about ideal body size and health (p. 865).

In a third article reviewed here, the authors address the common belief that new technology associated with inactive leisure activities—such as television, computers, and video games—is a very strong cause of increased obesity among children of all races. In Television Viewing and Its Associations with Overweight, Sedentary Lifestyle, and Insufficient Consumption of Fruits and Vegetables among U.S. High School Students: Differences by Race, Ethnicity and Gender (2002), Lowry, Wechsler, Galuska, Fulton, and Kann establish a greater understanding of the interplay between sedentary popular behavior and poor nutrition associated with media influence. Though the researchers are quick to point out that these factors alone do not cause obesity, they are significant as more and more people engage in relaxation that does not exercise the body. According to the authors, "Other than sleep, time spent watching TV represents the single greatest source of physical inactivity among American children" (Lowry et al., 2002, p. 2).

The survey questionnaire administered to high school-aged children assessed both the number of hours per school day they watched television and the number of servings of fruits and vegetables they ate, further broken down by three racial classifications—White, Hispanic, and Black—and by gender (p. 4). The results indicate that Hispanic children fall in the middle for excessive TV viewing (more than 2 hours per school day): Blacks (73.7%), Hispanics (52.2%), and Whites (34.2%). The overall rate of excessive TV viewing was alarming, and it is even more telling to examine how rates increase among younger school-aged children. Additionally, one in ten children was overweight and 30.5% had a sedentary lifestyle (pp. 4–5). Strangely, insufficient consumption of fruits and vegetables—a relatively high rate in general—did not vary by gender, age, or ethnicity (p. 5). The most important factor in this assessment is that the number of hours children view television is a modifiable factor associated with unhealthy lifestyle choices and can be addressed through programs that incorporate gender, ethnicity, and age as factors in 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 period (1988–1994). Though the study does not find significant differences between races in the number of cases of obesity, it must be noted that this study is limited in its attempt to stress the overall extremity of the problem among all children. Additionally, the study stresses the importance of recognizing the need for serious and rapid intervention, as the problem is likely to worsen significantly in the coming years. The number-one problem found—given that the study detected no statistical change in caloric intake among children—was the reduced level of physical activity, with particular fault found in the extreme reduction of physical education among older children (p. 16).

In a Journal of the American Medical Association article on the relatively recent increase in body weight among children in the U.S., the authors describe the changes as epidemic in the manner in which they will affect the future for children, adults, and society as a whole. 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, they 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 analyzed. Additionally, the distinct though sometimes vague difference between obesity and overweight in children could provide other clues to the differences between these two findings (Molnár & Livingstone, 2000, pp. 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, p. 1).

In summary, the defining research on childhood obesity agrees on many issues, the greatest being the extreme nature of the problem. A second important point of agreement is that those at greatest risk for obesity—as children and for life—are ethnic minorities. Yet the research also confirms that the hours of physical education offered by schools continue to decrease while sedentary technology commands an unrealistic portion of children's time. Additional research on long-term health effects and on the experimental implementation of culturally conscious programs to increase physical activity among children is called for.

Conclusion

Within this work there is substantial evidence and many expert reports confirming the intensity of the obesity problem among children. Changes have occurred within our society as a whole with regard to the increased level of sedentary activities we generally engage in and with regard to nutritional availability, and those changes have put our children in a detrimental position. Children are growing in girth far faster than they are growing in stature and, in so doing, are becoming increasingly more sedentary. Children return from school to an empty house where they spend hours watching television and playing video games. For safety reasons they are often not allowed to play outside, yet the results are devastating to their health. School programs and school-funded after-school programs should be able to provide safe, non-detrimental physical education that might challenge this sedentary lifestyle.

Within schools, the nutritional question is reviewed endlessly as individuals and groups lobby for nutritional guidelines that better serve the health of children. Yet when those same districts reduce, yet again, the funding and time committed to physical education, there is little public outcry. The detrimental effects of overly competitive physical education on self-esteem are well documented, yet with meaningful change, those hours could be well spent getting children out of their sedentary patterns. Simply allowing children to take frequent walking field trips during school hours could increase the number of hours they spend moving by tenfold. What amount of funding would be needed for children to be allowed to take a 15-minute guided walk every day through the streets around their schools?

The difference between how society responds to product safety recalls and how it responds to the childhood obesity crisis is striking. Particularly at risk are ethnic minority youth, for whom the compounding factors of socioeconomic status, cultural norms, and reduced access to physical activity programs create the greatest burden. The demand needs to go out to legislators and lobbyists that obesity among children is a substantial and deadly problem that this society will be paying for emotionally and economically for generations, and that this problem requires action from above—with mandatory physical education hours every day in every grade school, and especially in those with high attendance rates among at-risk youth.