Post on 30-Sep-2020
Running head: CHILDHOOD OBESITY IN RURAL LATINOS 1
Childhood obesity in rural Latinos:
Interventions and implications for its assessment, prevention and management
Nancy Gentry Perkins, BSN, RN
A Master’s Paper submitted to the faculty of
The University of North Carolina at Chapel Hill School of Nursing
in partial fulfillment of the requirements for the degree of Master of Science in Nursing
Spring 2013
Approved by:
Committee Chair: Ann Jessup, PhD, FNP-BC
Committee Member: Lisa Woodley, MSN, RN
CHILDHOOD OBESITY IN RURAL LATINOS 2
Childhood obesity, particularly among minority populations, has become an epidemic in
recent years (Spruijt-Metz, 2011). Latinos are the fastest growing minority population in the
United States, and currently represent the largest group of minority children in the U.S.
(Houston, Waldrop, & McCarthy, 2011; Lichter, 2012). In rural America, the Latino population
has grown by 44.6% in the last decade, which suggests that the rural Latino population will only
continue to grow exponentially in the coming years (Lichter, 2012). Rates of obesity during
childhood are typically higher in rural than urban areas due to a variety of factors, including a
lack of healthcare, a decreased number of close proximity supermarket chains and exercise
facilities, and a higher risk for lower socioeconomic status (Jilcott et al., 2011; Lutfiyya, Lipsky,
Wisdom-Behounek, & Inpanbutr-Martinkus, 2007; Rodriguez, Weffer, Romo, Aleman, & Ortiz,
2011). Latinos have been found to be more susceptible to overweight and obesity than their
Caucasian counterparts due to several genetic and cultural risk factors (Buscemi, Beech, &
Relyea, 2011; Butte, Cai, Cole & Comuzzie, 2006).
Purpose
Though many aspects of childhood obesity have been extensively documented in recent
years, evidence regarding implications and interventions for the prevention and management of
childhood obesity in Latino youth, particularly in rural areas, is scarce. As Latinos are America’s
fastest growing minority population, and many members of this population are living in rural
communities, there is a need for an evidenced-based approach to combat the childhood obesity
epidemic in this population. The purpose of this paper is to review the literature and describe the
primary care interventions and implications for the assessment, prevention and management of
childhood obesity in rural Latinos.
CHILDHOOD OBESITY IN RURAL LATINOS 3
Note: This author recognizes that there is much diversity among the different Latino subgroups.
However, this paper does not distinguish between the subgroups, and uses “Latino” as an
umbrella term to describe general implications and interventions for the prevention and
management of childhood obesity in rural Latinos as a whole.
Background
Obesity has been a global health problem for decades (Spruijt-Metz, 2011). In 1997, the
World Health Organization declared obesity to be an international epidemic, and since then,
numerous organizations have made efforts to decrease the rates of obesity worldwide (Spruijt-
Metz, 2011). Despite these efforts, rates of obesity have continued to grow exponentially in
adults and children, thus creating a global health crisis that has resulted in devastating individual
health outcomes and increasing costs to the public (Spruijt-Metz, 2011).
Obesity is a multifactorial disease, and major risk factors include genetic predisposition,
overweight or obesity during childhood and adolescence, poor diet and insufficient regular
physical activity (Smith et al., 2011). The consequences of obesity are great, and in addition to
increasing the individual risk of numerous health conditions, including diabetes, dyslipidemia,
hypertension, heart disease, stroke and certain cancers, obesity is one of the leading causes of
preventable, premature death in the U.S. (Biro & Wien, 2010; Smith et al., 2011). When obesity
occurs in childhood, the atherosclerotic process is accelerated and almost every organ system can
be adversely affected, resulting in serious medical and psychosocial complications (Han, Lawlor,
& Kim, 2010).
In adults, obesity is defined as a body mass index (BMI) greater than or equal to 30 kg/m2
(Flegal, Carroll, Kit, & Ogden, 2012). There are three grades of obesity: grade one (BMI 30 to
less than 35), grade two (BMI 35 to less than 40), and grade three (BMI greater than or equal to
CHILDHOOD OBESITY IN RURAL LATINOS 4
40) (Flegal et al., 2012). Persons with a BMI of 25.0 to 29.9 kg/m2 are classified as overweight
(Flegal et al., 2012). Seventy percent of the U.S. adult population is now considered overweight
or obese, and in 2010, the prevalence of obesity among U.S. adult men and women was 35.5%
and 35.8%, respectively (Flegal et al., 2012; Smith et al., 2011). It is estimated that by 2015 more
than 40% of all U.S. adults will be classified as obese (Biro & Wien, 2010).
Numerous studies have demonstrated that childhood and adolescent obesity are strong
predictors of adult obesity (Spruijt-Metz, 2011). In children, the evaluation of obesity status must
take into account the age and gender of the child (Spruijt-Metz, 2011). The Center for Disease
Control (CDC) created gender and age specific growth curves based on BMI for youth from 2 to
20 years of age in the year 2000 to better measure and assess the obesity status of children
(Kuczmarski et al., 2002). Children who fall within the 85th
to 94th
age and gender specific BMI
percentile are classified as “overweight”, and children who are in the greater than or equal to the
95th
age and gender specific BMI percentile or who have a BMI greater than or equal to 30,
whichever is lower, are classified as “obese” (Barlow & the Expert Committee, 2007).
According to data compiled by the CDC and the National Center for Health Statistics (NCHS),
the prevalence of obesity among children and teens has almost tripled since 1980, and currently,
an estimated 17% of all U.S. children and teens aged 2 to 19 years are obese (Ogden & Carroll,
2010). Preschool aged children, ages 2 to 5 years, had a lower prevalence of childhood obesity
than their older counterparts by approximately 10% (Wang, 2011). The highest rates of
adolescent obesity in 2008 were seen within the 6 to 11 year age group, where 19.6% of these
pre-adolescents were obese, compared with 18.1% of teens in the 12 to 19 year age group and
10.4% of children in the 2 to 5 year age group (Ogden & Carroll, 2010). Rates of childhood
obesity are increasing in all ethnic and racial groups, but its prevalence is highest in nonwhite
CHILDHOOD OBESITY IN RURAL LATINOS 5
populations (Caprio et al., 2008). This discrepancy is thought to be due to a combination of
complex factors, including genetics, physiology, culture, socioeconomic status and environment
(Caprio et al., 2008).
The physiology and consequences of childhood and adolescent obesity are complex, and
are thought to begin as early as the prenatal and infancy periods (Taveras, Gillman, Kleinman,
Rich-Edwards, & Rifas-Shiman, 2010). Research shows that adipose tissue not only stores
energy and provides thermal insulation for the body, but it also secretes adipokines, including
leptin (Neary, Goldstone, & Bloom, 2004; Spruijt-Metz, 2011). Together with gastrointestinal
peptides and neuropeptides, such as ghrelin and serotonin, respectively, one of the functions of
adipokines, particularly leptin, is to signal the brain to regulate appetite (Neary et al., 2004;
Spruijt-Metz, 2011). The level of adipokines secreted is, in general, directly related to the
amount of adipose tissue present, and when there are high levels of these circulating adipokines,
adverse health outcomes occur (de Ferranti & Mozaffarian, 2008; Spruijt-Metz, 2011).
Adipokines have great influence on the production of inflammatory mediators, such as TNF-
alpha, CRP and IL-6 (de Ferranti & Mozaffarian, 2008). These inflammatory mediators result in
a pro-inflammatory state, which has been linked to heart disease, the metabolic syndrome and
type 2 diabetes mellitus (de Ferranti & Mozaffarian, 2008; Spruijt-Metz, 2011). Adiponectin is
particularly important when considering the processes of type 2 diabetes mellitus and heart
disease, as adiponectin has been found to promote pancreatic beta-cell function and survival, in
addition to being cardio- and renal- protective (Turer, 2012). Adiponectin is secreted by adipose
tissue, but circulating levels are inversely related to the amount of central adipose tissue (Turer,
2012). Thus, with more central adiposity, there is less adiponectin secreted (Turer, 2012).
Additionally, adipose tissue secretes free fatty acids, and with increased adipose tissue, there is
CHILDHOOD OBESITY IN RURAL LATINOS 6
an increased concentration of free fatty acids (de Ferranti & Mozaffarian, 2008; Spruijt-Metz,
2011). An increased concentration of free fatty acids results in several events that increase
insulin resistance, including the reduction of muscle glucose uptake, increased liver glucose
production, and increased insulin secretion (de Ferranti & Mozaffarian, 2008; Spruijt-Metz,
2011).
While both non-Latino African Americans and Latinos are more susceptible to insulin
resistance than their Caucasian counterparts, the two ethnic groups differ in their response to
insulin resistance (Stovitz, Schwimmer, Martinez, & Story, 2008). Non-Latino African American
youth respond to their insulin resistance through a reduction in insulin extraction by the liver,
whereas Latino youth secrete more insulin (Stovitz et al., 2008). Thus, Latino adolescents and
children are believed to be particularly susceptible to obesity phenotypes, i.e. the metabolic
syndrome (Stovitz et al., 2008). In Latino youth with the metabolic syndrome, adiponectin levels
have been found to be approximately 25% lower compared with their healthy overweight
counterparts, even after controlling for insulin sensitivity, visceral adiposity and total body
composition (Shaibi et al., 2007). Thus, adiponectin is a significant and independent predictor of
the metabolic syndrome phenotype in Latino youth who are overweight (Shaibi et al., 2007). For
adolescents, it is widely believed that insulin sensitivity decreases at the onset of puberty
(Koebnick et al., 2008). In Caucasians, this physiological decrease in insulin sensitivity is
transient, but studies have demonstrated that Latino adolescents do not experience this transient
insulin resistance (Koebnick et al., 2008). In addition, pediatric non-alcoholic fatty liver disease
(NAFLD) is more common among Latinos than any other ethnic group, with more boys being
affected than girls (Stovitz et al., 2008). NAFLD, defined as “the accumulation of liver fat
greater than 5% in the presence of less than 10 grams of daily alcohol consumption” (Kim, Le,
CHILDHOOD OBESITY IN RURAL LATINOS 7
Mahurkar, Davis, & Goran, 2012, p. 158) is commonly associated with obesity, insulin
resistance, and dyslipidemia (Stovitz et al., 2008). Furthermore, Latinos are more likely to
experience hepatic-related morbidity and mortality, with some hepatic diseases being as much as
three times as common in Latinos than in Caucasians (Stovitz et al., 2008).
The role of genetics in the development of childhood obesity has been studied
extensively in recent years (Han et al., 2010). One of the strongest predictors of whether a child
is overweight or obese is the BMI of the mother and father (Vos & Welsh, 2010). The FTO (fat
mass and obesity-associated) gene located on chromosome 16 and its variations are strongly
associated with overweight and obesity (Vos & Welsh, 2010). A defect in the melanocortin 4
receptor gene (MC4R) is associated with a severe form of childhood obesity (Vos & Welsh,
2010). Rare single gene mutations, such as those related to the leptin signaling pathway, the key
biological pathway controlling energy balance, have been found to cause obesity in affected
individuals due to the subsequent development of hyperphagia (Farooqi & O’Rahilly, 2006).
Individuals who are born with a leptin deficiency typically have normal birth weight but
experience rapid weight gain in the first several months of life, resulting in severe obesity
(Farooqi & O’Rahilly, 2006). Other genetic syndromes, such as Prader-Willi syndrome, and the
mechanism of DNA methylation of regulatory genes in utero have been studied with animals in
relation to the development of obesity, but clear evidence of how these relate to obesity in
humans is scarce (Han et al., 2010). A genetic diagnosis should be considered in a severely obese
young child (less than 5 years of age) with hyperphagia and a positive family history of early-
onset obesity (Farooqi & O’Rahilly, 2006).
Genetics are thought to be highly contributory to the development of childhood obesity in
the Latino population (Butte et al., 2006). A major locus for insulin resistance on chromosome
CHILDHOOD OBESITY IN RURAL LATINOS 8
6q that is highly prevalent in Latinos has been identified as having strong effects on obesity
phenotypes (Duggirala et al., 2001). Another major locus that influences plasma triglyceride
concentrations that is located on chromosome 15q has also been found to be highly prevalent in
Latinos (Duggirala et al., 2000).
Primary perinatal risk factors for childhood obesity and metabolic dysregulation include
low birth weight and intrauterine growth restriction, in addition to early infant catch-up growth
and fetal overgrowth (Catalano et al., 2009). There are also many parental risk factors that are
associated with intrauterine fetal growth, especially maternal pregravid obesity and diabetes
(Catalano et al., 2009). These factors contribute significantly to the development of childhood
obesity because they have been shown to increase fetal adiposity (Catalano et al., 2009). Several
environmental exposures predispose children of overweight women to obesity, including over-
and undernutrition during the fetal period, never breastfeeding or early termination of
breastfeeding, and lack of control over the child’s eating (Johnson et al., 2011). These factors are
more likely to affect children of low socioeconomic status because of the strong association
between low socioeconomic status and overweight or obesity in women (Johnson et al., 2011).
Data also suggests that the percentage of body fat at birth, rather than birth weight, is an
important risk factor for the development of childhood obesity (Catalano et al., 2009).
Behavioral risk factors in early and late childhood have also been shown to significantly
contribute to the prevalence of childhood obesity (Han et al., 2010). High energy intake in early
infancy and high consumption of sugar-sweetened beverages in childhood are associated with an
increased risk of childhood obesity (Han et al., 2010). Additionally, high levels of physical
inactivity are associated with a high risk of childhood obesity (Han et al., 2010). Research has
also shown that a higher risk of childhood obesity exists in children who spend a large number of
CHILDHOOD OBESITY IN RURAL LATINOS 9
hours viewing television, and in children who have short sleep duration in infancy and childhood
(Han et al., 2010).
Racial and ethnic disparities are significant with regards to the prevalence of childhood
obesity (Ogden & Carroll, 2010). Though rates of childhood obesity are increasing in all ethnic
and racial groups, its prevalence is highest in nonwhite populations (Caprio et al., 2008). A
review of national survey data indicated that American Indians had the highest prevalence of
childhood obesity, African Americans and Mexican Americans had rates of childhood obesity
higher than Caucasians, and Caucasians and Asians had the lowest prevalence of childhood
obesity (Wang, 2011). It is thought that these racial and ethnic disparities in childhood obesity
prevalence are present as early as the preschool years (Taveras et al., 2010). Among U.S.
adolescents aged 12 to 19 years in 2008, 26.8% of Latino males were obese and 19.8% of non-
Latino black males were obese, compared to 16.7% of non-Latino white obese males (Ogden &
Carroll, 2010). In U.S. adolescent females aged 12 to 19 years in 2008, 29.2% of non-Latina
black females and 17.4% Latina females were obese, compared with only 14.5% of non-Latina
white females being obese (Ogden & Carroll, 2010). The discrepancy in the prevalence of
childhood obesity among racial and ethnic groups is thought to be due to a combination of
complex factors, including genetics, physiology, culture, socioeconomic status and environment
(Caprio et al., 2008). For example, Taveras et al. (2010) found that even after adjusting for
socioeconomic status and parental obesity, Latino and African American children were more
likely than their Caucasian counterparts to experience rapid weight gain, sleep for shorter periods
as infants, have televisions in their bedrooms, and have a higher intake of sugar-sweetened
beverages and fast food.
CHILDHOOD OBESITY IN RURAL LATINOS 10
Socioeconomic status is a contributing factor to the increasing disparities in childhood
obesity partly because of the fact that individuals with a higher socioeconomic status tend to
have more knowledge of nutrition, have positive attitudes towards healthy behaviors and are
more likely to live in environments in which a healthy lifestyle is easier to attain (Singh,
Siahpush, & Kogan, 2010; Johnson, Pratt, & Wardle, 2011). Levels of adiposity are higher with
each incremental decrease in socioeconomic status (Johnson et al., 2011). From 2003 to 2007,
socioeconomic inequalities related to race and ethnicity in childhood overweight and obesity
prevalence increased because Latino children and children of lower socioeconomic status
experienced increases in obesity rates at a faster pace than Caucasian children and children of
higher socioeconomic status (Singh et al., 2010). Children who lived below the poverty line in
2007 had 243% higher odds of developing childhood obesity than children from households with
an income greater than 400% of the poverty threshold (Singh et al., 2010). However, other
research has shown that large ethnic disparities in the prevalence of childhood obesity can exist
in homogenous socioeconomic groups (Wang, 2011). For example, one National Health and
Nutrition Examination Survey (NHANES) found that socioeconomic status was inversely related
to obesity in white children, but not among black or Mexican-American children (Wang, 2011).
Thus, evidence suggests that even after adjusting for socioeconomic status, minorities are still
more likely to experience childhood obesity than their Caucasian counterparts.
Parental education is another contributing disparity in childhood obesity and overweight
prevalence (Singh et al., 2010). Many studies have found parental education, particularly
maternal, to be the strongest single socioeconomic predictor of child obesity (Johnson et al.,
2011). In 2007, children with parents who had less than 12 years of education had 325%
increased odds of developing childhood obesity than children with parents who had a college
CHILDHOOD OBESITY IN RURAL LATINOS 11
degree (Singh et al., 2010). Additionally, children from households with higher unemployment,
households that are non-English speaking, single-mother households, and households in unsafe
neighborhoods were at a significantly increased risk of being obese and overweight in 2007
(Singh et al., 2010). Although most studies indicated an association between the neighborhood
and obesity of the individual, there is not enough evidence to assume a causal relationship
between the environment of a group of residents and their overweight status (Johnson et al.,
2011). Furthermore, minority children may experience health disparities when it comes to their
health care access and quality, including disparities in the health status and insurance coverage
among minority youth (Wilson, 2009).
Geographic location has been recognized in recent years as encompassing its own group
of health issues (Lutfiyya et al., 2007). NHANES III data demonstrated that the combined
prevalence of overweight and obesity was higher in urban areas for children aged 6 to 9 years,
but was higher in rural areas for adolescents (Wang, 2011). Still, some researchers have
suggested that there is a possible health benefit to non-rural residence (Lutfiyya et al., 2007).
Children who live in rural areas of the U.S. are approximately 25% more likely to be overweight
or obese than their urban counterparts (Lutfiyya et al., 2007). A national study found that rural
residency is an independent risk factor for being obese or overweight during childhood (Lutfiyya
et al., 2007). Other evidence indicates that the obesity prevalence in adolescents from small rural
communities, especially males, is almost two times that of their urban counterparts (Rodriguez et
al., 2010). Though the exact reasons as to why rural children are more likely to be obese than
their urban counterparts are uncertain, there are some risk factors that occur more frequently in
rural populations, such as lower socioeconomic status and poor dietary habits, that contribute to
this disparity (Rodriguez et al., 2011). Additionally, the “features of the rural environment that
CHILDHOOD OBESITY IN RURAL LATINOS 12
create special challenges for rural children to be physically active, including limited access to
parks, exercise facilities, fewer sidewalks, a lack of public transportation, and limited physical
education classes” also contribute to the disparities in childhood obesity rates among rural
children (Lutfiyya et al., 2007, p. 2354).
Additional elements in the rural setting, such as decreased access to healthy foods,
increased cost of fruits and vegetables, fewer opportunities for education and limited access to
nutrition experts contribute to its tendency to be obesegenic (Lutfiyya et al., 2007). “One study
found that greater distance from a child’s home to the nearest chain supermarket was associated
with greater risk of overweight only among children dwelling in less densely populated areas”
(Jilcott et al., 2011, p. 1611), which is significant because children living in rural areas are more
likely to be obese and typically live further from chain supermarkets than urban children (Jilcott
et al., 2011). Not only do health disparities with regards to health care status and access exist
among racial and ethnic groups, they also exist among geographic locations (Lutfiyya et al.,
2007). “Rural children were almost 50% less likely to have a preventive healthcare visit and also
less likely to have health insurance” (Lutfiyya et al., 2007, p. 2354).
Latino children are the largest minority group of children in the United States (Houston et
al., 2011). Latino children are more likely to be considered to be overweight or obese than
Caucasian or African American children (Rosas et al., 2011). In 2004, 37% of all Mexican
American children aged 2 to 19 years were overweight or at risk of being overweight compared
with 35.1% of African American children and 33.5% of non-Hispanic White children (Ogden et
al., 2006). Rates of childhood obesity among Latinos are surpassed only by those of American
Indians (Wang, 2011). However, due to the rapidly increasing number of Latinos in the U.S.,
which is expected to exceed 132 million by the year 2050, childhood obesity among Latino
CHILDHOOD OBESITY IN RURAL LATINOS 13
children is a serious health issue that requires immediate attention (United States Census Bureau,
2011).
Latinos are America’s largest minority population, and currently represent 16% of the
total U.S. population (Lichter, 2012). Between the years 2000 and 2010, the rural Latino
population grew by 44.6% (Lichter, 2012). The concept of acculturation, which is “the process
of adjusting to a new culture [and] describes the social, psychological, and behavioral changes
that an individual undergoes as a result of immigration” (p.149), has long been considered to be a
factor in the health disparities of Latinos (Buscemi et al., 2011). Acculturation is multi-factorial
and difficult to measure (Liu, Probst, Harun, Bennett, & Torres, 2009). However, obesity has
been found to be strongly associated with acculturation in Latino children (Buscemi et al., 2011).
Additionally, Latino youth are at greater adjusted odds of having no health insurance and no
usual source of healthcare than their Caucasians counterparts (Flores & The Committee on
Pediatric Research, 2010).
Food insecurity, the “limited or uncertain availability of nutritionally adequate and safe
foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways”
(Cook & Frank, 2008, p. 193), is a socioeconomic factor associated with acculturation that is a
predictor of becoming overweight or obese (Buscemi et al., 2011). Moreover, children in
households that are food insecure are more likely to have poor health than their food secure
counterparts (Sano et al., 2011). Food insecurity can result in obesity through several
mechanisms, including over reliance on inexpensive, energy-dense foods and overeating (Rosas
et al., 2011). The negative effects of food insecurity are particularly consequential in children,
who are undergoing substantial physical and mental development (Cook & Frank, 2008). Food
insecurity is believed to be especially prevalent among Latinos in rural areas due to cultural and
CHILDHOOD OBESITY IN RURAL LATINOS 14
language barriers (Sano, Garasky, Greder, Cook, & Browder, 2011). Furthermore, Latinos
typically live in spatial isolation from non-Latinos, which may contribute to their limited access
to information about local support and services (Sano et al., 2011).
Most minority populations, including Latinos, consume an excess of sugar-sweetened
beverages and fast food, and have a suboptimal consumption of fruits and vegetables, compared
to their Caucasian counterparts (Odoms-Young, Zenk, Karpyn, Ayala, & Gittelsohn, 2012).
Traditional Latino dishes are often high in fat and calories (Caballero, 2011). Latino youth who
are overweight or obese are more likely to have experienced chronic malnutrition and
consequently have a higher prevalence of height deficit, or stunting, than their Caucasian
counterparts (Iriart, Handal, Boursaw, & Rodriges, 2011). Research demonstrates that home and
parental eating behaviors significantly influence a child’s eating behavior (Hartley, Anderson,
Fox, & Lenardson, 2011). Latino families tend to use larger quantities of sodium, oils and sugars
than their Caucasian counterparts (Sealy, 2010). They are also more likely to fry foods, rather
than bake or broil them (Sealy, 2010). Latino families also eat together during meals at home,
thus making it potentially difficult to alter food choices for an obese child because the entire
family will be affected (Caballero, 2011). However, family meals have the potential to be
beneficial for the obese child if the entire family understands and commits to cooking and eating
healthy foods. Hammons and Fiese (2011) found that children who share family meals at least 3
times per week are more likely to eat healthier and be of normal weight.
The role of physical activity in preventing and decreasing rates of childhood obesity is
well documented. Latino adolescents in rural areas engage in less physical activity than non-
Latino white adolescents, regardless of BMI category (Rodriguez et al., 2011). This shows that
there may be strong cultural and socioeconomic barriers preventing Latino adolescents from
CHILDHOOD OBESITY IN RURAL LATINOS 15
engaging in physical activity in rural communities (Rodriguez et al., 2011). One cultural value
among some Latinos is the belief that physical robustness is an indicator of physical health
(Caballero, 2011). Thus, some Latinos are less likely to perceive themselves as overweight,
decreasing the likelihood that they will engage in physical exercise (Caballero, 2011).
Non-pharmacologic interventions including dietary modifications and increased physical
activity are the cornerstones of obesity prevention and management in youth of all ethnicities
(Han et al., 2010). It is well documented that provider failure to be culturally competent has
negative consequences on the affected populations, especially minorities and non-English
speaking patients (Brotanek, Seeley, & Flores, 2008). Regarding obesity prevention and
management in Latino youth, there is a great need for interventions that are specific to Latinos
and their culture (Ramirez, Chalela, Gallion, Green, & Ottoson, 2011). The level of the
acculturation of the individual, as well as cultural health beliefs, have great influence on the
success of general recommendations for preventing and treating childhood obesity in Latinos,
such as breastfeeding (Metzger & McDade, 2009). Additionally, preventing and treating
childhood obesity is not simply the responsibility of the individual (Vos & Welsh, 2010).
Successful interventions in preventing and treating childhood obesity require change at
governmental and community levels, school and childcare levels, and familial and individual
levels (Vos & Welsh, 2010). It is particularly challenging to implement change at these levels in
rural communities, particularly those of minorities, due to a lack of resources, opportunities and
funding (Lutfiyya et al., 2007). Thus, specific interventions to prevent and manage childhood
obesity in rural, minority youth are necessary. This paper aims to provide primary care clinicians
with a review of evidenced-based interventions and implications that may be helpful in the
assessment, prevention and management of childhood obesity in rural Latinos.
CHILDHOOD OBESITY IN RURAL LATINOS 16
Methods
Evidenced-based journal articles were chosen using the following search terms:
“childhood”, “obesity”, “Latino”, “youth”, “treatment”, “causes”, “genetics”, “rural”, “physical
activity”, “feeding practices”, “prevention”, “consequences”, “management”, “medications”,
“interventions”, “policies”. Additionally, all articles selected were in English and the majority
pertained to children and teens 21 years and under. A few articles not pertaining to this age group
were used for background information on obesity in general. Articles used in this paper range
from years 1994 to 2013, with the vast majority of articles ranging from the year 2007 to the year
2013. Numerous articles were found using the criteria above, and 109 unique evidenced-based
sources were used for this paper. I met with committee members periodically to continue to
focus the paper.
Discussion
Improving the Cultural Competence of the Providers Who Care for Rural Latino Youth
For Latinos, one of the most commonly reported themes among barriers to seeking health
care is distrust in providers, which likely stems from a general consensus among Latinos that
health providers “aren’t like [them]” and “don’t understand [them]” (Sherrill & Mayo, 2009).
Additionally, a review of national provider statistics found that Latino patients were significantly
less likely to receive pediatric obesity prevention counseling at office visits than patients of other
ethnicities (Branner, Koyama, & Jensen, 2008). Thus, there is a great need for culturally
sensitive and linguistically appropriate health care, particularly for the prevention and
management of childhood obesity in rural Latinos.
Appropriate, thorough and frequent communication between providers and patients is of
great importance when considering the health of rural Latino youth. Improved communication
CHILDHOOD OBESITY IN RURAL LATINOS 17
between patients and providers is considered to be one of the greatest potentials for promoting
quality health among Latinos (Elder, Ayala, Parra-Medina, & Talavera, 2009, p. 238). Research
shows that the language barrier not only prevents this group from seeking and obtaining quality
healthcare, it also increases their risk for adverse medical events (Brotanek et al., 2008). It is
unrealistic to expect that every provider caring for rural Latino youth be fluent in Spanish.
However, it should be the expectation that there are sufficient resources in the practices and
communities of these clinicians to provide routine and quality healthcare for rural Latino youth.
One such resource is on-site medically trained interpreters (Brotanek et al., 2008). Another is
promotores, or lay health advisors, who can be used to provide ongoing health education and
support for the members of their rural Latino community in addition to helping bridge the gap
between health delivery and patient compliance and understanding (Elder et al., 2009).
Telemedicine, mailed information, and information disseminated through Telenovela storylines
have also proven to be effective forms of communication for health education that can be used
with rural Latinos because they are convenient, cheap, relevant and easily offered in Spanish
(Elder et al., 2009). Clinicians of rural Latino youth must also consider more convenient office
hours and location, and better marketing through Spanish radio, newspaper and television ads as
methods to decrease the health disparities seen in this population (Elder et al., 2009).
Providers should implement certain strategies into their practice that convey cultural
sensitivity and competence to the rural Latino population (Wilson, 2009). Krueter et al. identified
five strategies that can be used by providers to enhance cultural appropriateness: peripheral,
evidential, linguistic, constituent-involving and sociocultural strategies (as cited in Wilson, 2009,
p. 232). When considering childhood obesity prevention and management in rural Latinos, one
peripheral strategy that could be utilized is to give health education materials regarding diet and
CHILDHOOD OBESITY IN RURAL LATINOS 18
exercise the appearance of cultural sensitivity by including images of rural Latino youth
engaging in culturally appropriate interventions for obesity (Wilson, 2009). An evidential
strategy that could be used for the prevention and management of childhood obesity in rural
Latinos is to make materials relevant by including statistics regarding the prevalence of obesity
and obesity-related behaviors in this ethnic group (Wilson, 2009). Creating materials that are
available in Spanish can also enhance the prevention and management of childhood obesity in
rural Latinos (Wilson, 2009). Additionally, these materials must be of an appropriate reading
level, as “more than half of the minority population in the U.S. is functionally or marginally
illiterate” (Elder et al., 2009, p. 240). Using the personal experiences of members of the rural
Latino community, a constituent-involving strategy, and integrating certain cultural values of
rural Latinos, a sociocultural strategy, can be effective in improving the understanding of and
compliance with interventions to combat childhood obesity in this group (Wilson, 2009).
The Impact of Acculturation on Childhood Obesity and its Measurement
As stated in the background section, the level of acculturation of the individual is
strongly associated with obesity in Latino children (Buscemi et al., 2011). In Latino youth,
acculturation is believed to mediate certain obesity-related behaviors, such as dietary choices and
physical activity (Allen et al., 2007). Evidence demonstrates that acculturative stress, rather than
the process of acculturation itself, has the greatest impact on the physical and emotional health of
Latinos (Caplan, 2007). Additionally, acculturation stress is linked to disruptions in allostasis
and chronic stress, which can contribute to and increase the risk of childhood obesity (D’Alonzo,
Johnson, & Fanfan, 2012). Though acculturation is difficult to accurately measure, it is important
for primary care providers to consider and attempt to assess the level of acculturation of each
CHILDHOOD OBESITY IN RURAL LATINOS 19
patient in order to best meet the health care needs of the individual and their family regarding
childhood obesity prevention and management (Liu et al., 2009).
Common measures of acculturation include, but are not limited to, how long the
individual has been in the U.S., the language use, preference and ability of the individual, the
culture of the individual and the location of their residence (Springer et al., 2010). Additionally,
the generation status of the individual can also be used to assess acculturation, as it “has been
associated with variations in health care access and utilization, education outcomes, and health-
risk behaviors” (Allen et al., 2007, p. 337), particularly in Latino youth. For example, among
Latinos, generational trends demonstrate worsening nutrition with regards to fruit, vegetable and
soda consumption (Allen et al., 2007). Compared with Caucasians, first-generation Latino youth
consumed more fruit and a similar amount of vegetables, but third-generation Latino youth
consumed fewer fruits and vegetables (Allen et al., 2007). With regards to soda consumption,
first- and second-generation Latino youth had approximately the same amount of soda
consumption as Caucasians, but third-generation Latino youth had a soda intake approximately
25% more than Caucasians (Allen et al., 2007). The more acculturated a Latino child is, the more
likely they are to reject more healthful, traditional Latino dishes (Kumanyika & Grier, 2006).
Latino school-aged children, particularly those who are bilingual, frequently reject the lower-
calorie traditional foods prepared at home in favor of the high-calorie substances offered at
school or advertised on television (Caprio et al., 2008). Additionally, in rural areas, Latinos often
abandon their traditional diets, which are rich in vegetables and instead prefer processed foods
(Caprio et al., 2008).
There are several evidenced-based scales that can be used in primary care to measure a
child’s level of acculturation. The Acculturation, Habits and Interests Multicultural Scale for
CHILDHOOD OBESITY IN RURAL LATINOS 20
Adolescents (AHIMSA) has been proven to be a valid measure of acculturation in adolescents
(Unger et al., 2002). The AHIMSA is comprised of eight brief and age appropriate questions that
assess multiple components of acculturation (Unger et al., 2002). The questions must be
answered with one of four response items: the U.S., the country the adolescent’s family is from,
both and neither (Unger et al., 2002). The AHIMSA scale generates four scores based on the
responses, and include an assimilation score (based on the number of “U.S.” answers), a
separation score (based on the number of “the country my family is from” answers), an
integration score (based on the number of “both” answers) and a marginalization score (based on
the number of “neither” answers) (Unger et al., 2002). Another acculturation scale that can be
used in Latino youth is the Short Acculturation Scale for Hispanic Youth (SASH-Y) (Barona &
Miller, 1994). The SASH-Y consists of 12 self-rated items that form a composite score from 12
to 60 where higher scores indicate the individual is more acculturated to the U.S. (Barona &
Miller, 1994). In addition, the Acculturative Stress Inventory for Children (ASIC) has also been
proven to be valid and accurate in assessing the amount of acculturative stress in Latino children
(Suarez-Morales, Dillon, & Szapocznik, 2007).
Cultural Implications for the Health Management of Rural Latino Youth
Respeto, or respect, “refers to the importance of teaching younger generations their
obligations for proper levels of courtesy and decorum required in various social contexts with
people of a particular social status, sex or age” (Elder et al., 2009, p. 242). Respeto for health
providers can prevent rural Latinos, particularly youth, from asking questions, which can lead to
poor health outcomes (Sherrill & Mayo, 2009). The cultural concept of simpatia, “a deferent
compliance with others’ wishes in order to maintain interpersonal relationships” (Caballero,
2011, p. S12), often results in the Latino population overeating at social occasions in order to be
CHILDHOOD OBESITY IN RURAL LATINOS 21
polite and maintain interpersonal relationships. Fatalismo is “the belief that individuals cannot
alter their disease processes because it is part of their destiny” (Caballero, 2011, p. S12). Also,
Latinos may view illness as unavoidable or as a punishment from God (Elder et al., 2009). Thus,
Latinos may be less likely to adhere to treatment regimens (Caballero, 2011). The cultural
concept of machismo refers to the expectation that men should engage in behavior that is
considered masculine, which often results in the beliefs among Latinos that physical robustness
indicates physical health and that visiting a clinician is a sign of weakness (Caballero, 2011).
Another important cultural concept among Latinos is familismo, the “feelings of loyalty,
reciprocity, and solidarity towards members of the family, as well as the notion of the family as
an extension of self” (Elder et al., 2009, p. 242). Many Latinos prioritize the needs of the family
over individual needs, and therefore, may not be influenced by health messages that only appeal
to personal autonomy (Elder et al., 2009). On the other hand, the concept of familismo may
potentially be used to elicit behavioral modifications of parents to positively affect the health of
the family as a whole, including their obese or overweight children. Culturally competent
clinicians must understand the importance of the family as the unit of change within Latino
populations (Lindsay, Sussner, Greaney, & Peterson, 2009).
Familial and Multi-ecological Implications and Interventions for the Prevention,
Assessment and Management of Childhood Obesity in Rural Latinos
The prevention, assessment and management of childhood obesity in rural Latinos
require interventions for all members of the family that must occur prenatally and continue
throughout childhood and adolescence. Family clinicians have a unique and important
opportunity to address obesity in rural Latino youth through interventions that affect the family
unit and take place on multiple ecological levels.
CHILDHOOD OBESITY IN RURAL LATINOS 22
Preventive interventions in the early years.
The prenatal period. Childhood obesity prevention should begin in the prenatal period
and continue through the postnatal, infancy, childhood and adolescent periods (Adair, 2008). The
in utero environment is widely considered to be a critical period for the development of obesity
later in life (Kelly et al., 2008). Maternal factors that influence the in utero environment include
overweight or obesity, gestational diabetes, smoking and depression (Taveras et al., 2010). The
prevalence of maternal obesity and gestational diabetes is higher among Latinas than Caucasian
women (Kumanyika, 2008). In many cases, maternal overweight or obesity and/or gestational
diabetes result in an infant who is of an increased birth weight (Kelly et al., 2008). For Latinos,
evidence shows that increased birth weight is significantly associated with increased BMI and
total body fat by age 11 (Kelly et al., 2008). Maternal smoking during pregnancy is associated
with a 50% increase in the risk of childhood obesity (Taveras et al., 2010). A study of
approximately 1200 pregnant Latina women in Massachusetts found that 21% of these women
smoked during pregnancy, and that higher levels of acculturation were associated with an
increased likelihood that Latina women would smoke during pregnancy (Detjen, Nieto,
Trentham-Dietz, Fleming, & Chasan-Taber, 2007). Maternal smoking during pregnancy restricts
fetal growth and often results in low birth weight infants (Adair, 2008). To compensate for this
low birth weight, there is often a period of rapid weight gain after birth that increases a child’s
risk for obesity (Adair, 2008). Dennison et al. (2006) found the rate of infant weight gain during
the first 6 months of life to be associated with a significantly increased risk of being overweight
at the age of 4. Latino ethnicity was found to be an independent risk factor for childhood obesity,
as Latino children were more than two times as likely as children of other ethnicities to be
overweight at the age of 4, even after adjusting for breast-feeding history and infant weight gain
CHILDHOOD OBESITY IN RURAL LATINOS 23
(Dennison et al., 2006). Latina women are also more likely to experience maternal depression
during pregnancy than their Caucasian and African American counterparts, which increases their
child’s risk of obesity (Taveras et al., 2010).
Breastfeeding. In the postnatal and infancy periods, providers should strongly encourage
all Latina mothers to exclusively breastfeed their infants for at least the first 6 months, as
breastfeeding has been found to be protective against childhood obesity (American Academy of
Pediatrics [AAP], 2011; Metzger & McDade, 2009; U.S Department of Health and Human
Services, 2010). Research indicates that the majority of Latinas do not consistently breastfeed or
exclusively breastfeed their children for the first 6 months of life, which is believed to be largely
due to their level of acculturation and individual health beliefs that are highly influenced by their
culture (Houston et al., 2011). Increased acculturation of the Latina mother decreases the
likelihood that she will breastfeed because she, like many Latinos, believes bottle-feeding to be
the “American way” (Houston et al., 2011; Faraz, 2010). In order to increase breastfeeding rates
among Latinas, the culturally competent provider must incorporate relevant cultural beliefs and
traditions including “la cuarenta del bebe” (Faraz, 2010). The word “cuarentena” is the origin of
this phrase, and in this context, it refers to “the 40 days after birth during which nothing except
the mother’s breast should enter the baby’s mouth” (Faraz, 2010, p. 296). Other interventions
providers can implement to improve breastfeeding rates among Latinas are personalized
breastfeeding plans and personal bilingual advocates, such as those trained by the La Leche
League (Faraz, 2010).
Sleep. Sleep is also an area that clinicians should address in the prevention of childhood
obesity in rural Latinos (Hart, Kuhl, & Jelalian, 2012). Latino children are sleeping less than
their Caucasian counterparts, especially between the ages of 6 months and 2 years (Taveras et al.,
CHILDHOOD OBESITY IN RURAL LATINOS 24
2010). Children who sleep less than 8 hours per night are at three times the risk of developing
obesity, as well as infants aged 6 months to 24 months who sleep less than 12 hours per night
(Paul et al., 2012; Spruijt-Metz, 2011). Chen et al. (2008) found a 58% higher risk for
overweight or obesity in children with shorter sleep duration. When sleep is restricted in
children, leptin levels decrease and ghrelin levels increase (Hart et al., 2012). Also, short sleep is
believed to be associated with hyperglycemia, increased insulin resistance, and lower fasting C-
peptide (Hart et al., 2012). Further, shorter sleep duration among school-aged children is
associated with an increased consumption of energy-dense foods (Hart et al., 2012). The
following are evidenced-based sleep duration guidelines per night for children: greater than or
equal to 11 hours for children less than 5 years of age, greater than or equal to 10 hours for
children aged 5 to 10 years, and greater than or equal to 9 hours for children greater than or equal
to 10 years of age (Chen, Beydoun, & Wang, 2008). The risk for overweight and obesity in
children is decreased by an average of 9% for every one-hour increase in sleep per night (Chen et
al., 2008). Thus, these sleep recommendations should be shared with parents and children, and
clinicians should assist families in increasing the number of hours of sleep per night for children
through a variety of interventions, such as setting bed time rules and teaching parents of infants
soothing strategies for non-hunger-related fussiness (Paul et al., 2012).
Parenting behaviors.
Understanding the parenting behaviors of rural Latinos is crucial to the proper
prevention, assessment and management of childhood obesity in this population. Not only is
parental involvement significantly related to adherence to treatment plans and weight loss in
children, dietary and physical activity patterns between parents and their children are similar
(Caprio et al., 2008; Heinberg et al., 2010; Vos & Welsh, 2010). Parental feeding behaviors, such
CHILDHOOD OBESITY IN RURAL LATINOS 25
as restriction, food prompting, and pressuring, have been shown to exacerbate the relationship
between uninhibited eating and increased BMI (Vos & Welsh, 2010, p. 282). Restrictive feeding
practices are more common among Latinos than Caucasians or African Americans (Taveras et
al., 2010). These feeding behaviors can result in “child preferences for foods that are high in
calories and fat, food consumption in the absence of hunger, and being overweight”
(Wisniewski, 2009, p. 78). Parents should be encouraged to allow their children to self-regulate
their meals within reason (Barlow & the Expert Committee, 2007). Latino parents are also more
likely to introduce solid foods to their infants before the recommended 4 to 6 months of age
(AAP, 2011; Taveras et al., 2010). The early introduction of solids in infancy increases the
energy density of the diet compared to a diet of formula or breast milk only, thus resulting in an
increased risk of obesity without adequate energy expenditure (Adair, 2008). Evidence shows
that Latina mothers have a preference for heavier babies, and therefore they may fail to see their
child as overweight and the need to alter feeding practices or seek medical help (Houston et al.,
2011; Olvera, Suminski, & Power, 2005). Additionally, within Latino families, extended family
members, particularly grandmothers, have a strong influence over the way a mother feeds her
baby (Houston et al., 2011).
Interventions that both prevent and manage childhood obesity.
Providers should consider and encourage the implementation of the following dietary and
activity interventions in all children, particularly those with a BMI between the 85th
and 95th
percentile, and should absolutely implement these in children with a BMI greater than or equal to
the 95th
percentile (AAP, 2011). Dietary interventions and activity behavior modifications are
recommended for both the prevention and management of childhood obesity in rural Latinos.
CHILDHOOD OBESITY IN RURAL LATINOS 26
Dietary interventions. Interventions to modify dietary behaviors are a cornerstone of
childhood obesity prevention and treatment (AAP, 2011; Barlow & the Expert Committee,
2007). The AAP (2011) created the evidenced-based Cardiovascular Health Integrated Lifestyle
Diet (CHILD-1), which is comprised of recommendations for a pediatric heart healthy diet. The
CHILD-1 focuses on and encourages pediatric diets that have limited total fat, saturated fat,
mono- and polyunsaturated fat content, in addition to restricted trans fat and cholesterol content
(AAP, 2011).
Children should consume between three to six servings of fruits and vegetables per day
depending on their individual caloric needs (AAP, 2011). Detailed components of the CHILD-1
diet and the individual caloric needs of children can be found in the “Expert panel on integrated
guidelines for cardiovascular health and risk reduction in children and adolescents: Summary
report” by the AAP (2011). The number of cups of fruits and vegetables recommended per day
is based on the age of the child and can be calculated through My Pyramid or the DASH eating
plan outlined in the “Expert panel on integrated guidelines for cardiovascular health and risk
reduction in children and adolescents: Summary report” (AAP, 2011; Barlow & the Expert
Committee, 2007). Infants can discriminate between the flavors of different fruits and
vegetables, and thus, in order to promote a child’s willingness to eat and preference for these
foods, parents should be encouraged to provide repeated opportunities for their children to
experience a variety of fruits and vegetables (Mennella, Nicklaus, Jagolino, & Yourshaw, 2008).
In order to consume fruits and vegetables, they must be accessible (Gatto, Ventura, Cook,
Gyllenhammer, & Davis, 2012). When children have first-hand experience with growing food,
their understanding of food and its relationship to health is increased (Gatto et al., 2012). A
gardening and nutrition program that also included exposure to farmer’s markets implemented
CHILDHOOD OBESITY IN RURAL LATINOS 27
among Latino school aged children found that after 12 weeks, this population had an increased
preference for fruits and vegetables (Gatto et al., 2012). Clinicians should promote gardening and
the use of farmer’s markets in rural Latino families. Assisting rural Latino families in creating a
coding system for foods can help educate children about nutrition, which can further promote
reduced rates of childhood obesity in this population (Johnston et al., 2007).
Beginning at age 2, children should consume the recommended amount of whole grains
each day and should make half of all of their grains whole (Whole Grains Council, 2012). Whole
grain intake is believed to delay the digestion and absorption of starch, which leads to lower
postprandial insulin and glucose responses (Choumenkovitch, 2012). Additionally, whole grains
are a major source of energy and fiber (AAP, 2011). Choumenkovitch et al. (2012) found that
children who consumed more than 1.5 servings of whole grains per day had lower BMIs and
were less likely to be obese than children who consumed less than one serving of whole grains
per day. After adjusting for age, gender, state of residence, race/ethnicity and physical activity,
whole grain intake was inversely related to BMI among rural minority children in the 3rd
to 6th
grades (Choumenkovitch et al., 2012).
Sugar-sweetened beverages (e.g. fruit juice, soda, sports drinks) should be eliminated or
at least minimized to no more than one serving per day in all children and adolescents (AAP,
2011; Barlow & the Expert Committee, 2007). In all children, water should be encouraged, and
100% fruit juice should be limited to less than or equal to four ounces per day (AAP, 2011).
Beginning at age 2, the primary beverage for children should be fat-free unflavored milk (AAP,
2011). In a study of rural Latino children aged 2 to 5 years, over half of them consumed soda on
a regular basis (Warner, Harley, Bradman, Vargas, & Eskenazi, 2006). Even modest reductions
CHILDHOOD OBESITY IN RURAL LATINOS 28
in the amount of sugars consumed per day can have an impact in the preservation of beta-cell
function in Latino youth (Davis et al., 2007).
Providers should encourage Latino families to eat out less, prepare more meals at home,
and eat at the table as a family at least five or six times per week in order to further prevent and
treat childhood obesity (Barlow & the Expert Committee, 2007). There are many traditional
Latino foods that have decreased calorie density, including hot cereals, breads, tortillas, rice,
fresh fruits, fresh vegetables, poultry, fish, eggs and beans (Johnston et al., 2007). Clinicians
must be cognizant of the fact that though these foods have decreased caloric density, sometimes
the preparation of these foods in traditional Latino manner (i.e. the addition of large quantities of
sodium, sugar and fat products and frying) makes these foods undesirable from the standpoint of
obesity prevention and treatment (Sealy, 2010). Thus, clinicians should provide local resources
or culturally appropriate handouts that assist Latino families in becoming knowledgeable of the
types of fruits and vegetables available in their community and how to prepare them (Morello,
Madanat, Crespo, Lemus, & Elder, 2012). Additionally, youth should be strongly encouraged to
eat a healthy breakfast every day (Barlow & the Expert Committee, 2007). In Latino youth,
eating breakfast is strongly associated with lower visceral adiposity (Alexander et al., 2009).
Clinicians caring for rural Latino youth should be very conscious of the retail food
environments of this population. In general, rural Latinos have decreased access to larger food
stores, which typically provide a better availability, selection, quality and price of foods (Liese,
Weis, Pluto, Smith, & Lawson, 2007). This decreased access is due in part to the general
unavailability of larger food stores in rural areas, and also to the fact that even if a larger food
store is present in a rural area, Latinos still have decreased access because they are less likely to
have access to a car (Emond, Madanat, & Ayala, 2011). As a result, Latinos who live in rural
CHILDHOOD OBESITY IN RURAL LATINOS 29
areas are more likely to shop in Latino grocery stores, known as tiendas (Emond et al., 2011). In
these tiendas, the cost of skim milk and 1% milk is higher and the availability of lean meats is
often limited (Emond et al., 2011). Thus, it is more difficult for rural Latino youth to meet the
lean meat and low-fat milk recommendations set forth by the AAP (2011). Additionally, the
availability of some canned and frozen alternatives to fresh produce has been shown to be lower
in tiendas than in larger food stores (Emond et al., 2011). This is significant because families
who cannot grocery shop frequently or have unreliable home refrigeration often prefer canned or
frozen alternatives to fresh produce because fresh produce spoils more quickly (Sano &
Richards, 2011).
Interventions related to activity behaviors. Modifications in activity behaviors are
crucial in the prevention and treatment of childhood obesity (AAP, 2011; Barlow & the Expert
Committee, 2007). All children at least 5 years of age should be physically active for greater than
or equal to 1 hour per day, which can be divided into short bursts of activity throughout the day
if necessary (AAP, 2011; Barlow & the Expert Committee, 2007). Unstructured play is
recommended for young children, and older children (aged 6 years and up) should be encouraged
to participate in activities they are interested in and enjoy (AAP, 2011; Barlow & the Expert
Committee, 2007). Beginning at age 5, children should engage in moderate-to-vigorous activity
daily (AAP, 2011). The activity chosen should be a combination of aerobic, muscle-
strengthening and bone-strengthening activity (National Association for Sport and Physical
Education [NASPE], 2012). Physical activity during school hours should also be supported and
encouraged; however, recent evidence demonstrates that for Latino youth, particularly females,
participation in physical activity outside of school is crucial in minimizing their risk of being
overweight or obese (AAP, 2011; Rodriguez et al., 2011). Gender differences in physical activity
CHILDHOOD OBESITY IN RURAL LATINOS 30
participation and health benefit from physical activity are present in all ethnic groups, but are
very pronounced among Latinos, particularly in rural areas (Rodriguez et al., 2011). In rural
areas, girls participate in less moderate-to-vigorous physical activity than boys, particularly after
the transition to adolescence (Rodriguez et al., 2011). Additionally, the relationship between
cardiorespiratory fitness and obesity in Latino youth is gender specific (Byrd-Williams et al.,
2008).
Cardiorespiratory fitness is defined as “the ability of the cardiovascular and respiratory
systems to supply oxygen to skeletal muscles during sustained physical activity” (Byrd-Williams
et al., 2008, p. 1075). Cardiorespiratory fitness is important in the prevention and treatment of
childhood obesity because it is believed to decrease blood pressure, total cholesterol and
proinflammatory markers in youth (Byrd-Williams et al., 2008). Additionally, cardiorespiratory
fitness has been shown to result in higher scores in math, reading and language among
adolescents (Vos & Welsh, 2010). In overweight Latino boys, increased initial cardiorespiratory
fitness results in less body fat gain, but this is not the case for their female counterparts (Byrd-
Williams et al., 2008). This may be due in part to the fact that in general, girls have a greater fat
mass, have a distinct pattern of fat distribution and are less sensitive to insulin than boys during
infancy, childhood and adolescence (Wisniewski & Chernausek, 2009). Therefore, providers
must keep in mind the age and gender of the child when formulating individualized plans to
prevent and manage childhood obesity in rural Latinos (AAP, 2011).
Specific physical activity interventions that have proven to be effective in the prevention
and management of childhood obesity in rural Latinos include strength training, aerobic exercise,
community-based interventions with familial support, and organized activities involving local
parks and fields (Davis et al., 2010; Olvera et al., 2010; Perry, Saelens, & Thompson, 2011;
CHILDHOOD OBESITY IN RURAL LATINOS 31
Stovitz et al., 2008). Strength training has been found to significantly improve insulin sensitivity
in Latinos, particularly boys (Davis et al., 2010; Stovitz et al., 2008). Combination regimens
including aerobic exercise and strength training significantly reduce all adiposity measures in
Latina girls (Davis et al., 2010).
Community-based interventions for Latino youth with familial support are also effective
in changing lifestyle behaviors of this population (Olvera et al., 2010). One study of low-income
mother-daughter Latina pairs found that after participation in a 12-week exercise, nutrition
education and counseling intervention, the daughters’ aerobic capacity had significantly
increased and they had a higher reduction in fatty foods and sugar-sweetened beverages in
addition to an increased intake of fruits and vegetables compared to the control group (Olvera et
al., 2010). Additionally, the mothers in this study reported they had learned more strategies to
increase the fruit and vegetable consumption of their children than the mothers in the control
group (Olvera et al., 2010).
For the majority of rural Latino youth, organized activities, particularly those involving
the use of parks and fields, are a main source of physical activity (Perry et al., 2011). Even
without organized activities, parks and fields are the preferred facilities for physical activity
among rural Latino youth (Perry et al., 2011). However, in many rural areas, there is a lack of
adequate fields and parks, or the parks and fields available are in poor condition and are unsafe
(Kaiser & Baumann, 2010). Clinicians in rural areas need to be familiar with the community
resources available to best serve the physical activity needs and preferences of the local Latino
youth.
As screen time is strongly associated with childhood obesity, clinicians should instruct
and encourage that daily screen time (e.g. television viewing and computer usage) be less than or
CHILDHOOD OBESITY IN RURAL LATINOS 32
equal to 2 hours for all children greater than 2 years of age (AAP, 2011). For children less than 2
years of age, the goal should be no screen time (AAP, 2011). Children with increased screen
time per day are more likely to snack more frequently, particularly on low-energy dense foods
and sugar-sweetened beverages that are advertised on television or the Internet (Dennison et al.,
2006). Additionally, children with televisions in their bedrooms are more likely to be overweight
or obese (Dennison et al., 2006). Further, evidence shows that televisions in rooms where
children sleep is one of the strongest predictors of overall sleep disturbance (Taveras, Hohman,
Price, Gortmaker, & Sonneville, 2009). Providers should encourage a standard of no televisions
in bedrooms among patients and their families (AAP, 2011).
Latino children have high rates of total media exposure (Kumanyika & Grier, 2006).
Latino children are more likely to have a television in their bedroom; one study of minority
children found that 74% of Latino children had a television in the room where they slept
(Taveras et al., 2009). Many Latino parents report the use of bedroom televisions as distracters or
babysitters for their children (Taveras et al., 2009). Thus, clinician efforts to remove televisions
from the bedrooms of Latino youth must include parental counseling regarding the importance of
this behavior change on the weight and overall health of their child, in addition to the provision
of alternatives to keep children occupied while they are at home (e.g. reading or drawing) and
rewarding good behavior (Taveras et al., 2009).
Assessment of childhood obesity and status.
The AAP (2011) and Barlow and the Expert Committee (2007) outline a universal
assessment of childhood obesity risk for all children, including Latinos. Primary care providers
should assess the obesity risk of all pediatric patients at every visit, including a thorough history,
physical exam and laboratory testing, if indicated (Barlow & the Expert Committee, 2007).
CHILDHOOD OBESITY IN RURAL LATINOS 33
Accurate assessment of a child’s obesity risk or status requires the provider to thoroughly
investigate the dietary and physical activity patterns of the child, as these patterns are
inextricably linked to weight status (Krebs et al., 2007). As comprehensive dietary and physical
activity assessments are often difficult to implement due to time constraints, Barlow and the
Expert Committee (2007) recommend that providers focus on the assessment of certain health
behaviors that are most strongly associated with energy balance and are modifiable. These eating
behaviors include the frequency of eating food prepared outside the home (e.g. fast food and
food prepared in restaurants), the amount of sugar-sweetened beverages (including fruit juice)
consumed each day, portion sizes, the frequency and quality of breakfast, the number of fruits
and vegetables consumed each day, the number and quality of snacks consumed each day, and
the daily consumption of foods that are of high energy density (Barlow & the Expert Committee,
2007). Traditional tools for determining energy intake, such as a 24-hour diet recall and a food
diary, have proven to be impractical for use in the majority of clinical settings (Krebs et al.,
2007). The WAVE measure, Rate Your Plate, and the Healthy Eating Index are feasible and
reliable measures of a child’s energy intake that are easy to use in most clinical settings (Krebs et
al., 2007). The physical activity patterns on which providers should focus their assessments
include the time spent in moderate to vigorous physical activity each day, routine activities (e.g.
walking to school) and sedentary activities (e.g. television watching) (Barlow & the Expert
Committee, 2007). Providers should use their focused physical activity assessments to determine
if the goals of 60 minutes of moderate-vigorous activity each day and less than 2 hours of screen
time per day are being met (AAP, 2011).
Clinicians should also obtain a focused family history assessment if a child’s BMI is high
(Krebs et al., 2007). Assessment of obesity, type 2 diabetes mellitus, hyperlipidemia and
CHILDHOOD OBESITY IN RURAL LATINOS 34
hypertension in parents and grandparents is helpful in determining the risks of co-morbidities
that may be associated with a child’s overweight or obesity status currently or in the future
(AAP, 2011). Parental obesity is strongly related to the risk for overweight or obesity in children
less than 6 years of age (Krebs et al., 2007).
A comprehensive physical exam for assessing the overweight or obese child includes
anthropometry, vital signs, and a head to toe examination (Krebs et al., 2007). The BMI is the
best screening tool of obesity risk, and therefore should be plotted and used to assess weight-for-
height relationships at each well-child visit (AAP, 2011; Barlow & the Expert Committee, 2007).
In children less than 2 years of age, growth curves do not include BMI percentiles (Barlow & the
Expert Committee, 2007). Thus, providers should plot weight for height values and pay special
attention to those values that are above the 95th
percentile, in addition to parental weight status,
as these are strong indicators of obesity risk (AAP, 2011; Barlow & the Expert Committee,
2007). Skin fold thickness and waist circumference measurements are not recommended in the
assessment of childhood obesity (Barlow & the Expert Committee, 2007). Relevant vital signs
include the pulse rate and blood pressure, and values should be interpreted with the use of
evidenced-based reference tables (AAP, 2011). Annual blood pressure measurements should be
obtained in all children beginning at age 3 (AAP, 2011). At age 18, youth should undergo a
blood pressure measurement at each office visit (AAP, 2011). Several findings on physical
examination can indicate overweight and obesity related problems, such as insulin resistance
(Krebs et al., 2007). For example, “acanthosis nigricans may be a valid indicator of insulin
resistance and decreased plasma HDL cholesterol levels in Mexican American adolescents”
(Krebs et al., 2007, p. S216). Other physical exam findings of concern when considering
childhood obesity include headaches with photophobia, keratosis pilaris, cardiac arrhythmias,
CHILDHOOD OBESITY IN RURAL LATINOS 35
wheezing, organomegaly, early development of secondary sexual characteristics and premature
pubarche, Blount disease and slipped capital femoral epiphyses (Krebs et al., 2007).
As a thorough history and physical examination cannot adequately screen and assess all
conditions associated with overweight and obesity, serum laboratory testing is often indicated
(Barlow & the Expert Committee, 2007). The most common dyslipidemic pattern in obese
children is mildly elevated total cholesterol and LDL-cholesterol levels, a moderate to severe
elevation in triglycerides and a low HDL-cholesterol level (AAP, 2011). For children from birth
to age 2, lipid screening is not recommended (AAP, 2011). At ages 2 to 8 years, lipid screening
is recommended for children with a significant family history of heart disease or cardiovascular
events, parental history of total cholesterolemia or known dyslipidemia, or an individual history
of diabetes, hypertension or a BMI greater than or equal to the 95th
percentile (AAP, 2011). This
group should have a fasting lipid panel drawn twice, after 2 weeks but within 3 months, and the
average of those tests should be calculated (AAP, 2011). All children aged 9 to 11 years should
undergo universal screening via two fasting lipid panels, with the results of those tests averaged
(AAP, 2011). Children 12 to 16 years of age should have a fasting lipid panel measured twice if
there is new knowledge of significant familial cardiovascular events, a parent with total
cholesterolemia or known dyslipidemia, or individual history of diabetes, hypertension, a BMI
greater than or equal to the 85th
percentile, or cigarette smoking (AAP, 2011). Otherwise, routine
screening in this age group is not recommended (AAP, 2011). At ages 17 to 21 years, youth
should undergo universal screening for dyslipidemias once (AAP, 2011). Screening for type 2
diabetes mellitus should occur in children at 10 years of age, or at the onset of puberty if it comes
first, who have a BMI greater than or equal to the 85th
percentile plus any two of the following
risk factors: a family history of type 2 diabetes mellitus, being of an ethnic minority population,
CHILDHOOD OBESITY IN RURAL LATINOS 36
having signs of insulin resistance, or maternal history of diabetes or gestational diabetes during
the child’s gestation (American Diabetes Association [ADA], 2013). Screening should occur in
these children every 3 years via fasting serum glucoses (ADA, 2013). Other specialty tests may
be warranted to evaluate obesity related illnesses depending on the history and physical exam
findings (Krebs et al., 2007). Additionally, a child or adolescent may need pharmacotherapeutic
management of co-morbidities based on their lab results, history and physical exam, but
management of these co-morbidities is beyond the scope of this paper.
Management of childhood obesity in rural Latinos.
The following overweight and obesity management interventions are recommended for
all children, including Latinos. As described above in the prevention section, interventions that
modify both dietary and activity behaviors are the first line treatment for overweight and obesity
in all children (AAP, 2011; Barlow and the Expert Committee, 2007). The CHILD-1 diet
outlined in the prevention discussion above and described in great detail in the “Expert panel on
integrated guidelines for cardiovascular health and risk reduction in children and adolescents:
Summary report” is the first stage in dietary modification for those children with clinically
identified dyslipidemia, overweight or obesity, and high-risk medical conditions that may
eventually require more intensive dietary interventions (AAP, 2011). This diet is also
recommended for children with multiple risk factors for obesity and obesity-related co-
morbidities, including a positive family history of cardiovascular disease, obesity, hypertension,
diabetes, exposure to smoking at home and dyslipidemia (AAP, 2011). At all ages, primary care
providers should identify children at high risk for obesity due to parental obesity, excessive BMI
increases and changes in physical activity (AAP, 2011). If the child is identified as being obese
CHILDHOOD OBESITY IN RURAL LATINOS 37
or at high risk for obesity, the following age-related management recommendations should be
implemented (AAP, 2011).
Management of children at an increased risk for being overweight or obese. In infants
from birth to 2 years, the CHILD-1 diet should be used to decrease cardiovascular risk related to
overweight and obesity (AAP, 2011). Between ages 2 and 21 years, if a child is identified as
obese or at high risk for obesity, the provider should develop a focused CHILD-1 diet and
physical activity program for the child (AAP, 2011). This program should be sustained for at
least 6 months in youths aged 12 to 21 years (AAP, 2011). If the BMI or BMI percentile remains
stable, the current program should be continued and follow-up should occur in 6 months (AAP,
2011). If the BMI or BMI percentile is increasing despite the CHILD-1 diet and the activity
interventions, the child should be referred to a registered dietician for energy-balanced
counseling, physical activity modifications should be intensified, and follow-up should occur in
6 months for children aged 2 to 5 years, and in 3 months for children aged 6 to 21 years (AAP,
2011).
Management of overweight children.
2 to 11 year olds. If the child’s BMI is between the 85th
and 95th
percentile between the
ages of 2 and 11 years, weight-gain prevention strategies, including physical activity and an
energy-balanced diet, should be implemented with the parents as the focus for ensuring child
compliance and behavioral change (AAP, 2011). If there is improvement in the child’s BMI
percentile after 6 months, the current program should be continued, with another follow-up in 6
months (AAP, 2011). If the child’s BMI percentile is increasing after 6 months, the child and
their parents should be referred to a registered dietician for nutrition counseling, physical activity
CHILDHOOD OBESITY IN RURAL LATINOS 38
interventions should be intensified, and follow-up should occur in an additional 6 months or 3
months, for children aged 2 to 5 years and 6 to 11 years, respectively (AAP, 2011).
12 to 21 year olds. If a child’s BMI is between the 85th
and 95th
percentile between the
ages of 12 to 21 years, intensive dietary and physical activity modifications, including the energy
balanced CHILD-1 diet, must be implemented with the adolescent as the focus of change and
sustained for 6 months (AAP, 2011). If the adolescent’s BMI percentile is improving, the current
program should be continued and follow-up should occur in an additional 6 months (AAP,
2011). If the BMI is increasing, the adolescent should be referred to a registered dietician for a
weight-controlled diet that emphasizes energy balance and physical activity interventions should
intensified for 3 months (AAP, 2011).
Management of obese children with no co-morbidities. In all youth aged 2 to 21 years
with a BMI greater than or equal to the 95th
percentile, providers should specifically assess for
co-morbidities, including hypertension, dyslipidemia and type 2 diabetes mellitus (AAP, 2011).
In obese children aged 6 to 21 years with no co-morbidities, an office-based individualized
weight-loss program should be developed (AAP, 2011). This program should be family-centered,
with the parents as the focus for behavioral modification and change for children aged 6 to 11
years, and the adolescent as the focus for behavioral modification and change for youth aged 12
to 21 years (AAP, 2011). The program should include an energy-balanced diet plan, counseling
provided by a registered dietician, interventions to increase moderate-to-vigorous physical
activity and decreased sedentary activity for 6 months (AAP, 2011). If there is improvement in
the BMI or BMI percentile of the child at 6 months, the current program should be continued
(AAP, 2011). If there is no improvement in the BMI or BMI percentile of the child at 6 months,
referral to a comprehensive multidisciplinary lifestyle weight-loss program or specialist is
CHILDHOOD OBESITY IN RURAL LATINOS 39
warranted (AAP, 2011). In youth 12 to 21 years of age with no improvement in BMI or BMI
percentile, the initiation of pharmacotherapy under the care of a specialist should also be
considered (AAP, 2011).
Management of obese children with co-morbidities or morbidly obese children.
6 to 11 year olds. For children 6 to 11 years of age with a BMI greater than or equal to
the 95th
percentile with co-morbidities, a BMI greater than the 97th
percentile, or a consistent
increase in BMI despite the previous stages of management, referral to a comprehensive
multidisciplinary weight-loss program for intensive management by a specialist for at least 6
months is warranted (AAP, 2011). Gradual weight loss not to exceed 1 pound per month is
recommended (AAP, 2011). If there is improvement in the BMI percentile after 6 months, the
current program should be continued (AAP, 2011). If the BMI percentile has not improved after
6 months, the primary care provider should consider referring the child to a different specialist or
comprehensive multidisciplinary weight-loss program (AAP, 2011).
12 to 21 year olds. Children aged 12 to 21 years who have a BMI greater than or equal to
the 95th
percentile with co-morbidities or a BMI greater than 35, should be referred to a
comprehensive lifestyle weight-loss management program for intensive therapy and monitoring
by a specialist for 6 to 12 months (AAP, 2011). Gradual weight loss not to exceed 2 pounds per
week is recommended (AAP, 2011). If there is improvement in the BMI or BMI percentile of the
adolescent, the current program should be continued (AAP, 2011). If there is no BMI or BMI
percentile improvement after 6 to 12 months, the initiation of pharmacotherapy by a specialist
should be seriously considered (AAP, 2011). If the BMI of the adolescent is high above 35 with
co-morbidities that are unresponsive to therapy for more than 1 year, the primary care provider
should consider referral to a bariatric surgeon (AAP, 2011).
CHILDHOOD OBESITY IN RURAL LATINOS 40
Evidence for management interventions used to combat childhood obesity.
The AAP (2011) found that combined weight-loss programs, including behavior-change
counseling, dietary modifications that support negative energy balance and increased moderate-
to-vigorous activity are effective in managing obesity in children greater than 6 years of age with
a BMI of greater than or equal to the 95th
percentile. There is no evidence on the effectiveness of
weight loss programs in children less than 6 years of age (AAP, 2011). Combination
interventions that include dietary and activity modifications are effective at improving the BMI
and weight status of children and adolescents compared with diet-only interventions (AAP,
2011).
In children aged 6 to 12 years, family-based comprehensive weight-loss programs
addressing both diet and activity are effective at initiating and sustaining significant weight loss
for up to 10 years (AAP, 2011). For this age group, the most weight loss is achieved when the
parents are the focus of the change or intervention (AAP, 2011). The best results of the
effectiveness of comprehensive weight loss programs come from those in research settings
(AAP, 2011). For adolescents, the most weight loss occurs in programs that focus on the
adolescent as the agent for change (AAP, 2011). Thus, primary care providers in rural settings
will likely achieve the best weight loss results for their obese Latino pediatric patients if they
implement familial interventions for children and individualized interventions with peers for
adolescents. Further, significant weight loss results will be achieved if primary care providers in
rural areas implement interventions that address the modification of both diet and physical
activity in their Latino pediatric patients.
Pharmacotherapy. The addition of medication under the supervision of a specialist can
be safe and effective in achieving significant reductions in weight and BMI with follow-up from
CHILDHOOD OBESITY IN RURAL LATINOS 41
4 to 12 months (AAP, 2011). Unfortunately, safety and efficacy data over long periods of time
are not currently available (AAP, 2011).
When combined with intensive lifestyle and behavioral interventions, there is currently
one medication that is labeled and available for weight loss in adolescents: orlistat (AAP, 2011;
Caprio et al., 2008). Orlistat is currently approved for weight loss in adolescents greater than age
12 who have a BMI more than two units greater than the 95th
percentile for age and gender (Han
et al., 2010; Kanekar & Sharma, 2010). Orlistat contributes to weight loss by inhibiting the
activity of intestinal lipases, which decreases dietary fat absorption by approximately one third
(Bogarin & Chanoine, 2009). The use of orlistat in conjunction with behavioral modifications in
adolescents results in significant reductions in weight and BMI (AAP, 2011; Bogarin &
Chanoine, 2009). Additionally, orlistat has not been found to affect pubertal development or
cause an increase in lean body mass during puberty when it is used in younger adolescents
(Bogarin & Chanoine, 2009). However, adolescents are often unable to tolerate orlistat due to its
frequent gastrointestinal side effects including fatty and oily stools, oily spotting, abdominal
pain, fecal urgency, flatus with discharge and flatulence (AAP, 2011; Viner, Hsia, Tomsic, &
Wong, 2010). A rare side effect of orlistat in adolescents is severe liver injury that can result in
transplantation or even death (AAP, 2011). If orlistat is used, a multivitamin should be
concomitantly prescribed, and providers should be aware that orlistat safety has only been
evaluated in up to 1 year of use in adolescents (Bogarin & Chanoine, 2009). No information
could be obtained regarding the use of orlistat in an exclusively Latino adolescent population.
More research is needed regarding the effects of orlistat in this population.
The biguanide metformin, though only approved by the U.S. Food and Drug
Administration (FDA) for type 2 diabetes mellitus in children aged 10 years and up, has also
CHILDHOOD OBESITY IN RURAL LATINOS 42
been used off-label for weight loss in obese adolescents (AAP, 2011; Caprio et al., 2008).
Though its weight loss effect is modest compared to orlistat, metformin exudes its main benefits
in obesity-related consequences, such as hyperglycemia (Caprio et al., 2008). Currently, the AAP
(2011) recommends the addition of metformin to a comprehensive lifestyle weight-loss program
at a grade of “B” for severely obese or insulin resistant adolescents, as it has been shown to
improve fasting insulin levels and significantly reduce weight and BMI in this population. A 48-
week study of the effects of metformin XR with behavioral therapy in obese adolescents found
that those using metformin XR compared with placebo had a statistically significant decrease in
BMI (Wilson, 2010). Gastrointestinal side effects were minimal, and metformin was found to be
safe and tolerated in the population studied (Wilson, 2010). When considering the effects of
metformin in minority adolescents, one study found that monotherapy with metformin was not a
promoter of weight loss in this population; however, all of the participants in this study who lost
any weight were taking metformin (Love-Osbourne, Sheeder, & Zeitler, 2008). No evidence
could be found regarding the use of metformin in an exclusively Latino adolescent population.
However, if utilized in obese rural Latino youth, metformin may have the most benefit if
combined with structured dietary and physical activity interventions.
Sibutramine, a serotonin-norepinephrine reuptake inhibitor, was approved for weight loss
in conjunction with behavioral therapy in adolescents aged 16 and older until the FDA removed
it from the market in October 2010 due to concerns for serious cardiovascular events in patients
(Caprio et al., 2008; FDA, 2010).
Implementing a very restrictive diet for children or adolescents has not been widely
studied (Barlow & the Expert Committee, 2007). Clinicians should consider the fact that Latinos
who are severely obese are up to six times as likely to suffer from an eating disorder than Latinos
CHILDHOOD OBESITY IN RURAL LATINOS 43
with a BMI between 18.5 and 30 before considering a very restrictive diet (Alegria et al., 2007).
Additionally, clinicians in rural areas are less likely to have the local resources needed to monitor
and supervise this type of diet in rural Latino youth (Lutfiyya et al., 2007).
There are few centers in the United States that offer surgical treatment, including gastric
bypass and gastric banding, for severely obese youth, due in large part to “the perioperative risks,
post-procedure nutritional risks, and the necessity of lifelong commitment to altered eating”
(Barlow & the Expert Committee, 2007, p. S185). Thus, surgical treatments for childhood
obesity are reserved for morbidly obese children who are emotionally mature and despite
attempting weight loss for at least 6 months, still have a BMI of greater than or equal to 50kg/m2
or have a BMI greater than or equal to 40kg/m2 with a medical condition (Barlow & the Expert
Committee, 2007; Han et al., 2010). Even if a child or adolescent meets the above requirements,
extreme caution should still be used in choosing surgical treatment (Han et al., 2010). Surgical
interventions in obese adolescents have been largely limited to Caucasians (Caprio et al., 2008).
No evidence could be found on the use of surgical interventions for obesity in an exclusively
Latino adolescent population.
Implementing comprehensive multidisciplinary weight-loss programs in the management
of childhood obesity in rural Latinos may be difficult due to a lack of local resources and
decreased insurance coverage among this population (Lutfiyya et al., 2007). Thus, the preventive
interventions are the most important and effective in the prevention and treatment of childhood
obesity in rural Latinos, and must be emphasized by all clinicians caring for this population at
every visit.
CHILDHOOD OBESITY IN RURAL LATINOS 44
The Role of the Clinician in the Community to Prevent Childhood Obesity
In rural communities, the role of the clinician in the prevention and treatment of
childhood obesity must extend past the clinical setting. Curtis, Waters, & Brindis (2010)
recognize that “the context of a rural community presents distinct challenges to the health of
adolescents, particularly in an economy with limited private and public resources available to
provide for adolescent health services” (p. 61). Additionally, the exponential growth of the
Latino immigrant population in rural areas has increased stress on the already limited resources
of these communities (Sano et al., 2011). Thus, rural providers must play a role in policy setting
locally and nationally and in schools to help develop a healthy environment that prevents obesity
in rural Latino youth (Caprio et al., 2008).
Currently, the majority of physical environments of ethnic minority neighborhoods and
communities, particularly in rural areas, are less favorable for weight control (Kumanyika,
2008). For example, evidence demonstrates that even after controlling for individual and familial
characteristics, there was a strong association between living in a community with or in very
close proximity to a large food store and better dietary quality overall (Odoms-Young et al.,
2012). Additionally, most rural communities lack a public transportation infrastructure, which
further reduces access to resources that are more likely to prevent obesity, such as larger food
stores and routine medical care (Sano & Richards, 2011). Clinicians should strongly appeal to
local officials to consider a public transportation infrastructure or the provision of a larger food
store in their rural communities. Clinicians should also advocate for the safety and availability of
areas in rural communities where people could be active (Khan et al., 2009). For example, many
rural Latinos have reported concerns about the lack of sidewalks or the number of sidewalks in
poor condition in their communities (Kaiser & Baumann, 2010). Rural Latinos have also
CHILDHOOD OBESITY IN RURAL LATINOS 45
supported the availability, promotion and expansion of community gardens (Kaiser & Baumann,
2010).
Policy changes in schools and the development of school-based programs that target
childhood obesity prevention have great potential in curbing the childhood obesity epidemic
since most children spend the majority of their time in school, particularly in rural communities
(Lytle, 2012). According to the Shape of the Nation report, only six states require physical
education at every grade level, from kindergarten through grade 12, and over half of states either
allow students to substitute another activity for their physical education credit or do not specify
the amount of physical education time required (NASPE, 2012). The 2011 Youth Risk Behavior
Survey found that 69% of students did not attend a physical education class every day while in
school (as cited in NASPE, 2012, p. 4).
Currently, there is no federal mandate requiring U.S. public schools to provide physical
education to students, nor are there federal incentives for physical education provisions, despite
the fact that childhood obesity rates are growing at an exponential rate (NASPE, 2012). The
median physical education budgets for schools in the U.S. each school year are only $460 for
elementary schools, $900 for middle schools and $1,370 for high schools (NASPE, 2012).
Comparatively, the obesity epidemic is estimated to cost the U.S. health care system $344 billion
by 2018 (NASPE, 2012). The NASPE recommends that all schools “provide 150 minutes per
week of instructional physical education for elementary school children, and 225 minutes per
week for middle and high school students throughout the school year” (NASPE, 2012, p. 4).
Thus, it is important for clinicians in rural areas be strong advocates in their respective
communities for adequate physical education in schools. Rural clinicians should advocate for
comprehensive physical activity programs in the local schools that include “health education,
CHILDHOOD OBESITY IN RURAL LATINOS 46
elementary school recess, after-school physical activity clubs and intramurals, high school
interscholastic athletics, walk/bike to school programs and staff wellness programs” (NASPE,
2012, p. 9).
School-based policy changes regarding healthy food and beverages offered are also a
cornerstone to creating an obesity prevention environment (Foster et al., 2008). As the majority
of children in rural communities are low-income, particularly if Latino, they partake in the free
and reduced-price school meal program, which often provides breakfast and lunch (National
Council of La Raza [NCLR], 2010). Latino children comprise approximately one-third of all
children receiving free or reduced-priced lunches through the National School Lunch Program
(NCLR, 2010). Thus, rural clinicians should advocate for healthy food and beverages to be
served in the schools (Khan et al., 2009).
For example, providers should appeal to state and local lawmakers for a ban of sugar-
sweetened beverages in schools, as evidence strongly demonstrates that when sugar-sweetened
beverages are limited in school, children consume fewer calories from sugar-sweetened
beverages at school (Briefel, Crepinsek, Cabili, Wilson, & Gleason, 2009). Further, many states
lack legislation that prohibits the sale of sugar-sweetened beverages or high calorie snack foods.
Thus, the majority of schools in the U.S. permit the marketing of sugar-sweetened beverages and
high calorie snack foods in schools in the form of sponsored athletic fields and educational
activities, agreements that place brand names on items such as clothing, fundraising programs
and direct advertising through news programs that air in schools during the day (Molnar, Garcia,
Boninger, & Merrill, 2008). Latinos, in particular, have high rates of media exposure, and thus
are exposed to a large amount of food and beverage advertising (Kumanyika & Grier, 2006).
Therefore, policies that improve marketing and advertising, particularly in schools, are likely to
CHILDHOOD OBESITY IN RURAL LATINOS 47
be extremely beneficial for low-income rural Latino children (Kumanyiak & Grier, 2006). Rural
clinicians should educate local and state lawmakers on the harmful effects of strong corporate
influence via the marketing of sugar-sweetened beverages and high calorie snack food in school.
Notwithstanding the increased availability of these obesegenic products in schools with
corporate marketing, school children are also likely to interpret the corporate marketing as a
school endorsement of the products (Molnar et al., 2008). There is also a great need for the
availability of fresh produce in schools (Khan et al., 2009). Rural communities have a unique
opportunity to develop a type of farm-to-school program that could incorporate fresh produce
into school meals. In order to create a school environment that is conducive to preventing
childhood obesity, rural clinicians must educate the public and advocate for local and state
policies supporting this environment.
Conclusion
In order to curb the childhood obesity epidemic, which is more pronounced in rural
Latinos, clinicians caring for this population must aggressively assess for and work to prevent
overweight and obesity in every child at every visit. Rural clinicians must recognize that an
approach to childhood obesity in their Latino pediatric patients requires intervention at multiple
ecological levels, in addition to pre-conception interventions that must be implemented in the
whole family and continued throughout childhood and adolescence, as family members have a
great influence on many behaviors that affect a child’s weight and overall health (Gentile et al.,
2009). Providers should use evidenced-based interventions in addition to the cultural
implications discussed in this paper to appropriately prevent and manage childhood obesity in
rural Latino youth. Additionally, clinicians must be community educators and staunch advocates
CHILDHOOD OBESITY IN RURAL LATINOS 48
for local and state policies that create and promote an anti-obesity environment, particularly in
schools.
CHILDHOOD OBESITY IN RURAL LATINOS 49
References
Adair, L. (2008). Child and adolescent obesity: Epidemiology and developmental
perspectives. Physiology & Behavior, 94(1), 8-16. doi: 10.1016/j.physbeh.2007.11.016
Alegria, M., Wood, M., Cao, Z., Torres, M., Meng, X., & Striegel-Moore, R. (2007).
Prevalence and correlates of eating disorders in Latinos in the United States.
International Journal of Eating Disorders, 40, S15-S21. doi: 10.1002/eat.20406
Alexander, K.E., Ventura, E.E., Spruijt-Metz, D., Weigensberg, M.J., Goran, M.I., &
Davis, J.N. (2009). Association of breakfast skipping with visceral fat and insulin indices
in overweight Latino youth. Obesity, 17(8), 1528-1533. doi: 10.1038/oby.2009.127
Allen, M.L., Elliott, M.N., Morales, L.S., Diamant, A.L., Hambarsoomian, K., &
Schuster, M.A. (2007). Adolescent participation in preventive health behaviors, physical
activity, and nutrition: Differences across immigrant generations for Asians and Latinos
compared with whites. American Journal of Public Health, 97(2), 337-343.
doi: 10.2105/AJPH.2005.076810
American Academy of Pediatrics. (2011). Expert panel on integrated guidelines for
cardiovascular health and risk reduction in children and adolescents: Summary report.
Pediatrics, 128(5), S213-S256. doi: 10.1542/peds.2009-2107C
American Diabetes Association. (2013). Standards of medical care in diabetes – 2013. Diabetes
Care, 36(S1), S11-S66. doi: 10.2337/dc13-S011
Barlow, S.E. & the Expert Committee. (2007). Expert committee recommendations
regarding the prevention, assessment, and treatment of child and adolescent overweight
and obesity: Summary report. Pediatrics, 12(4), S164-S192.
doi: 10.1542/peds.2007-2329C
CHILDHOOD OBESITY IN RURAL LATINOS 50
Barona, A. & Miller, J.A. (1994). Short Acculturation Scale for Hispanic Youth
(SASH-Y): A preliminary report. Hispanic Journal of Behavioral Sciences, 16(2), 155-
162. doi: 10.1177/07399863940162005
Biro, F.M. & Wien, M. (2010). Childhood obesity and adult morbidities. The American
Journal of Clinical Nutrition, 91(5), 1499S-1505S. doi: 10.3945/ ajcn.2010.28701B
Branner, C.M., Koyama, T., & Jensen, G.L. (2008). Racial and ethnic differences in
pediatric obesity-prevention counseling: National prevalence of clinician practices.
Obesity, 16(3), 690-694. doi: 10.1038/oby.2007.78
Briefel, R.R., Crepinsek, M.K., Cabili, C., Wilson, A., & Gleason, P.M. (2009). School
food environments and practices affect dietary behaviors of US public school children.
Journal of the American Dietetic Association, 109(2), S91-S107.
doi: 10.1016/j.jada.2008.10.059
Brotanek, J.M., Seeley, C.E., & Flores, G. (2008). The importance of cultural
competency in general pediatrics. Current Opinion in Pediatrics, 20, 711-718.
doi: 10.1097/MOP.0b013e328317efff
Buscemi, J., Beech, B.M., & Relyea, G. (2011). Predictors of obesity in Latino children:
Acculturation as a moderator of the relationship between food insecurity and body mass
index profile. The Journal of Immigrant Minority Health, 13, 149-154.
doi: 10.1007/s10903-009-9263-6
Butte, N.F., Cai, G., Cole, S.A., & Comuzzie, A.G. (2006). Viva la familia study: Genetic
and environmental contributions to childhood obesity and its comorbidities in the
Hispanic population. The American Journal of Clinical Nutrition, 84(3), 646-654.
Retrieved from http://ajcn.nutrition.org/content/84/3/646.full
CHILDHOOD OBESITY IN RURAL LATINOS 51
Byrd-Williams, C.E., Shaibi, G.Q., Sun, P., Lane, C.J., Ventura, E.E., Davis, J.N., …
Goran, M.I. (2008). Cardiorespiratory fitness predicts changes in adiposity in overweight
Hispanic boys. Obesity, 16(5), 1072-1077. doi: 10.1038/oby.2008.16
Caballero, A.E. (2011). Understanding the Hispanic/Latino patient. The American
Journal of Medicine, 124(10), S10-S15. doi: 10.1016/j.amjmed.2011.07.018
Caplan, S. (2007). Latinos, acculturation, and acculturative stress: A dimensional concept
analysis. Policy, Politics, & Nursing Practice, 8(2), 93-106.
doi: 10.1177/1527154407301751
Caprio, S., Daniels, S.R., Drewnowski, A., Kaufman, F.R., Palinkas, L.A., Rosenbloom,
A.L., & Schwimmer, J.B. (2008). Influence of race, ethnicity, and culture on childhood
obesity: Implications for prevention and treatment. Diabetes Care, 31(11), 2211-2221.
doi: 10.2337/dc08-9024
Catalano, P.M., Farrell, K., Thomas, A., Huston-Presley, L., Mencin, P., Hauguel de
Mouzon, S., & Amini, S.B. (2009). Perinatal risk factors for childhood obesity and
metabolic dysregulation. The American Journal of Clinical Nutrition, 90(5), 1303-1313.
doi: 10.3945/ ajcn.2008.27416
Chen, X., Beydoun, M.A., & Wang, Y. (2008). Is sleep duration associated with
childhood obesity? A systematic review and meta-analysis. Obesity, 16(2),
265-274. doi: 10.1038/oby.2007.63
Choumenkovitch, S.F., McKeown, N.M., Tovar, Al., Hyatt, R.R., Kraak, V.I., Hastings,
A.V., … Economos, C.D. (2012). Whole grain consumption is inversely associated with
BMI Z-score in rural school-aged children. Public Health Nutrition, 1-7.
doi: 10.1017/S1368980012003527
CHILDHOOD OBESITY IN RURAL LATINOS 52
Cook, J.T. & Frank, D.A. (2008). Food security, poverty, and human development in the
United States. Annals of the New York Academy of Sciences, 1136, 193-209.
doi: 10.1111/j.1549-0831.2012.00070.x
Curtis, A.C., Waters, C.M., & Brindis, C. (2010). Rural adolescent health: The
importance of prevention services in the rural community. The Journal of Rural Health,
27, 60-71. doi: 10.1111/j.1748-0361.2010.00319.x
D’Alonzo, K.T., Johnson, S., & Fanfan, D. (2012). A biobehavioral approach to
understanding obesity and the development of obesogenic illnesses among Latino
immigrants in the United States. Biological Research for Nursing, 14(4), 364-374.
doi: 10.1177/1099800412457017
Davis, J.N., Ventura, E.E., Alexander, K.E., Salguero, L.E., Weigensberg, M.J., Crespo,
N.C. … Goran, M.I. (2007). Feasibility of a home-based versus classroom-based
nutrition intervention to reduce obesity and type 2 diabetes in Latino youth. International
Journal of Pediatric Obesity, 2(1), 22-30. doi: 10.1080/17477160601133077
Davis, J.N., Ventura, E.E., Shaibi, G.Q., Byrd-Williams, C.E., Alexander, K.E., Vanni,
A.K., … Goran, M.I. (2010). Interventions for improving metabolic risk in overweight
Latino youth. International Journal of Pediatric Obesity, 5(5), 451-455.
doi: 10.3109/17477161003770123
de Ferranti, S., & Mozaffarian, D. (2008). The perfect storm: Obesity, adipocyte
dysfunction, and metabolic consequences. Clinical Chemistry, 54(6), 945-955.
doi: 10.1373/clinchem.2007.100156
Dennison, B.A., Edmunds, L.S., Stratton, H.H., & Pruzek, R.M. (2006). Rapid infant
weight gain predicts childhood overweight. Obesity, 14(3), 491-499.
CHILDHOOD OBESITY IN RURAL LATINOS 53
doi: 10.1038/oby.2006.64
Detjen, M.G., Nieto, F.J., Trentham-Dietz, A., Fleming, M., & Chasan-Taber, L. (2007).
Acculturation and cigarette smoking among pregnant Hispanic women residing in
the United States. American Journal of Public Health, 97(11), 2040-2047.
doi: 10.2105/AJPH.2006.095505
Duggirala, R., Blangero, J., Almasy, L., Dyer, T.D., Williams, K.L., Leach, R.J., …
Stern, M.P. (2000). A major susceptibility locus influencing plasma triglyceride
concentrations is located on chromosome 15q in Mexican Americans. The American
Journal of Human Genetics, 66(4), 1237-1245. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1288191/
Duggirala, R., Blangero, J., Almasy, L., Arya, R., Dyer, T.D., Williams, K.L., … Stern,
M.P. (2001). A major locus for fasting insulin concentrations and insulin resistance on
chromosome 6q with strong pleiotropic effects on obesity-related phenotypes in
nondiabetic Mexican Americans. The American Journal of Human Genetics, 68(5), 1149-
1164. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1226096/
Elder, J.P., Ayala, G.X., Parra-Medina, D., & Talavera, G.A. (2009). Health
communication in the Latino community: Issues and approaches. Annual Review of
Public Health, 30, 227-251. doi: 10.1146/annurev.publhealth.031308.100300
Faraz, A. (2010). Clinical recommendations for promoting breastfeeding among Hispanic
women. Journal of the American Academy of Nurse Practitioners, 22, 292-299.
doi: 10.1111/j.1745-7599.2010.00510.x
Farooqi, I.S. & O’Rahilly, S. (2006). Genetics of obesity in humans. Endocrine Reviews,
27(7), 710-718. doi: 10.1210/er.2006-0040
CHILDHOOD OBESITY IN RURAL LATINOS 54
Flegal, K.M., Carroll, M.D., Kit, B.K., & Ogden, C.L. (2012). Prevalence of obesity and
trends in the distribution of body mass index among US adults, 1999-2010. The Journal
of the American Medical Association, 307(5), 491-497. doi: 10.1001/jama.2012.39
Flores, G. & The Committee on Pediatric Research. (2010). Racial and ethnic disparities
in the health and health care of children. Pediatrics, 125(4), e979-e1020.
doi: 10.1542/peds.2010-0188
Food and Drug Administration. (2010). FDA drug safety communication: FDA
recommends against the continued use of Meridia (sibutramine). Retrieved from
http://www.fda.gov/Drugs/DrugSafety/ucm228746.htm
Foster, G.D., Sherman, S., Borradaile, K.E., Grundy, K.M., Vander Veur, S.S.,
Nachmani, J., … Shults, J. (2008). A policy-based school intervention to prevent
overweight and obesity. Pediatrics, 121(4), e794-e802. doi: 10.1542/peds.2007-1365
Gatto, N.M., Ventura, E.E., Cook, L.T., Gyllenhammer, L.E., & Davis, J.N. (2012). LA
sprouts: A garden-based nutrition intervention pilot program influences motivation and
preferences for fruits and vegetables in Latino youth. Journal of the Academy of Nutrition
and Dietetics, 112, 913-920. doi: 10.1016/j.jand.2012.01.014
Gentile, D.A., Welk, G., Eisenmann, J.C., Reimer, R.A., Walsh, D.A., Russell, D.W., …
Fritz, K. (2009). Evaluation of a multiple ecological level child obesity prevention
program: Switch what you do, view, and chew. BMC Medicine, 7(49), 1-12.
doi: 10.1186/1741-7015-7-49
Hammons, A.J. & Fiese, B.H. (2011). Is frequency of shared family meals related to the
nutritional health of children and adolescents? Pediatrics, 127(6), e1565-e574.
doi: 10.1542/peds.2010-1440
CHILDHOOD OBESITY IN RURAL LATINOS 55
Han, J.C., Lawlor, D.A., & Kimm, S.Y. (2010). Childhood obesity. The Lancet,
375(9727), 1737-1748. doi: 10.1016/S0140-6736(10)60171-7
Hart, C.N., Kuhl, E.S., & Jelalian, E. (2012). Short sleep and obesity risk in children. In
P. Shiromani, T. Horvath, S. Redline, & E.V. Cauter (Eds.), Sleep loss and obesity:
Intersecting epidemics. Retrieved from http://link.springer.com/chapter/10.1007/978-1-
4614-3492-4_7?LI=true. doi: 10.1007/978-1-4614-3492-4_7
Hartley, D., Anderson, N., Fox, K., & Lenardson, J. (2011). How does the rural food
environment affect rural childhood obesity? Childhood Obesity, 7(6), 450-461.
doi: 10.1089/chi.2011.0086
Heinberg, L.J., Kutchman, E.M., Berger, N.A., Lawhun, S.A., Cuttler, L., Seabrook,
R.C., & Horwitz, S.M. (2010). Parent involvement is associated with early success in
obesity treatment. Clinical Pediatrics, 49(5), 457-465. doi: 10.1177/0009922809337531
Houston, K., Waldrop, J.B., & McCarthy, R. (2011). Evidence to guide feeding practices
for Latino children. The Journal for Nurse Practitioners, 7(4), 271-276.
doi: 10.1016/j.nurpra.2010.06.008
Iriart, C., Handal, A.J., Boursaw, B., & Rodrigues, G. (2011). Chronic malnutrition
among overweight Hispanic children: Understanding health disparities. Journal of
Immigrant Minority Health, 13, 1069-1075. doi:10.1007/s10903-011-9464-7
Jilcott, S.B., Wade, S., McGuirt, J.T., Wu, Q., Lazorick, S., & Moore, J.B. (2011). The
association between the food environment and weight among eastern North Carolina
youth. Public Health Nutrition, 14(9), 1610-1617. doi: 10.1017/S1368980011000668
Johnson, F., Pratt, M., & Wardle, J. (2011). Socio-economic status and obesity in
childhood. Epidemiology of Obesity in Children and Adolescents, 2(2), 377-390.
CHILDHOOD OBESITY IN RURAL LATINOS 56
doi: 10.1007/978-1-4419-6039-9_21
Johnston, C.A., Tyler, C., McFarlin, B.K., Poston, W.S.C., Haddock, K., Reeves, R., &
Foreyt, J.P. (2007). Weight loss in overweight Mexican American children: A
randomized, controlled trial. Pediatrics, 120(6), e1450-e1457.
doi: 10.1542/peds.2006-3321
Kaiser, B.L. & Baumann, L.C. (2010). Perspectives on healthy behaviors among low-
income Latino and non-Latino adults in two rural counties. Public Health Nursing, 27(6),
528-536. doi: 10.1111/j.1525-1446.2010.00893.x
Kanekar, A. & Sharma, M. (2010). Pharmacological approaches for management of child
and adolescent obesity. Journal of Clinical Medicine Research, 2(3), 105-111.
doi: 10.4021/jocmr2010.05.288w
Kelly, L.A., Lane, C.J., Ball, G.D.C., Weigensberg, M.J., Vargas, L.G., Byrd-Williams,
C.E., … Goran, M.I. (2008). Birth weight and body composition in overweight Latino
youth: A longitudinal analysis. Obesity, 16(11), 2524 – 2528. doi: 10.1038/oby.2008.401
Khan, L.K., Sobush, K., Keener, D., Goodman, K., Lowry, A., Kakietek, J., & Zaro, S.
(2009). Recommended community strategies and measurements to prevent obesity in the
United States. CDC Recommendations and Reports, 58(RR07), 1-26. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5807a1.htm
Kim, J.S., Le, K.-A., Mahurkar, S., Davis, J.N., & Goran, M.I. (2012). Influence of
elevated liver fat on circulating adipocytokines and insulin resistance in obese Hispanic
adolescents. Pediatric Obesity, 7(2), 158-164. doi: 10.1111/j.2047-6310.2011.00014.x
Koebnick, C., Roberts, C.K., Shaibi, G.Q., Kelly, L.A., Lane, C.J., Toledo-Corral, C.M.
CHILDHOOD OBESITY IN RURAL LATINOS 57
…Goran, M.I. (2008). Adiponectin and leptin are independently associated with insulin
sensitivity, but not with insulin secretion or beta-cell function in overweight Hispanic
adolescents. Hormone and Metabolic Research, 40, 708-712.
doi: 10.1055/s-2008-1077097
Krebs, N.F., Himes, J.H., Jacobson, D., Nicklas, T.A., Guilday, P., & Styne, D. (2007).
Assessment of child and adolescent overweight and obesity. Pediatrics, 120(4), S193-
S228. doi: 10.1542/peds.2007-2329D
Kuczmarski, R., Ogden, C., Guo, S., Grummer-Strawn, L., Flegal, K., Mei, Z., …
Johnson, C.L. (2002). 2000 CDC growth charts for the United States: Methods and
development. CDC and NCHS Vital and Health Statistics, 11(246), 1-203. Retrieved
from http://europepmc.org/abstract/MED/12043359
Kumanyika, S.K. (2008). Environmental influences on childhood obesity: Ethnic and
cultural influences in context. Physiology & Behavior, 94(1), 61-70.
doi: 10.1016/j.physbeh.2007.11.019
Kumanyika, S.K. & Grier, S. (2006). Targeting interventions for ethnic minorities and
low-income populations. The Future of Children, 16(1), 187-207.
doi: 10.1353/foc.2006.0005
Lichter, D.T. (2012). Immigration and the new racial diversity in rural America. Rural
Sociology, 77(1), 3-35. doi: 10.1111/j.1549-0831.2012.00070.x
Liese, A.D., Weis, K.E., Pluto, D., Smith, E., & Lawson, A. (2007). Food store types,
availability, and cost of foods in a rural environment. Journal of the American Dietetic
Association, 107(11), 1916-1923. doi: 10.1016/j.jada.2007.08.012
Lindsay, A.C., Sussner, K.M., Greaney, M.L., & Peterson, K.E. (2009). Influence of
CHILDHOOD OBESITY IN RURAL LATINOS 58
social context on eating, physical activity, and sedentary behavior of Latina mothers and
their preschool-age children. Health Education & Behavior, 36(1), 81-96.
doi: 10.1177/1090198107308375
Liu, J., Probst, J.C., Harun, N., Bennett, K.J., & Torres, M.E. (2009). Acculturation,
physical activity, and obesity among Hispanic adolescents. Ethnicity & Health, 14(5),
509-525. doi: 10.1080/13557850902890209
Love-Osbourne, K., Sheeder, J., & Zeitler, P. (2008). Addition of metformin to a lifestyle
modification program in adolescent with insulin resistance. Journal of Pediatrics, 152(6),
817-822. doi: 10.1016/j.jpeds.2008.01.018
Lutfiyya, M.N., Lipsky, M.S., Wisdom-Behounek, J., & Inpanbutr-Martinkus, M. (2007).
Is rural residency a risk factor for overweight and obesity for U.S. children? Obesity,
15(9), 2348-2356. doi: 10.1038/oby.2007.278
Lytle, L.A. (2012). Dealing with the childhood obesity epidemic: A public health
approach. Abdominal Imaging, 37, 719-724. doi: 10.1007/s00261-012-9861-y
Mennella, J.A., Nicklaus, S., Jagolino, A.L., & Yourshaw, L.M. (2008). Variety is the
spice of life: Strategies for promoting fruit and vegetable acceptance during infancy.
Physiology & Behavior, 94(1), 29-38. doi: 10.1016/j.physbeh.2007.11.014
Metzger, M.W. & McDade, T.W. (2009). Breastfeeding as obesity prevention in the
United States: A sibling difference model. American Journal of Human Biology, 22, 291-
296. doi: 10.1002/ajhb.20982
Molnar, A., Garcia, D.R., Boninger, F., & Merrill, B. (2008). Marketing of foods of
minimal nutritional value to children in schools. Preventive Medicine, 47(5), 204-207.
doi: 10.1016/j.ypmed.2008.07.019
CHILDHOOD OBESITY IN RURAL LATINOS 59
Morello, M.I., Madanat, H., Crespo, N.C., Lemus, H., & Elder, J. (2012). Associations
among parent acculturation, child BMI, and child fruit and vegetable consumption in a
Hispanic sample. Journal of Immigrant Minority Health, 14, 1023-1029.
doi: 10.1007/s10903-012-9592-8
National Association for Sport and Physical Education. (2012). Shape of the nation
report. Retrieved from http://www.aahperd.org/naspe/publications/upload/2012-Shape-
of-Nation-full-report-web.pdf
National Council of La Raza. (2010). Profiles of Latino health: A closer look at Latino
child nutrition. Retrieved from
http://www.nclr.org/images/uploads/pages/Jan12_Profiles_Issue_10.pdf
Neary, N.M., Goldstone, A.P., & Bloom, S.R. (2004). Appetite regulation: From the gut
to the hypothalamus. Clinical Endocrinology, 60(2), 153-160.
doi: 10.1046/j.1365-2265.2003.01839.x
Odoms-Young, A.M., Zenk, S.N., Karpyn, A., Ayala, G.X., & Gittelsohn, J. (2012).
Obesity and the food environment among minority groups. Current Obesity Reports, 1,
141-151. doi: 10.1007/s13679-012-0023-x
Ogden, C.L. & Carroll, M. D. (2010). Prevalence of obesity among children and
adolescents: United States, trends 1963-1965 through 2007-2008. National Center for
Health Statistics, 1-5. Retrieved from
http://www.cdc.gov/nchs/data/hestat/obesity_child_07_08/obesity_child_07_08.pdf
Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.A., Tabak, C.J., & Flegal, K.M.
(2006). Prevalence of overweight and obesity in the United States, 1999-2004. The
Journal of the American Medical Association, 295(13), 1549-1555.
CHILDHOOD OBESITY IN RURAL LATINOS 60
doi: 10.1001/jama.295.13.1549
Olvera, N., Bush, J.A., Sharma, S.V., Knox, B.B., Scherer, R.L., & Butte, N.F. (2010).
BOUNCE: A community-based mother-daughter healthy lifestyle intervention for low-
income Latino families. Obesity, 18(S1), S102-S104. doi: 10.1038/oby.2009.439
Olvera, N., Suminski, R., & Power, T.G. (2005). Intergenerational perceptions of body
image in Hispanics: Role of BMI, gender, and acculturation. Obesity, 13(11), 1970-1979.
doi: 10.1038/oby.2005.242
Paul, I.M., Savage, J.S., Anzman, S.L., Beiler, J.S., Marini, M.E., Stokes, J.L., & Birch,
L.L. (2012). Preventing obesity during infancy: A pilot study. Obesity, 19(2), 353-361.
doi: 10.1038/oby.2010.182
Perry, C.K., Saelens, B.E., & Thompson, B. (2011). Rural Latino youth park use:
Characteristics, park amenities, and physical activity. Journal of Community Health, 36,
389-397. doi: 10.1007/s10900-010-9320-z
Ramirez, A.G., Chalela, P., Gallion, K.J., Green, L.W., & Ottoson, J. (2011). Salud
America! Developing a national Latino childhood obesity research agenda. Health
Education and Behavior, 38(3), 251-260. doi: 10.1177/1090198110372333
Rodriguez, R., Mowrer, J., Romo, J., Aleman, A., Weffer, S.E., & Ortiz, R.M. (2010).
Ethnic and gender disparities in adolescent obesity and elevated systolic blood pressure in
a rural US population. Clinical Pediatrics, 49(9), 876-884.
doi: 10.1177/0009922810368135
Rodriguez, R., Weffer, S.E., Romo, J., Aleman, A., & Ortiz, R.M. (2011). Reduced
physical activity levels associated with obesity in rural Hispanic adolescent females.
Childhood Obesity, 7(3), 194-205. doi: 10.1089/chi.2011.0007
CHILDHOOD OBESITY IN RURAL LATINOS 61
Rosas, L.G., Guendelman, S., Harley, K., Fernald, L.C.H., Neufeld, L., Mejia, F., &
Eskenazi, B. (2011). Factors associated with overweight and obesity among children of
Mexican descent: Results of a binational study. The Journal of Immigrant Minority
Health, 13, 169-180. doi: 10.1007/s10903-010-9332-x
Sano, Y., Garasky, S., Greder, K.A., Cook, C.C., & Browder, D.E. (2011).
Understanding food insecurity among Latino immigrant families in rural America. The
Journal of Family Economic Issues, 32, 111-123. doi: 10.1007/s10834-010-9219-y
Sano, Y. & Richards, L.N. (2011). Physical health, food security, and economic well-
being: The rural perspective. In J.W. Bauer & E.M. Dolan (Eds.), Rural Families and
Work, 77-98. Retrieved from http://link.springer.com/chapter/10.1007/978-1-4614-0382-
1_5?LI=true. doi: 10.1007/978-1-4614-0382-1_5
Sealy, Y.M. (2010). Parents’ food choices: Obesity among minority parents and children.
Journal of Community Health Nursing, 27(1), 1-11. doi: 10.1080/07370010903466072
Shaibi, G.Q., Cruz, M.L., Weigensberg, M.J., Toledo-Corral, C.M., Lane, C.J., Kelly,
L.A. …Goran, M.I. (2007). Adiponectin independently predicts metabolic syndrome in
overweight Latino youth. The Journal of Clinical Endocrinology & Metabolism, 92(5),
1809-1813. doi: 10.1210/jc.2006-2294
Sherrill, W.W. & Mayo, R.M. (2009). Impacting the health of Latino communities: A
model for rural areas. Global Health, 2(1), 1-8. Retrieved from
https://globalhealthonline.findlay.edu/index.php/findlay-edu-index-php-
pat/article/view/34/17
Singh, G.K., Siahpush, M., & Kogan, M.D. (2010). Rising social inequalities in US
childhood obesity, 2003-2007. Annals of Epidemiology, 20(1), 40-52.
CHILDHOOD OBESITY IN RURAL LATINOS 62
doi: 10.1016/j.annepidem.2009.09.008
Smith, A.W., Borowski, L.A., Liu, B., Galuska, D.A., Signore, C., Klabunde, C.
…Ballard-Barbash, R. (2011). U.S. primary care physicians’ diet-, physical activity-, and
weight-related care of adult patients. American Journal of Preventive Medicine, 41(1),
33-42. doi: 10.1016/j.amepre.2011.03.017
Springer, A.E., Lewis, K., Kelder, S.H., Fernandez, M.E., Barrosco, C.S., & Hoelscher,
D.M. (2010). Physical activity participation by parental language use in 4th
, 8th
, and 11th
grade students in Texas, USA. Journal of Immigrant Minority Health, 12, 769-780.
doi:10.1007/s10903-009-9249-4
Spruijt-Metz, D. (2011). Etiology, treatment, and prevention of obesity in childhood and
adolescence: A decade in review. Journal of Research on Adolescence, 21(1), 129-152.
doi: 10.1001/jama.2012.39
Stovitz, S.D., Schwimmer, J.B., Martinez, H., & Story, M.T. (2008). Pediatric obesity:
The unique issues in Latino-American male youth. American Journal of Preventive
Medicine, 34(2), 153-160. doi: 10.1016/j.amepre.2007.09.034
Suarez-Morales, L., Dillon, F.R., & Szapocznik, J. (2007). Validation of the acculturative
stress inventory for children (ASIC). Cultural Diversity and Ethnic Minority Psychology,
13(3), 216-224. doi: 10.1037/1099-9809.13.3.216
Taveras, E.M., Gillman, M.W., Kleiman, K., Rich-Edwards, J.W., & Rifas-Shiman, S.L.
(2010). Racial/ethnic differences in early-life risk factors for childhood obesity.
Pediatrics, 125(4), 686-695. doi: 10.1542/peds.2009-2100
Taveras, E.M., Hohman, K.H., Price, S., Gortmaker, S.L., & Sonneville, K. (2009).
CHILDHOOD OBESITY IN RURAL LATINOS 63
Televisions in the bedrooms of racial/ethnic minority children: How did they get there
and how do we get them out? Clinical Pediatrics, 48(7), 715-719.
doi: 10.1177/0009922809335667
Turer, A.T. & Scherer, P.E. (2012). Adiponectin: Mechanistic insights and clinical
implications. Diabetologia, 55, 2319-2326. doi: 10.1007/s00125-012-2598-x
Unger, J.B., Gallaher, P., Shakib, S., Ritt-Olson, A., Palmer, P.H., & Johnson, C.A.
(2002). The AHIMSA acculturation scale: A new measure of acculturation for
adolescents in a multicultural society. The Journal of Early Adolescence, 22(3), 225-251.
doi: 10.1177/02731602022003001
United States Census Bureau. (2011). Hispanic heritage month 2012. Profile America
Factors for Features. Retrieved from
http://www.census.gov/newsroom/releases/archives/facts_for_features_special_ed
itions/cb12-ff19.html
United States Department of Health and Human Services. (2010). The surgeon general’s
vision for a healthy and fit nation. Retrieved from
http://www.surgeongeneral.gov/initiatives/healthy-fit-nation/obesityvision2010.pdf
Viner, R.M., Hsia, Y., Tomsic, T., & Wong, I.C.K. (2010). Efficacy and safety of anti-
obesity drugs in children and adolescents: Systematic review and meta-analysis. Obesity
Reviews, 11(8), 593-602. doi: 10.1111/j.1467-789X.2009.00651.x
Vos, M.B. & Welsh, J. (2010). Childhood obesity: Update on predisposing factors and
prevention strategies. Current Gastroenterology Reports, 12, 280-287.
doi: 10.1007/s11894-010-0116-1
Wang, Y. (2011). Disparities in pediatric obesity in the US. Advances in Nutrition, 2,
CHILDHOOD OBESITY IN RURAL LATINOS 64
23-31. doi: 10.3945/an.110.000083
Warner, M.L., Harley, K., Bradman, A., Vargas, G., & Eskenazi, B. (2006). Soda
consumption and overweight status of 2-year-old Mexican-American children in
California. Obesity, 14(11), 1966-1974. doi: 10.1038/oby.2006.230
Whole Grains Council. (2012). U.S. dietary guidelines and whole grains. Retrieved from
http://wholegrainscouncil.org/whole-grains-101/us-dietary-guidelines-and-wg
Wilson, D.K. (2009). New perspectives on health disparities and obesity interventions in
youth. The Journal of Pediatric Psychology, 34(3), 231-244.
doi: 0.1093/jpepsy/jsn137
Wilson, D.M. (2010). Metformin extended release treatment of adolescent obesity: A 48-
week randomized, double-blind, placebo-controlled trial with 48-week follow-up.
Archives of Pediatrics & Adolescent Medicine, 164(2), 116-123.
doi: 10.1001/archpediatrics.2009.264
Wisniewski, A.B. & Chernausek, S.D. (2009). Gender in childhood obesity: Family
environment, hormones, and genes. Gender Medicine, 6, 76-85.
doi: 10.1016/j.genm.2008.12.001