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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.


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


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


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


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,


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


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


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.


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


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


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


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


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


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.


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


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


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


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


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


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.


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


(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.,


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


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.


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


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


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


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


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;


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


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).


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


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,


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,


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


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


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


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).


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


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


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


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.


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


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,


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


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


for local and state policies that create and promote an anti-obesity environment, particularly in

schools.


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