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Obesity Among Latino Children Within a Migrant Farmworker Community

      Background

      Childhood obesity has increased substantially among Latino children, placing them at risk for its related health consequences. Limited attention has been given to childhood obesity among Latino migrant farm-working communities.

      Purpose

      To examine, within a migrant farm-working community, (1) the prevalence of obesity among Latino children and parents and (2) parent perceptions of children's weight status and intentions to take corrective action.

      Methods

      Structured interviews were completed with the parents of 495 children seen for well-child office visits in the pediatric department of a community health center during a 15-month period between 2010 and 2011. Medical chart reviews were completed for each child participant.

      Results

      Forty-seven percent of the children were overweight (20%) or obese (27%). In comparison to preschool-aged children, those in elementary and middle school were more likely to be obese. In elementary school, girls were more likely than boys to be overweight or obese. Child obesity was associated with parent obesity. Parental concern about their child's weight was associated with child obesity but not with child overweight. Parental concern was associated with parent intention to address the child's weight, particularly in older children. Analysis was completed in 2012.

      Conclusions

      Interventions are needed that address both childhood obesity and parent weight status among Latino migrant farmworkers. Prevention programs that address the weight status of Latino children who are overweight, but not necessarily obese, are also needed, as their parents tend to be no more concerned about a child who is overweight than one who is normal weight.

      Introduction

      In the past 3 decades, childhood obesity has increased markedly,
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      • Daniels S.R.
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      Influence of race, ethnicity, and culture on childhood obesity: implications for prevention and treatment.
      IOM Committee on prevention of obesity in children and youth

      Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R. CDC growth charts 2000; U.S. Adv Data, 1–27.

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      Latino children are among those at greatest risk.
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      Influence of race, ethnicity, and culture on childhood obesity: implications for prevention and treatment.
      The National Health and Nutrition Examination Survey (NHANES) reported that of children aged 2–5 years (preschool), 24.4% nationwide and 29.9% of Mexican-American children were overweight or obese in 2003–2006.
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      High body mass index for age among U.S. children and adolescents, 2003–2006.
      During 2007–2008, NHANES reported a similar preschool overweight prevalence of 21.2% nationwide and 27.7% for Mexican-American children.
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      • Carroll M.D.
      • Curtin L.R.
      • Lamb M.M.
      • Flegal K.M.
      Prevalence of high body mass index in U.S. children and adolescents, 2007–2008.
      A separate study
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      Elevated body mass index in Texas Head Start children: a result of heredity and economics.
      with Mexican-American preschool children over the 2003–2008 time period found that 40.79% of boys and 36.73% of girls had BMIs exceeding the 85th percentile. This study replicated an important gender gap previously reported in Latino children, with boys having higher prevalence of obesity than girls.
      • Caprio S.
      • Daniels S.R.
      • Drewnowski A.
      • et al.
      Influence of race, ethnicity, and culture on childhood obesity: implications for prevention and treatment.
      Obesity appears to be more prevalent in elementary school children than in preschoolers. Data from the 2007–2008 NHANES survey indicated that 35.5% of children aged 6–11 years had a BMI percentile ≥85; the prevalence for Mexican-American children was 41.7%.
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      Prevalence of high body mass index in U.S. children and adolescents, 2007–2008.
      A study
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      Prevalence of overweight in north Florida elementary and middle school children: effects of age, sex, ethnicity, and socioeconomic status.
      in North Florida elementary schools found increasing prevalence of overweight children across the elementary school years, with the percentage of children with a BMI percentile ≥85 increasing from 29.5% in kindergarten to 39.7% in Grade 5. In that sample, Latino boys had one of the highest prevalences of obesity/overweight (46%).
      Parents can play key roles in early identification and intervention efforts to address childhood obesity by shaping eating behaviors and encouraging physical activity.
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      Influence of parents' physical activity levels on activity levels of young children.
      However, parents often underestimate their children's weight,
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      or define overweight in regard to functional impairments such as limited physical ability.
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      Parents may also disagree with an overweight diagnosis, particularly if a weight-related complication is not present.
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      Perceptions of overweight and obesity in their community: findings from focus groups with urban, African American caretakers of preschool children.
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      Culture can influence parental perceptions of weight. In the Latino culture, mothers have a preference for plumper children,
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      associate thinness with poor health,
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      and may fail to perceive their children as overweight.
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      Body image, weight, and food choices of Latina women and their young children.
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      • et al.
      Counseling Latina mothers of preschool children about weight issues: suggestions for a new framework.
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      Parental perceptions of the preschool obese child.
      Children of migrant Latino farmworkers are at risk for obesity; their parents' occupation fosters a lifestyle that often places them at risk for suboptimal health, including obesity.
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      • et al.
      The health of Latino children.
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      Health care for children of migrant farm workers.
      Migrant children often lack adequate preventive care as a result of Medicaid eligibility being hampered by the family's interstate mobility for work and difficulties with residency and citizenship status. However, large-scale studies focusing on children of migrant Latino farmworkers are scarce. Existing studies looking at this population have highlighted the need for additional research. One study
      • Kilanowski J.F.
      • Moore L.C.
      Food security and dietary intake in Midwest migrant farmworker children.
      addressing the prevalence of obesity with a small sample of Latino children from migrant farm-working families yielded a median BMI percentile of 97.5, providing initial evidence of obesity in this population.
      The purpose of the current study was to examine the prevalence of overweight and obesity among Latino children of primarily migrant farmworkers. Children's medical charts were reviewed, and structured interviews were conducted with 495 parents to measure parental concern about the child's weight status and inquire about parent intention to take action to improve their child's weight. These findings can better inform primary care–based interventions for overweight children, which have been effective for helping adults and adolescents reduce weight
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      and improve diet and physical activity.
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      • et al.
      Randomized controlled trial of a primary care and home-based intervention for physical activity and nutrition behaviors: PACE+ for adolescents.
      Effective interventions that target prevention of obesity among young children are lacking.
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      Prevention and early treatment of overweight and obesity in young children: a critical review and appraisal of the evidence.
      Findings from the present study can also foster the development of culturally appropriate interventions for children from Latino migrant farm-working families.

      Methods

      Data Collection and Measures

      The study was approved by the Florida State University IRB. During a 15-month period between 2010 and 2011, Latino parents and their children (aged 3–16 years) at a community health center were invited to participate in an interview and a review of their child's medical records by a bilingual research assistant prior to their well child appointments. The center's protocol asks that parents self-report their child's ethnicity during an intake process; when parents selected “Hispanic” from a list of choices (e.g., Caucasian, African-American, Asian), a research assistant was alerted and the family was invited to participate in the study. Following the provider's exam, informed consent was obtained from the parent and a structured interview was completed, in their preferred language, regarding that day's office visit; all questions were directed to the parent.
      Questions were adapted from an interview previously developed to assess parental reactions to BMI screenings.
      • Johnson S.B.
      • Pilkington L.L.
      • Lamp C.
      • He J.
      • Deeb L.C.
      Parent reactions to a school-based body mass index screening program.
      Interview questions assessed parental concern about the child's weight (e.g., Are you concerned or worried about your child's weight?) and their intention to take action to improve their child's weight (e.g., After today's office visit, do you plan to change what your child eats or how much exercise your child gets?). Several yes/no questions were asked to assess parental perceptions of health consequences associated with childhood obesity (e.g., Do you think overweight children are more likely to have asthma/high blood pressure/high cholesterol/heart problems?) and their perceptions about a person's influence over their own weight (e.g., Some people are overweight and there is very little that they can do about it, yes or no?). Several revisions to the original interview were made prior to finalizing the interview guide.
      Demographic information collected included child's grade, race, and eligibility for free/reduced-price school lunch, the parent's age, race, gender, education and self-reported height and weight. A total of 437 (92.6 %) interviews were completed with mothers; 21 (4.4%) with fathers; and 14 (3.0%) with other custodial guardians. Providers were informed that an interview would follow the office visit to “measure parent perceptions of their children's health.” They were not given further details about the nature of the interview or provided with any follow-up instruction regarding the office visit.
      Following the visit, the child's electronic health record (EHR) was reviewed for birth date, gender, height, weight, and BMI. The EHR auto-calculated BMI utilizing height and weight information entered by clinical staff on the day of the office visit. The center's protocol required staff to measure height to the nearest 0.25 inches and weight to the nearest 0.5 pounds; the center used a stadiometer scale (Seca 214) to obtain measurements. All active medical diagnoses made on, or prior to, the date of the office visit were recorded.
      The child's age- and gender-specific BMI percentile were calculated using the CDC's child/teen online calculator.
      CDC
      BMI percentile calculator for child and teen.
      Children were placed into one of four weight categories
      • Krebs N.F.
      • Himes J.H.
      • Jacobson D.
      • Nicklas T.A.
      • Guilday P.
      • Styne D.
      Assessment of child and adolescent overweight and obesity.
      : obese, BMI percentile ≥95; overweight, BMI percentile ≥85 and <95; healthy, BMI percentile ≥5 and <85; and underweight, BMI percentile <5. The CDC's adult BMI calculator was used to calculate parent BMI, and the National Heart, Lung, and Blood Institute's reference categories
      NIH, National Heart, Lung, and Blood Institute (NHLBI)
      Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults.
      were used to determine the appropriate weight category (i.e., obese: BMI ≥30; overweight: BMI ≥25 and <30; healthy: BMI ≥18.5 and <25).

      Sample

      Participants were recruited during a 15-month period from the pediatric department of a community health center serving a predominantly Spanish-speaking, migrant, farm-working population located within a rural area of southwest Florida. A total of 495 parents agreed to participate. The sample included a small number (n=23) of high school–age adolescents; these were dropped from the analysis, thus yielding a final sample of 472.

      Data Analysis

      Descriptive data were presented as means, SDs, frequencies, and percentages. Multiple regression was used to determine correlates of the child's BMI percentile. Model assumptions were checked and validated (independently/identically distributed errors, independence between predictors). Logistic multiple regression was used to determine associations between the child's weight classification (obese, overweight, obese); parental concern about their child's weight (yes/no); and parental intent to take corrective action to improve their child's weight (yes/no). For the logistic regression, the assumption of independent predictors was met. Data were analyzed using Stata, version 11, in 2012.

      Results

      All children were of Latino ethnicity, with the majority U.S.-born of Mexican descent (Table 1). The sample was predominately preschool or elementary school age and almost all of the school-age children qualified for free/reduced-price lunch, reflecting a low SES. The majority of parents were foreign-born mothers who had resided in the U.S. for an average of 11.8 years. Most families were farm-working (80.3%), with about half being migrants who relocate frequently for seasonal work. Most parents had less than a high school education, and almost all were overweight/obese.
      Table 1Characteristics of the study sample
      Child characteristicn% or M (SD)Parent characteristicn% or M (SD)
      Gender
       Male24151.1Male/father214.4
       Female23148.9Female/mother43792.6
      Other guardian143.0
      Age (years)
       Child6.4 (3.2)Parent32.1 (6.6)
      Education and employment
       Grade levelNo formal schooling347.4
       Preschool25253.4Elementary school20544.9
       Elementary16635.2Middle school265.7
       Middle school5411.4Some high school6915.1
      High school diploma9220.1
      Above high school316.8
      Free or reduced-price lunch30697.5Farm-working family37480.3
      Migrant family21858.3
      Place of birth
       U.S.45697.0U.S.7716.4
      Non-U.S.39383.6
      Number of years in U.S.11.6 (5.6)
      Weight status
       BMI47118.8 (4.3)BMI24530.2 (6.2)
       BMI percentile46771.99 (27.86)
        Obese12627.0Obese10944.5
        Overweight9420.1Overweight9438.4
        Healthy24352.0Healthy/normal4217.1
        Underweight40.9Underweight00
      Child Latino ethnicity
       Mexico35776.0
       Guatemala7716.4
       Other265.5
       Cuba51.1
       Puerto Rico30.6
       El Salvador20.4

      Child Body Mass Index Percentile and Weight Classification

      The average child BMI percentile was 72, and 47.1% of children were either obese or overweight (Table 1); only five children fell within the underweight category. Table 2 depicts the multiple-regression results predicting child BMI percentile and the logistic multiple regression predicting categoric placement into normal weight versus overweight/obese or obese versus healthy weight (the five underweight children were removed from this analysis). In all three analyses, parent BMI was a predictor of child BMI percentile or weight classification. When compared to the preschool group, elementary school–age children had a greater probability of being overweight/obese versus healthy weight. Further, elementary school girls had a greater probability than boys of being overweight/obese.
      Table 2Multiple regression results
      Predictions: child weight, parental concern: child's weight, parental intent: corrective action
      Outcome variable and predictorsCoefficientp-value
      CHILD'S WEIGHT (BMI PERCENTILE)
      Linear regression
      Child grade (vs preschool)
       Elementary school9.5490.067
       Middle school13.6050.058
      Child gender (ref: male)1.6060.750
      Child gender X child grade
       Male X elementary school−11.5800.124
       Male X middle school−17.5630.079
      Parent BMI0.6120.030
      p<0.05
      CHILD'S WEIGHT (OVERWEIGHT OR OBESE VS HEALTHY WEIGHT)
      Logistic regression, n=424
      Child grade (vs preschool)
       Elementary school0.88570.030
      p<0.05
       Middle school0.62560.259
      Child gender (ref: male)0.28120.474
      Child gender X child grade
       Male X elementary school−1.17120.047
      p<0.05
       Male X middle school−0.61960.421
      Parent BMI0.06130.007
      p<0.05
      CHILD'S WEIGHT (OBESE VS HEALTHY WEIGHT)
      Logistic regression, n=424
      Child grade (vs preschool)
       Elementary school1.96840.001
      p<0.05
       Middle school1.81160.012
      p<0.05
      Child gender (ref: male)1.66850.005
      p<0.05
      Child gender X grade
       Male X elementary school−2.46410.001
      p<0.05
       Male X middle school−2.77700.009
      p<0.05
      Parent BMI0.1009<0.001
      p<0.05
      PARENTAL CONCERN ABOUT CHILD'S WEIGHT (YES VS NO)
      Logistic regression, n=424
      Child gender (ref: male)−0.02160.953
      Child obese (yes/no)2.4686<0.001
      p<0.05
      Child overweight (yes/no)−0.21070.687
      Parent age0.01790.478
      Parent BMI−0.00440.884
      Parent place of birth (U.S. or non–U.S. born) (ref: U.S.)−0.85600.054
      Child age0.06878240.032
      p<0.05
      Child gender (ref: male)0.21406970.308
      Child obese (yes/no)1.68826<0.001
      p<0.05
      Child overweight (yes/no)0.3996830.125
      Note: Boldface indicates significance. Predictors are shown as subentries for each outcome variable.
      a Predictions: child weight, parental concern: child's weight, parental intent: corrective action
      b Linear regression
      c Logistic regression, n=424
      low asterisk p<0.05
      There was a gender-by-grade-level interaction that was most striking in the analysis of obese versus healthy weight children (Figure 1). Among preschool children, boys were more likely to be obese, although girls were more likely to be overweight. Among elementary school children, girls were more likely to be obese and overweight. In middle school, the prevalence of obesity and overweight was comparable between the two genders. Figure 1 also highlights the increase in obesity by grade level.
      Figure thumbnail gr1
      Figure 1Percentage of children in each weight category, by grade and gender

      Parental Concern About Child Weight

      Parents were asked whether they had any concern about the weight of each of their children. Figure 2 shows the percentage of parents expressing concern about their child's weight by gender and by weight category. Logistic multiple regression was used to identify predictors of parental concern. Only the child's obesity status (yes/no) was a predictor of parental concern, although there was a nonsignificant trend for parents born in the U.S. to be less concerned (Table 2); there were no grade-level or gender interactions. A majority of parents of obese children were concerned about their child's weight, regardless of gender (Figure 2). In contrast, few parents of overweight children were concerned. In fact, parent concern about overweight children was no different than parent concern about normal-weight children.
      Figure thumbnail gr2
      Figure 2Percentage of parents expressing concern about child's weight and intent to take corrective action (diet or exercise)

      Parental Report of Intent to Take Corrective Action

      Parents were also asked about intent to do something to improve their child's weight. Figure 2 shows the percentage of parents indicating intent to take corrective action to improve their child's weight status, by gender and by weight category. The logistic multiple regression model found that child age and child obesity status were predictors of parent intent to take corrective action; there were no age or gender interactions (Table 2). Parents of obese children were more likely to report intentions to take corrective action, when asked of their intent to do so following the office visit (Figure 2). In contrast, the percentage of parents of overweight children who planned to take corrective action was much lower and nearly equivalent to the percentage of parents of healthy-weight children who planned to take corrective action.
      Parents were also more likely to state that they intended to take corrective action if the child was older and if they acknowledged concern about the child's weight. Parents were also asked to report the type of corrective action they intended to take, either exercise or diet (change in eating behaviors). The majority of parents reported intending to modify both their child's exercise (62.7% for boys and 63.6% for girls) and dietary behaviors (66.1% for boys and 63.6% for girls). Parents also were asked if they were willing to change their own diet and exercise patterns in order to help their children, and 100% of respondents indicated willingness to do so.

      Parental Perceptions of the Impact of Childhood Obesity

      Parent interviews included questions measuring parental perceptions of obesity and its health consequences. Parents were asked open-ended questions about whether or not they felt that overweight children would outgrow their weight problems or become overweight adults. Parents were also asked to indicate if they thought certain medical conditions were associated with childhood obesity (e.g., diabetes, high blood pressure). More than half of parents (65%) believed that overweight children would outgrow their weight problems, although a similar percentage (64%) stated that overweight children will become overweight adults. The majority of parents believed that being overweight places a child at risk for several medical conditions: diabetes (87%); high blood pressure (88%); high cholesterol (85%); and heart complications (85%).
      However, only half of parents (49%) identified asthma as a potential risk associated with childhood obesity. Of the participating obese/overweight children, 36.9% had been diagnosed with asthma. Almost all parents indicated that changing one's exercise (90%) and eating (95%) habits can lead to weight loss and expressed an interest in intervention programs to improve their child's weight and overall health (97%). Few parents believed that there is nothing that can be done to improve one's weight status (15%) or size (11%).

      Discussion

      Previous research has given little attention to obesity among children from migrant farm-working families. Results from the current study point out that the prevalence of obesity is substantial among this population. Almost half (47.1%) of the children in this study were either obese or overweight. This number is higher than that in other national studies
      • Ogden C.L.
      • Carroll M.D.
      • Curtin L.R.
      • Lamb M.M.
      • Flegal K.M.
      Prevalence of high body mass index in U.S. children and adolescents, 2007–2008.
      • Hoelscher D.M.
      • Day R.S.
      • Lee E.S.
      Measuring the prevalence of overweight in texas school children.
      The Arkansas Center for Health Improvement
      The Arkansas Assessment of Childhood and Adolescent Obesity–tracking progress.
      but consistent with reports available from rural communities.
      • Piziak V.
      • Morgan-Cox M.
      • Tubbs J.
      • Hasan R.
      Elevated body mass index in Texas Head Start children: a result of heredity and economics.
      • King C.
      • Meadows B.
      • Engelke M.
      • Swanson M.
      Prevalence of elevated body mass index and blood pressure in a rural school-aged population: implications for school nurses.
      The higher prevalence of overweight/obesity may be attributed, in part, to the family lifestyle that is fostered by the occupation of migrant farmworkers. Child health is affected, as well as adult health: Nearly 83% of parents in this study had a BMI that fell into either the obese or overweight categories. Other studies with migrant farmworkers have found similar numbers of overweight and obese adults.
      • Weigel M.M.
      • Armijos R.X.
      • Hall Y.P.
      • Ramirez Y.
      • Orozco R.
      The household food insecurity and health outcomes of U.S.-Mexico border migrant and seasonal farmworkers.
      This highlights the importance of addressing weight with the entire family, as the health of both the parents and children is at risk. In a primary care pediatric setting, this may be accomplished by setting goals that imply positive behavior change for the entire family versus just for the child being treated.
      Previous national studies
      IOM Committee on prevention of obesity in children and youth

      Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R. CDC growth charts 2000; U.S. Adv Data, 1–27.

      have demonstrated that Latino boys tend to have a higher prevalence of overweight/obesity than girls. The current study did not replicate this pattern. Among preschoolers, boys were more likely to be obese than girls, but girls were more likely to be overweight. In elementary school, girls were more likely to be overweight and obese than boys. In middle school, boys and girls were essentially comparable in terms of overweight and obesity prevalence (54.5% for boys and 52.4% for girls). Because there are no prior large-sample, published studies of obesity among children of Latino migrant farmworkers, future research is needed to determine whether this high prevalence of obesity/overweight among girls is consistent across other migrant populations.
      Findings show that children's weight levels were associated with parents' concern about their child's weight. Parents of obese children were most concerned about their child's weight; however, parents of overweight children infrequently reported being concerned. There was no difference in parental concern between parents of overweight and of normal-weight children, suggesting that parents of overweight children are unlikely to take corrective action or unlikely to take any action beyond what they would take for a normal-weight child. There was a trend for parents born in the U.S. to express less concern about their child's weight. It may be possible that parents' levels of acculturation influence their levels of concern. In order to better address the childhood obesity epidemic, better understanding is needed of the cultural factors that may underlie parental concerns about their child's weight.
      Findings from the present study indicated that a large percentage of parents expressed intentions to engage in some form of corrective action to improve their child's weight; parents were more likely to endorse intent to engage in action when their child's weight fell in the obese category. This again is an indication of the need for interventions that address the weight status of overweight children, as there seems to be both a lack of awareness and reduced likelihood of corrective action when a child falls within this weight category. A child's age was a predictor of parent intent to take action, with intent increasing as the child becomes older. If parents are not likely to take action until after the preschool years, an opportunity for early intervention could be missed. Parents of preschool-age overweight/obese children should be encouraged to take early measures to improve their child's weight.
      All parents who participated in the current study reported willingness to change their own diet or exercise patterns in order to improve their child's health. A majority of parents expressed interest in participating in programs designed to improve their child's weight. However, questions about intent to change were asked immediately following the office visit and may have been influenced by information presented moments earlier; true intent for behavior change was not measured. This finding is nevertheless encouraging and highlights the importance of including the whole family in interventions that target childhood overweight and obesity.
      Parents who provided responses in this study generally had some understanding of the relationship between obesity and chronic health conditions. However, although more than one third of the overweight or obese children in this sample had been diagnosed with asthma, less than half of parents understood the association between obesity and asthma. Further, many parents believed that children usually outgrow weight problems. It may be important to educate parents on proactive strategies one can take to improve a child's weight. For instance, providers can explain the health benefits of following physical activity guidelines and can describe the different types of activities (e.g., aerobic, muscle-strengthening, bone-strengthening) and make specific recommendations for each (e.g., including gymnastics for muscle strengthening).

      Limitations

      This study is limited by data collection at a single site, as well as by the use of a convenience sample, although a different method of sampling may be difficult with a migrant population. Given the study design, there are cross-sectional limitations, such as the inability to infer causality. Children in this study were all attending a well child office visit; parents who schedule such appointments may be more concerned about their child's health and weight than parents who do not schedule well child appointments.
      This study found that a large percentage of parents were overweight/obese; however, such findings are limited, as parent BMI data were based on self-reported height and weight. All parents participating in this study indicated willingness to change their own diet and exercise patterns to help their children; future studies should also measure the extent to which parents actually change their own behaviors. This study is also limited by using single questions to measure parental concern about their child's weight. The structured interview developed included several yes/no questions to assess parental awareness of health consequences related to obesity; future studies may consider using more in-depth methods of assessing parental awareness.

      Conclusion

      Overall, findings further document the problem of childhood obesity among Latino children. Healthcare providers in primary-care settings can play important roles in assessing and reporting a child's weight status. Encounters with healthcare professionals present an opportunity to identify and address parental (mis)perceptions of their children's weight status.
      • Guerrero A.D.
      • Slusser W.M.
      • Barreto P.M.
      • Rosales N.F.
      • Kuo A.A.
      Latina mothers' perceptions of healthcare professional weight assessments of preschool-aged children.
      No studies have evaluated how parents from minority groups perceive weight assessments completed by healthcare providers.38 Future studies should examine how the weight status of Latino children can be addressed during primary-care office visits.
      Publication of this article was supported by the Robert Wood Johnson Foundation.
      This study was funded by the Robert Wood Johnson Foundation through its national program, Salud America! The RWJF Research Network to Prevent Obesity Among Latino Children (www.salud-america.org). Salud America!, led by the Institute for Health Promotion Research at The University of Texas Health Science Center at San Antonio, Texas, unites Latino researchers and advocates seeking environmental and policy solutions to the epidemic.
      No financial disclosures were reported by the authors of this paper.

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