Breaking down the barriers:
a look at
“Por la Salud de Nuestros Ninos”
A diabetes and obesity prevention
program for Latino children
Suzanne E. Walker-Pacheco, Ph.D.
MSU Dept of Sociology and Anthropology
Tracy Cleveland, MS, PA-C
MSU Physician Assistant Program
Deborah Piland, PhD, RD/LD
College of the Ozarks Dietetics Program
The Problem: Obesity
• Obesity, a growing “epidemic” for all ages
• Recent focus on healthy lifestyles
• Pediatric obesity: U.S. obesity rate in 6-19 yr-olds
more than tripled
• Pediatric obesity: current and future problems
• First U.S. generation destined to have shorter life
span than its predecessor
The Problem: Disparities
• Disparities in rates of pediatric obesity
• Overall risk of obesity-related illness higher in U.S.
minorities
• Immigrant families face barriers while adapting to life
in United States
• U.S. Latinos: high incidence of children 2-19 yrs old
overweight/obese
Percentage overweight among children and
adolescents 6-11 years of age
(NHANES 2007-2010)
Mexican
American
Non-Hispanic
White
Boys
24.3%
18.6%
Girls
22.4%
14.0%
Obesity Rates in U.S. Adolescents aged 12-19
(NHANES 2007-2008)
Mexican
American
NonHispanic
White
NonHispanic
Black
Total
Obesity
Rates
Boys
26.8%
16.7%
19.8%
19.3%
Girls
17.4%
14.5%
29.2%
16.8%
Comorbidities
Diabetes: Prevalence, Some Facts
• Diabetes
• Metabolic disorder
• Ineffective use of insulin leads to high blood glucose
• Total # of people with diabetes worldwide projected to
rise from 171 million in 2000 to 366 million in 2030
• Over 18 million people in U.S. have diabetes
• ~ 41 million have “pre-diabetes”
• Leading cause of heart disease, stroke, kidney disease,
blindness, and amputations
• Prevalence decreases w higher education levels
• Overall prevalence among Latinos almost twice that of
non-Hispanic whites (9.8% vs. 5%)
• Latinos susceptible at younger ages than non-Hispanic
whites
Type 2 Diabetes: Causes
Genetic Basis
• “Thrifty gene” hypothesis and alternatives
• Some gene variants increase susceptibility to type 2
diabetes
• Familial aggregation
• Twin studies
• Prevalence varies by ethnic group
• Variants of the TCF7L2 gene
Type 2 Diabetes: Causes
Environment
• Lack of physical activity
• Dietary correlates
• High intake of fats & sweeteners
• Low intake of fruits, vegetables, & whole grains
Who are the Latinos?
• Race concept: social construct
• Shared ancestry
• Affinities with Native Americans; Asian roots
• Diverse
• Shared cultural aspects
• Hispanic vs. Latino
Why high rates of obesity &
diabetes in Latinos?
Combination of:
• Genetic risk
• Environmental factors
• Immigration process & resulting changes in diet and
physical activity
• Relatively low socioeconomic status
Results in high rates & susceptibility at young age
Purpose of Study: Por la Salud de
Nuestros Niños
• To reduce obesity and prevent type 2 diabetes in a group of
Latino children in Springfield, MO
• To arm members of this population with tools to improve
overall health and decrease the need for future medical care
• To serve as a model for those interested in implementing
applied programs, and academic and medical communities
• Since health education programs aimed at children and that
encourage family participation have documented success,
parents and other family members would also be educated and
receive similar benefits
• To contribute to the incomplete database concerning health
issues among Missouri’s Latinos
Objectives
1. Comprehensive survey including: family health
history, demographics, preventive healthcare,
knowledge about diabetes, and information on the
children’s daily activities and diet
2. Identify children at risk for developing diabetes
through medical and anthropomorphic indicators
3. Promote and increase awareness of healthy lifestyle
habits via weekly interactive health education
program targeting proper nutrition and exercise
habits
4. Collect comparative data in Central Mexico on health
status, diet and activity level, and physical health
indicators
Methods: Location and Study
Group
• Local church, convenience
sample
• Study group: 64 Latino children,
3-9 yrs old (avg 5.3)
• Multidisciplinary team
• Holistic, multifaceted approach
Methods: Procedures
• Quantitative & qualitative data collection
• Comprehensive caregiver & child surveys, 24hour recall nutritional assessments
• Focus group
• Weekly interactive health education program
• Nutrition and exercise education
• Information for caregivers
• Daily nutritional intake and physical activity as
reported by caregivers
• Monthly physical measurements
Methods: Physical Measurements
• Variables
•
•
•
•
•
•
Height
Weight
BMI calculated
Blood pressure
Waist circumference
Triceps skinfold thickness
• N=56 (N=38 for early & late in study)
• Aged 3-9 (average 5.3 yrs)
• Time between 1st and last meas avgd 8.3
mos
Methods: Focus Group
• 22 parents & grandparents
• Purpose:
• Investigate factors contributing to childhood
obesity in study group
• Receive feedback on program
• Discussion included:
• Caregivers’ knowledge about nutrition,
diabetes, obesity
• Impact of program
• Physical activity
• Barriers to a healthy lifestyle
Specific Questions
Program
• Do you read the
materials we send
home?
• What has been most
helpful about these
materials? What
hasn’t been helpful?
• Do you have any
suggestions?
Diet
Physical Activity
• Have you made any
• How important do you
changes in diet as a
feel exercise is for kids
result of information
(for all of us)?
received from our
program? What kind? • Is your activity level
different from your
• Have you experienced
native country?
changes in your diet
since your arrival (to
• Have you increased
the US)?
your family’s level of
physical activity as a
• Do you cook more or
result of our program?
less than you did
when in your native
country? Are the
ingredients different?
Results: Diet and Nutrition
New Foods Survey
Facilitated Survey
16
14
12
10
8
6
4
2
0
total
tried new foods/liked
tried new foods/dislike stated fruit & veggies were
healthy
Results: Diet and Nutrition
Nutrition Assessments
• 21 assessments completed for children ages 3 to 10
• 24% consumed adequate servings of fruits and
vegetables
• General Dietary Tendencies
• High in added sugars, particularly in beverages
• High in fat and saturated fat
• High in sodium
• Not much soda consumption
• Low in whole grains and fiber
Results: Diet and Nutrition
Post-Study Nutrition Survey
40
35
30
25
20
15
10
5
0
total
id healthy foodsportion control
healthy
activities
id healthy
meals
tried new foodsstated soda was
healthy
Results: Focus Group
Food Labels Difficult
to Understand
Barriers
Cultural
• Walk and cook less in
America
• Less beans in American diet
Nutritious, fresh food more
expensive and less accessible
• More breads sweeteners, candy and
frozen or dried foods
• Buy in bulk
Results: Focus Group
Children
increased
physical
activity
Increased Caregiver
Awareness on Child’s
Health
• Incentive charts identified
deficits
Children showed increased interest
in foods being purchased
• Made lists of veggies for purchase
Program
Successes
Children eating more vegetables and
less sugary foods and drinks
• Consuming less soda and juice
• Trying a variety of foods
Parent Quotes
“By filling out the charts I started to
notice what foods my child was lacking”
“We all participate
because were trying to
improve our kids diet”
“Really nice to get a tip on mixing
vegetables with their favorite foods”
“I cooked a whole lot more in my
country of origin. Back there you
sometimes cook three times a day.
Here you only cook once a day
usually.”
“They also share
what they learn…
And it makes me
conscious and when
I’m buying groceries
they will make sure
that I try and buy
healthier foods”
“Your program has
helped my kids not
want to eat as much
candy as they used
to”
Results: Changes in Physical Data
Beginning BMI Percentile
N=38
Ending BMI Percentile
N = 38
Paired sample t-test
t=1.27
df=37
Sig (2-tailed) = .211
Results: Mexico and Springfield
Study Groups
Results: Mexico and Springfield
Study Groups (BMI Percentile)
Mexico
(N=203)
Sprfld
(N=56)
Mean
BMI
%ile
59th
%
overwt
%
obese
13%
16%
% above
healthy
weight
29%
69th
16%
23%
39%
Mexico
• Urban BMI higher than rural
• Impoverished urban lower BMI than
wealthier
• Boys more overwt than girls
Results: Cultural Considerations
Which picture depicts a healthy body form for a boy?
10% 19% 38% 33%
Which picture depicts a healthy body form for a girl?
Χ2 = 9.34
p<0.01
df=2
N=42
19% 24% 50% 7%
Results: Cultural Considerations
Parents’ perceptions of child’s body form
Is my child’s body form (height, weight)
 Normal?
 Too heavy?
 Too light?
Parents’
Perception
Too light
Actual Wt
Underwt
3%
17%
Healthy Wt
57%
Normal
71%
Overwt
14%
Too heavy
12%
Obese
26%
Χ2=12.82
df=6
p<0.05
N=42
Effects of Immigration
• Assimilation: increased overweight with more
time in U.S. (individuals and populations)
• Dietary differences in U.S. vs. native country
• Differences in physical activity
Summary
• Nutrition
• Only ¼ appeared to consume enough fruits/veggies
• Diet high sugar, high fat, high sodium, low whole grains
• Most children tried new foods, recognized healthy foods
• Focus Group Identified…
• Barriers= cost and cultural/immigration issues
• Successes = increased awareness of healthy diets and importance of
physical activity
• BMI
• Decreased over course of study for Springfield study group
• Springfield study group > Mexico study group
• Mexico urban > Mexico rural
• Body Form
• Boys more overweight than girls
• More parents rated heavier body form as healthier for boys than girls
• Many parents underestimated child’s body weight
Recommendations
• Family Centered Healthcare
• Family involvement
• Provide facts to parents
• Empower families with appropriate tools
and skill development opportunities
• Provide simple tips on nutrition &
exercise
• Identify Community Partners
• Develop health information delivery
strategies
• Incorporate cultural perceptions of
health
• Start ‘em young!
Our material
will be made available ([email protected])
Acknowledgments
• Funded by Missouri State University Provost’s Incentive
and Dean’s Incentive grants
• The participating families
• Sacred Heart Catholic Church
• Dr. Linda Vaught
• Abe Ledezma
• Trevor Schunemann
• Todd Daniels
References
• Childhood Overweight and Obesity, CDC Centers for
Disease Control and Prevention (CDC):
http://www.cdc.gov/obesity/childhood/index.html
• Das SK, Elbien SC (2006) The Genetic Basis of Type 2
Diabetes. Cellscience 2(4):100-131.
• National Health and Nutrition Examination Survey
http://www.cdc.gov/nchs/nhanes.htm
• National Diabetes Information
Clearinghouse (NDIC), U.S. Department of Health and
Human Services
http://diabetes.niddk.nih.gov/dm/pubs/causes/#what
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Breaking down the barriers: a look at *Por la Salud de Nuestros Ninos*