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

AnthropologyTracy Cleveland, MS, PA-C

MSU Physician Assistant ProgramDeborah 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

Obesity Rates in U.S. Adolescents aged 12-19 (NHANES 2007-2008)

Mexican American

Non-Hispanic

White

Non-Hispanic

Black

Total Obesity Rates

Boys 26.8% 16.7% 19.8% 19.3%

Girls 17.4% 14.5% 29.2% 16.8%

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%

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

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

Why high rates of obesity & diabetes in Latinos?

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

~

Objectives1. 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, 24-

hour 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 QuestionsProgram Diet Physical Activity

• 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?

• Have you made any changes in diet as a result of information received from our program? What kind?

• Have you experienced changes in your diet since your arrival (to the US)?

• Do you cook more or less than you did when in your native country? Are the ingredients different?

• How important do you feel exercise is for kids (for all of us)?

• Is your activity level different from your native country?

• Have you increased your family’s level of physical activity as a result of our program?

Results: Diet and NutritionNew Foods Survey

total tried new foods/liked tried new foods/dislike stated fruit & veggies were healthy

0

2

4

6

8

10

12

14

16

Facilitated Survey

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 NutritionPost-Study Nutrition Survey

total

id healthy fo

ods

portion co

ntrol

healthy acti

vities

id healthy m

eals

tried new fo

ods

stated so

da was h

ealthy

0

5

10

15

20

25

30

35

40

Results: Focus Group

Barriers

Food Labels

Difficult to Understan

dNutritious, fresh food more expensive and less accessible• More

breads sweeteners, candy and frozen or dried foods

• Buy in bulk

Cultural• Walk and

cook less in America

• Less beans in American diet

Results: Focus Group Children

increased physical activity

Children eating more vegetables and less sugary foods and drinks• Consuming less soda and juice• Trying a variety of foods

Children showed increased interest in foods being purchased• Made lists of veggies for purchase

Increased Caregiver Awareness on Child’s Health• Incentive charts identified

deficits Program Successes

Parent Quotes

“By filling out the charts I started to notice what foods my child was lacking”

“Really nice to get a tip on mixing vegetables with their favorite foods”

“We all participate because were trying to improve our kids diet”

“Your program has helped my kids not want to eat as much candy as they used to”

“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”

“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.”

Results: Changes in Physical Data

N=38

Beginning BMI Percentile

N = 38

Ending BMI Percentile

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• Urban BMI higher than rural • Impoverished urban lower BMI than

wealthier • Boys more overwt than girls

Mean BMI %ile

% overwt

% obese

% above healthy weight

Mexico (N=203)

59th 13% 16% 29%

Sprfld (N=56)

69th 16% 23% 39%

Which picture depicts a healthy body form for a boy?

Which picture depicts a healthy body form for a girl?

Results: Cultural Considerations

10% 19% 38% 33%

19% 24% 50% 7%

Χ2 = 9.34p<0.01 df=2N=42

Results: Cultural Considerations Parents’ perceptions of child’s body form

Is my child’s body form (height, weight) Normal? Too heavy? Too light?

Parents’ PerceptionToo light 17%

Normal 71%

Too heavy 12%

Χ2=12.82 df=6 p<0.05 N=42

Actual Wt

Underwt 3%

Healthy Wt 57%

Overwt 14%

Obese 26%

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 (suzannewalker@missouristate.edu)

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 InformationClearinghouse (NDIC), U.S. Department of Health and Human Services http://diabetes.niddk.nih.gov/dm/pubs/causes/#what