Research

Hispanic Health Care International

1-14
Mexican American Parental Knowledge ª The Author(s) 2019
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and Perceptions of Childhood Obesity: DOI: 10.1177/1540415319873400
journals.sagepub.com/home/hci
An Integrative Review

Nathalie Confiac, MSN, RN, PHN1 , Melanie T. Turk, PhD, MSN, RN1,
Rick Zoucha, PhD, PMHCNS-BC, CTN-A, FAAN1,
and Marilyn McFarland, PhD, RN, FNP-BC, CTN-A2

Abstract
Introduction: For the past two decades, childhood obesity has remained a national public health concern, particularly among
Hispanic populations. Multiple cross-sectoral obesity prevention strategies have been implemented yet remain unsuccessful in
generating sustainable lifestyle changes. Method: The purpose of this integrative review, using the Whittemore and Knafl
method, was to examine the literature from 2009 to 2018 regarding Mexican American parental knowledge and perceptions of
childhood obesity. The CINAHL, PubMed, PsycINFO, and ERIC databases were used to search the literature, and 13 peer-
reviewed articles met the inclusion criteria. Results: Three main themes emerged from the literature synthesis: (1) parental
misperception of child body weight and size, (2) influence of cultural health and growth beliefs on parental perception of child
weight, and (3) parental perspectives of causes and consequences of childhood obesity and how to address it. However, cultural
variations in parental perceptions were found; therefore, attempts to generalize Mexican Americans’ cultural practices should be
avoided. Conclusion: Studies using qualitative approaches are needed to gain deeper insights about Mexican American culture
regarding children’s health as it relates to body weight, the roles of different family members in the Mexican American childrearing
tradition, and the impact of their associated health beliefs.

Keywords
childhood obesity, Mexican Americans, cultural beliefs, integrative review

Introduction addressing social determinants of health (U.S. Department of

For the past two decades, childhood obesity in the United States
has been a public health concern with alarming consequences,
such as increases in early onset of chronic diseases in children
(diabetes, hypertension, hypercholesterolemia, cardiovascular
diseases; Centers for Disease Control and Prevention [CDC],
2015) and an overall shortening of life expectancy (Daniels,
2006). In addition, overweight and obese children are subject to
psychological problems including depression, low self-esteem,
bullying, and social stigmatization (CDC, 2015). The latest
national trends indicate an overall obesity prevalence of
18.5% among youth 2 to 19 years of age, with higher rates
among Hispanics—25.8%—compared with 22% in non-
Hispanic Black, 14.1% in non-Hispanic White, and 11% in
non-Hispanic Asian youth (Hales, Carroll, Fryar, & Ogden,
2017). The national census of 2010 revealed that 16.3% of the
U.S. population was of Hispanic or Latino ethnicity of which
10.3%—the largest proportion—reported being of Mexican
descent, hence, the need of examining their health (U.S. Census
Bureau, n.d.). The health status of Hispanic Americans has
been a focus at the national, state and local levels with the
Healthy People 2020 goal to eliminate health disparities by
Health and Human Services, & Office of Disease Prevention
and Health Promotion., 2017).
Problem Identification
Research has addressed multiple obesity prevention strategies
including evidence-based interventions (Berger-Jenkins et al.,
2014; Zoorob et al., 2013) and qualitative approaches (Lindsay
et al., 2012; Martinez, Rhee, Blanco, & Boutelle, 2014) to
better understand Hispanic families’ points of view about obe-
sity. Long-term and short-term interventions targeting multiple
age groups in various settings (primary care, home, school)
have been implemented, yet remain unsuccessful in generating
sustainable lifestyle changes (Ayala et al., 2010; Bender,
Nader, Kennedy, & Gahagan, 2013; Boudreau, Kurowski,
1
Duquesne University, Pittsburgh, PA, USA
2
The University of Michigan–Flint, Flint, MI, USA
Corresponding Author:
Nathalie Confiac, 4428 La Paloma Avenue, Santa Barbara, CA 93105, USA.
Email: confiacn@duq.edu
2 Hispanic Health Care International XX(X)
Gonzalez, Dimond, & Oreskovic, 2013; Hammons, Wiley,
Fiese, & Teran-Garcia, 2013; Zoorob et al., 2013). Moreover,
much of the previous research has not specified subgroups
among Hispanics despite significant differences, for example,
children of Mexican decent have been found to be at a greater
risk for obesity and its negative health consequences (Domin-
guez et al., 2015; Kornides, Kitsantas, Yang, & Villarruel,
2011; Wojcicki, Schwartz, Jiménez-Cruz, Bacardi-Gascon, &
Heyman, 2012). Parents have been acknowledged as the main
influence in children’s development (Skouteris, McCabe,
Swinburn, & Hill, 2010), and studies have found a positive
relationship between parental perceptions and practices (feed-
ing styles, role modeling) and children’s eating habits and
weight status (Aguirre, 2010; Pesch, Harrell, Kaciroti, Rosen-
blum, & Lumeng, 2011; Skouteris et al., 2010). Thus, examin-
ing Mexican American parental perceptions and beliefs with
regard to childhood obesity causes, consequences, and preven-
tive strategies is a necessary step (Skouteris et al., 2010).
In a review of the literature from 2000 to 2009, Sosa (2012)
described the state of the science regarding Mexican American
mothers’ knowledge and perceptions of childhood obesity, as
well as maternal knowledge, perceptions and role in childhood
obesity prevention. A main finding was that Mexican American
parents did not fully understand short-term consequences of
childhood obesity and did not consider excess weight as a
health concern to address in the moment. Additionally, parental
ability to engage in childhood obesity preventive behaviors was
affected by issues related to social determinants of health, such
as no safe outdoor play area for activity. Furthermore, of the 22
articles in the systematic review, only 7 specifically included
Mexican Americans as a subgroup in their sample. Information
regarding Mexican American parental perspectives of child-
hood obesity is lacking. Therefore, there is a need to further
explore the literature in this area.
Purpose
The purpose of this integrative review is to examine the current
literature from 2009 to 2018 on Mexican American parents’
perceptions of childhood obesity, knowledge of causes and
consequences of childhood obesity, and beliefs about the par-
ental role in childhood obesity prevention in order to provide an
update of the systematic review of Sosa (2012).
Method
Design
The literature was reviewed using the five-stage method for
performing integrative reviews proposed by Whittemore and
Knafl (2005), which includes the following: (1) the problem
identification: clearly delineating the problem, study purpose,
and variables of interest; (2) the literature search: ideally
encompassing all relevant literature addressing the topic and/
or identified problem; (3) the data evaluation: assessing the
quality of the primary source of the review (4) the data analy-
sis: consisting of categorizing the primary sources; and (5) the
presentation stage: consisting of a synthesis of the evidence,
limitations and implications for nursing practice.
Literature Search
The CINAHL, PubMed, PsycINFO, and ERIC databases were
used to search the literature using combinations of key terms
based on consultation with a health science librarian. Search
terms included the following: Mexican American(s), Chican(os),
parent, mother, father, parental perceptions, parental views,
health knowledge, overweight, and obesity. These terms were
further assessed through the controlled vocabulary features of
each database to compose the most relevant syntax formula. Arti-
cles were reviewed for inclusion based on the following criteria:
(1) peer-reviewed articles published in English between 2009
and 2018; (2) study sample included at least 95% Mexican Amer-
ican parents; (3) discussed parental perceptions of childhood
obesity and its prevention; (4) discussed parental knowledge of
childhood obesity including causes and consequences; (6) dis-
cussed parental involvement in childhood obesity preventive
behaviors and/or perceived barriers to engage in such behaviors.
For the purpose of this review, childhood obesity prevention
behaviors include balancing food intake (portion control, qual-
ity of food, increase of fruits and vegetables consumption)
decreasing sugary drinks, maintaining an active lifestyle,
including decreased screen time (TV, computers; CDC,
2017). Additionally, children’s weight categories are defined
by the CDC (2016) and Ogden and Flegal (2010); as such, a
body mass index (BMI) between the 85th and 94th percentile
on the BMI-for-age growth chart corresponds to the overweight
weight category. BMI values at or above the 95th percentile are
classified as obese. Also “Mexican-Americans” are defined as
individuals of Mexican descent residing in the United States
regardless of their place of birth and/or generation status.
Articles were first screened against inclusion criteria by
looking at title contents. An article whose title seemed to match
inclusion criteria was further assessed by reviewing the
abstract. Full text review was also performed to confirm elig-
ibility. In addition to the database searches, ancestry search was
used as a secondary search strategy. Reference lists of selected
articles from the primary search were reviewed for relevance to
inclusion criteria. A total of 707 articles were identified. After
duplicates were removed, 607 abstracts were screened, and 539
were excluded based on the eligibility criteria, leaving 68 arti-
cles for full text review. An additional 55 articles did not meet
the criteria for inclusion after full text review. Thirteen articles
were included in the final analysis (see Figure 1). Table 1 dis-
plays the details of the reviewed articles including authors, date
of publication, study design, purpose, sample characteristics,
methodology, major findings, and methodology quality rating.
Data Evaluation
The final articles included in the review were evaluated with a
Methodological Quality Score (MQS) as used in previous
reviews (Buhi & Goodson, 2007; Chen & Goodson, 2007;
Confiac et al. 3

Records identified Records identified Records identified Records identified Additional records
through CINAHL through PubMed through PsycINFO through Eric identified through
Database Database Database database other sources
(n = 318) (n = 131) (n = 99) (n = 28) (n = 131)

Articles remaining after duplicates removed

(n = 607)

Articles screened Articles excluded

(n = 607) (n = 539)

Full-text articles excluded

Full-text articles assessed
(n = 55)
for eligibility
(n = 68) - Studies published prior to
2009;
- Study sample did not;
specify Mexican Americans
Qualitative studies included subgroup or sample size
in the review included less than 95%
(n = 5) Mexican Americans;
- Article did not discuss
parental knowledge and
perceptions of childhood
Quantitative studies included
in the review obesity and obesity
(n = 7) prevention including
perceived barriers/obstacles
to implementing childhood
obesity preventive behaviors

Mixed Studies - Article discussed parental

included in the review perceptions/beliefs about
(n = 1) adults only or children older
than 18 years of age

Figure 1. PRISMA diagram for literature search.

Sosa, 2012). Criteria assessed study design, instrument(s) used,
validity and reliability of instrument(s), sample size, sample
characteristics, use of theoretical framework and data analysis.
Scores range from 0 to 20. Studies with higher scores are con-
sidered to have a better methodological quality (Chen & Good-
son, 2007). Table 2 displays the MQS criteria.
The MQSs ranged from 8 to 14. All seven quantitative stud-
ies were methodologically strong using validated tools. Five
studies had large sample sizes ranging from 309 to 609 subjects
(Kersey, Lipton, Quinn, & Lantos, 2010; Pasch et al., 2016;
Rosas et al., 2010; Sadeghi et al., 2017; Su et al., 2014). Only
two studies used theoretical frameworks (Bayles, 2010; Kersey
et al., 2010). In spite of their relatively low scores (8 to 9), all 5
qualitative studies were methodologically sound, using valid
qualitative methods and theoretical approaches (Gallagher,
2010; Guendelman, Fernald, Neufeld, & Fuentes-Afflick,
2010; Guerrero, Slusser, Barreto, Rosales, & Kuo, 2011; Small,
Melnyk, Anderson-Gifford, & Hampl, 2009; Zhang, Hurtado,
Flores, Alba-Meraz, & Reicks, 2018). Finally, the mixed
method study was methodologically sound but did not include
a theoretical framework (Guendelman et al., 2010). See Table 1
for each study’s score.
Data Analysis and Synthesis
To ensure all aspects of the integrative review’s purpose were
addressed, analysis and synthesis of the data followed the
 Table 1. Characteristics of Included Studies.
4
Authors/year Study type Study purpose
Bayles (2010) Cross-sectional  Determine whether a cultural
descriptive consensus regarding what is
study considered a healthy and/or
obese child exist among
Mexican American mothers.
 Examine if a relationship exists
between mothers’ perception of
their child weight category
(visual accuracy) and mothers’
own weight category,
satisfaction of current body
image, and household food
category.
Davis et al. Qualitative study To develop a better understanding
(2015) of Mexican-born mothers’ core
values, attitudes, and beliefs that
may be associated with childhood
obesity risk behaviors.
Sample
 61 Mexican American mothers
(22 to 62 years of age) of male
children under the age of 18 in
Texas-Mexico border (Rio
Grande Valley).
 36 Mexican American male
children between the age of 6
and 7, unrelated to participant
mothers.
 80.3%of the participants were
born in Mexico and 19.7% were
born in the United States.
 39 low-income Mexican-origin
mothers of 3- to 4-year-old
children, WICparticipants with
a high consumption of juices and
sugar-sweetened beverages
(SSB)
 All participants were born in
Mexico
Method
 Anthropometric measurements
(height, weight, BMI) for
participant mothers and children
 Pictures of the 36 children
 Demographics, food insecurity
and self-assessment of own
weight category surveys
 Use of pile sorting (Q-sort task)
using photographs of
participating children
 Assistance of a research
associate promotora (as trained
lay health worker) for
recruitment, survey clarity,
and comprehension
 Two face-to-face interviews
 Descriptive data and
demographics collected via
surveys
 12-item acculturation rating
scale for Mexican Americans II
 2 items child TV viewing
 Semi-scripted interview guide
Major findings MQS
 51% of participants’ ideal healthy 12
child and ideal body size felt in
the overweight or obese BMI
category as defined by the CDC
growth charts with half of the
truly overweight children were
misperceived as normal weight
or underweight.
 Mothers with greater BMI
tended to be more accurate in
their classification compared
with nonobese mothers who
misclassified the overweight
children in the underweight pile
twice as much.
 Significant intracultural
variations were found in
mothers’ perceptions.
 Mothers felt responsible for 8
their child’s health but did not
mention health or nutrition
when talking about hopes for
their children.
 Mothers perceived American
food as unhealthy and were not
interested in teaching it to their
children.
 Mothers viewed TV as a valuable
tool to teach English to younger
children.
 Mothers voiced that hearing
their children labeled as
overweight or obese made
them feel like bad mothers; it led
to sadness, anguish, anxiety,
hurt, despair, and guilt.
 Mothers considered cultural
transmission (who they are:
Mexican traditions, language,
food, and values, beliefs) as a
determining factor in their
child’s well-being and
biculturality as a leading factor
to become successful and a
good person.
(continued)
 Table 1. (continued)
Authors/year Study type Study purpose
Gallagher Qualitative Describe the Mexican American
(2009) naturalistic mothers’ point of views about the
study lifestyle habits of food/nutrition,
physical activity, and televisions
that may lead to preschool
children obesity.
Guendelman Mixed methods 1. Evaluate maternal perceptions
et al. study of children current and ideal
(2010) body size
2. Explore what being overweight
in infancy and childhood means
3. Examine early childhood
obesity contributing factors in
Mexican born mothers of 4- to
6-year-old children
5
Sample
 9 Mexican American mothers, Ethnographic interviews (3 sets)
WIC participants
 At least one child between the
age of 2 and 5
 All study participants were born
in Mexico
 84 low-income Mexican
mothers of 4- to 6-year-old
children in Mexico (MX, Jalisco,
and Guanajuato) and California
(CA, San Francisco Bay Area
and Salina Valley)
 Sample was recruited from WIC
participants in CA and
Oportunidades (similar to WIC;  MacArthur Network on
it provides money and food
supplements to low-income
young children, pregnant, and
lactating women).
 Sample included mothers in
both urban and rural area of
Mexico and CA.
 All study participants including obese
those living in CA were born in
Mexico
Method
 Observational experiences
 Spradley’s developmental
research sequence for data
collection and data analysis
 Acculturation Rating Scales for
Mexican Americans II (ARSMA-
II)
 8 focus groups conducted in
Spanish, in schools, clinics, and
community centers; child care
was offered.
 Self-administered questionnaires
about demographics (age,
educational attainment) and
children’s information
Socioconomic Status and Health  Mothers living in MX favored a
Scale of Subjective Social Status.
 Modified Stunkard Body Rating
Scale adapted for children
A visual scale of seven male and  Overconsumption of unhealthy
female silhouettes representing body
images that range from very thin to
Major findings MQS
Mothers stated the following: 9
 Preschool children must eat
balanced meals that will prevent
diseases.
 The word diet relates to
restriction of food consumption
that is inappropriate for children
growth.
 Discipline (eating at regular
times) is necessary to develop
good eating habits.
 Junk food has to do with foods
that are not natural or fresh.
 Physical activity depends on
child’s age and development
stage and could be play, dance
and sports; it is important for
both body and mind.
 TV is used as a means to learn
English and prepare children for
school; it enhances children’s
intellectual development.
Perception of body size: 13
 No differences in maternal
perceptions of children’s actual
body size were found by
country of residence: A
preference for bigger babies was
expressed with the cultural
belief that “babies outgrow their
fat.”
significantly larger ideal body
size than mothers living in CA.
Causes of overweight:
foods, genetic factors, toxic
stress, and maternal separation
induced sadness, lack of physical
activity, and excessive TV and
video games hours.
 Mothers in both CA and Mexico
saw a tendency to eat bigger
portions and dining out more
often in the United States.
(continued)
6
Table 1. (continued)
Authors/year Study type Study purpose
Guerero Qualitative study Explore and learn about Latino
et al. (grounded parents’ perspectives on the
(2011) theory) management of the health and
weight of their children
(perception of child weight status,
beliefs regarding causes of
overweight, perceptions of
physicians’ role and weight
measurements)
Kersey et al. Quantitative Assess parental knowledge,
(2010) cross-sectional attitudes, and beliefs of Mexican
study mothers of preschoolers
regarding childhood obesity
Sample
 24 low-income mothers of
Mexican descent with children 2
to 5 years of age
 Birthplace was not reported.
 Families were recruited from a
free clinic of West Los Angeles,
CA.
 369 Mexican immigrant parents
of 2- to 5-year-old children (90% Instruments developed based on four
mothers and 10% fathers)
 Interviewed in an outpatient
clinic waiting room and
surveyed in a community health
center of Chicago
 Participants birthplace included
Mexico (91%), the United States
Method
 Demographic questionnaire
 Mothers’ classification of their
child’s weight category as
underweight, normal weight, or
overweight
 Anthropometric measurements
(height, weight, BMI) for
participant mothers
 Children BMI weight category
was identified at their physical.
4 focus groups using the same open-
ended questions guide
Participants were grouped based on
child weight categories: mothers with
overweight and obese (85 percentile
and above) children together and
mothers with children at a healthy
weight (5 to 85 percentile) separate.
 Interviews and surveys
theoretical models and adapted from
previous tools
 Anthropometric measurements
for children
 Anthropometric measurements
for parents but were incomplete
so not considered for analysis
Major findings MQS
Ways to control children’s weight:
From both samples:
 Mexican tradition of fresh
meals, and walk to places
 Monitoring traditional use of
lard particularly prepared by
grandparents
 No differences observed 9
between answers from mothers
of overweight/obese children
and normal weight children
Mothers answers included the
following:
 A healthy child is active and
playful.
 An overweight child has
decreased physical abilities.
 Providers’ assessment is
important to inform parents
about their child being out of
the normal range.
 Causes of overweight/obese in
young children include high-fat
diets and dining out of the
home, lack of exercise, and poor
role modeling.
 Parents identified children’s
food intake (amount and type)
regulation at home as an obesity
intervention or preventive
measure; however, it is often a
cause of tension and argument
among family members. This
theme was brought up by
participants in all four focus
groups.
 Parents had a good 12
understanding of childhood
obesity health risks and
consequences and their
perceptions of ideal body size
was of a child within normal BMI
range when using a line drawing
of children.
(continued)
 Table 1. (continued)

Authors/year Study type Study purpose Sample Method Major findings MQS

(7%), South America (2%),  However, parents

Central American (1%), and underestimated their own child
Puerto Rico (0.5%). weight, did not identify,
recognize and/or relate these
obesity health risks for their
own child.
 A majority of parents shared
that the main reason to take
their children to a fast food is to
use the playground equipment
or get the toy offered with the
meal.
McLeod et al. Quantitative To clarify the role of cultural factors  86 Mexican born caregiver-child  Instruments included the  Only 51.5% of parents with 12
(2018) study such as acculturation in parental pairs (children 6 to 10 years of following: questionnaires overweight/obese children
Cross- underestimation of child weight age; children’s birthplace not addressing parental perceptions accurately estimated their child
sectional study status specified) of child weight, ARSMA-II, weight category (oblivobesity)
Examine the of immigrant specific  96.5% mothers, 3.5% fathers and Hispanic Stress Inventory (HSI); compared with 94.9% of the
factors such as stress and coping one aunt and Responses to Stress parents of children with normal
affect parental perception of  Families were low income Questionnaire (RSQ) range BMI.
children’s weight category  Children’s BMI  Children from second
generation immigrant were
significantly heavier than
children from first generation,
which might be related to
acculturation.
 Parents who experienced
difficulty in coping with stress
were found to be more accurate
in estimating their child weight
compared with parent with
higher level of coping skills.
Pasch et al. Quantitative To determine if parents who prefer a  312 mothers, 312 children (8 to  Preferred child body size  Of the 50% of overweight and 14
(2016) cross-sectional heavier child underestimate their 10 years of age) and 173 fathers measured with set of pictures obese children of the sample,
study child’s weight more than those of Mexican descent.  Anthropometric measurements only 11% of moms and 10% of
who prefers a thinner child  Most parent participants were and BMI of all participants fathers identified them as being
born in Mexico; 22% of mothers  Questionnaires to assess overweight.
and 19% of fathers were born in parents’ perceptions of child’s  Parents who preferred heavier
the United States; 95% of weight child size underestimated their
children were born in the child’s weight to a greater
United States. extent than parents preferring a
thinner body size.
Rosas et al. Quantitative Examine mothers’ perceptions of  314 Mexican mothers in Mexico  Anthropometric measurements 11
(2010) comparative children weight in Mexico and  60 immigrant mothers in for mothers and children
study California compared with child California  Collins’ Scale of seven figures for
actual weight and mother’s ideal  100% of the participants were mothers’ perceptions
weight born in Mexico

7
(continued)
8
Table 1. (continued)

Authors/year Study type Study purpose Sample Method Major findings MQS

Children 5 years of age  Children from CA were twice

as much likely to be at risk for
overweight and six times more
likely to be overweight than
children in MX.
 Mother underestimated their
child’s weight more in CA than
in Mexico.
 Californian mothers wanted
their child to be smaller and
Mexican mothers wanted theirs
to be bigger.
Sadeghi et al. Quantitative Identify BMI patterns within a  609 children 3 to 8 years of age  Anthropometric measurements  45% of children and 82% of 14
(2017) cross-sectional population of Mexican origin  466 mothers (86% were born in of children and mothers to mothers were in the
study children and their families. Mexico) determine BMI overweigh.t or obese weight
longitudinal Determine patterns’ context by  Interviews of mothers by category
examining parental perceptions of bilingual staff to determine  92% of the overweight and 53%
children weight status. maternal perception of child of the obese children were
weight perceived as children with
 Administration of ARSMA-II for normal weight by their mother.
acculturation  Elevated BMIs in mothers is a
predictor of child obesity.
Small et al. Qualitative Examine the beliefs of Mexican 11 Mexican mothers of preschoolers  Focus groups  Overweight and obese children 8
(2009) exploratory mothers regarding weight and born in Mexico  Purnell theoretical model used were described as children with
study health for cultural competence to poor physical and mental health
examine the concepts of health  Excess weight in children is
and overweight from the unhealthy
perspective of Mexican parents  Parents were concerned about
of preschool children how they would be informed
about their child’s weight being
out of range
Su et al. Quantitative Evaluate perception of child body  309 Mexican American parents Use of Texas Risk Assessment for  96.9% of the children were 14
(2013) correlational weight and health in Mexican and their children with AN. Type 2 Diabetes in Children obese, and 6.5% were
Americans parents of children  91.6% were mothers and 8.4% (TRAT2 DC). It is a legislatively overweight.
with AN. were fathers. mandated program developed,  63% of parent were obese and
(AN is a cutaneous mark that has  67% of the parents were born in coordinated, and administrated by 29.2% were overweight.
been identified as a risk factor for Mexico and the rest in the The University of Texas Pan-  Parental misconception of
diabetes type II.) United States. American Border Health Office child’s health.
Children’s birthplace were not spec- (BHO).  Significant differences between
ified. The program assesses in 1st, 3rd, mothers and fathers’
Children’s age not restricted but the 5th, and 7th graders children who perceptions of children health
average was 10.5 years. may be at high risk of developing and body weight.
Type 2 diabetes in selected Texas
Education Agency Regional
Education Service Centers.
(continued)
 Table 1. (continued)

Authors/year Study type Study purpose Sample Method Major findings MQS

Certified individuals assess these  Fathers reported that their

children for the AN marker. children were healthier than
Additionally, BMI and blood they were.
pressure are measured for  Fathers were less likely than
children who present a positive mothers to be concerned by
AN marker. their child body weight health.
Zhang et al. Qualitative study Examine Latino fathers’ perspectives 26 Mexican American fathers of 4 Focus groups audio recorded, Mexican Americans fathers: 8
(2018)  Community- and parenting experiences early adolescents aged 10 to 14 conducted in Spanish by male  Viewed poor diet as a cause of
based regarding early adolescents’ years moderators (Participants only impaired health for their entire
participatory eating, physical activity, and 25 fathers were born in Mexico; attended one) family
research screen-time behaviors children’s birthplace were not Bilingual, bicultural, and expert  Viewed good (healthy) nutrition
approach stated research team as a protection from illness and
 Grounded were able to describe such
theory nutrition
approach  Concerned about screen time
affecting their children’s vision
and decreasing physical activity
time.
Food and activity preventive parent-
ing practices included the following:
 Setting expectations and limits
 Role modeling (by doing physical
activities together with the
children)
 Managing food availability in the
home and monitoring food
intake
Barriers to healthy lifestyles included
the following:
 Conflicts and disagreement
between spouses
 Perceived gender roles
(expectation of women as
primary caregivers in
childrearing and food parenting
practices)
 Busy schedules leading to
unhealthy food choices and
decreased physical activity
 The physical and economic
environment referred to as
challenging
Fathers were likely to adopt healthy
lifestyles for themselves if it could
help their children to remain healthy

9
Note. MQS ¼ methodological quality score.
10 Hispanic Health Care International XX(X)

Table 2. Methodological Quality Score Criteria. the researcher to highlight the main components of the studies
and articles were examined for research methodology type. For
Scoring
Methodological characteristics options
example, all qualitative studies were examined together. This
process facilitated visualization of patterns and associations
Study design across studies, which provided a starting place for interpreta-
Correlation/cross-section 1 point tion of the data. Related findings were highlighted and clus-
Retrospective design 2 points tered together to uncover similarities. The clusters were then
Prospective design 3 points
organized by topic and arranged in categories. Similar cate-
Theoretical framework for quantitative studies
Study had no theory 0 point gories were summarized and synthesized to determine patterns
Study was based on an implicit theory 1 point in the data, which lead to the identification of three major
Study was based on a specific theory 2 points themes.
Theoretical framework for qualitative studies
Study neither built a theory nor linked its findings to 0 point
a specific theory Results
Study linked its findings to a specific theory 1 point
The study developed a theory 2 points Three main themes emerged from the data analysis: (1) paren-
Sample Size tal misperception of child body weight and size, (2) influence
Small sample (<100) 1 point of cultural health and growth beliefs on parental perception of
Medium sample (>100 and <300) 2 points child weight, (3) parental knowledge and perspectives of
Large sample (>300) 3 points causes and consequences of childhood obesity and how to
Age
address it.
Not reported 0 points
Reported 1 point
Birthplace Parental Misperception of Child Body Weight and Size
Not reported 0 points
Reported 1 point A common theme among studies (8 out of 12) was parental
Participants description underestimation of child weight and size (Bayles, 2010; Guen-
Parental perception and knowledge of mother only 1 point delman et al., 2010; Kersey et al., 2010; McLeod, Bates, Heard,
or father only Bohnert, & Santiago, 2018; Pasch et al., 2016; Rosas et al.,
Parental perception and knowledge of both parents 2 points 2010; Sadeghi et al., 2017; Su et al., 2014). Studies used terms
Measurement instrument(s)
such as parental underestimation, parental misperceptions, and
Authors developed the instrument (s) to measure 1 point
parental perception and/or knowledge parental “oblivobesity” (McLeod et al., 2018). The term
Authors adopted a previously established 2 points “oblivobesity” (Katz, 2015) refers to a difficulty in identifying
instrument (s) to measure parental perception excess weight in their child due to a change in what is per-
and/or knowledge ceived as the norm for healthy weight, based on the national
Data validity testing average weight and physical appearance of a child. Fathers
Not reported 0 points were found to underestimate their child’s weight to a greater
Reported 1 point
extent (Kersey et al., 2010; Pasch et al., 2016; Su et al., 2014).
Data reliability testing
Not reported 0 points The level of misperception was substantial for all eight studies
Reported 1 point in which at least 50% of participants underestimated their
Data analysis child’s weight, including binational studies (Guendelman
Qualitative analyses (thematic analysis) 1 point et al., 2010; Rosas et al., 2010).
Univariate statistics/descriptive 1 point Bayles (2010) introduced a possible explanation for the mis-
Qualitative (content analysis) 2 points perception of children’s weight. From participants’ perspec-
Bivariate statistics/ANOVA 2 points
tives, the term “sobrepeso” (overweight) corresponded to
Logistic regression/ANCOVA 3 points
Multivariate statistics (structural equation 4 points children in the 98th percentile for BMI on CDC growth chart;
modeling) the term “peso normal” (normal weight) was at the 84th per-
Total 20 possible centile; and “bajo de peso” (underweight) related to the 52th
points percentile. The current CDC BMI-for-Age growth charts cate-
gorized children in the 85 to 94 BMI percentile range as over-
Note. ANOVA ¼ analysis of variance; ANCOVA ¼ analysis of covariance.
weight while children falling at and above the 95th percentile
are considered obese. Children are not identified as under-
process of Miles and Huberman (1994) to reduce, display, weight until they are below the 5th BMI percentile. Other
compare, and drawn conclusions about the data. The study possible associations with parental underestimation include
purpose, sample characteristics, research methodology, and elevated maternal BMI, acculturation, parental preferred and
summary of the major findings of each article were closely ideal body size, and food insecurity (Bayles, 2010; Kersey
reviewed and systematically compared across studies using a et al., 2010; McLeod et al., 2018; Pasch et al., 2016; Rosas
tabular data display method (Table 1); table headings allowing et al., 2010; Sadeghi et al., 2017).
Confiac et al.
Significant intracultural differences existed between parents
in term of perceptions that could not be linked to actual anthro-
pometric results. Bayles (2010) explored intracultural consen-
sus among Mexican American mothers who were asked to
select photographs that best represented the healthiest children
with the most appropriate body size for their age; mothers
chose photographs of children with a BMI percentile ranging
from the 17th to the 98th percentile. Similarly, Su et al. (2014)
noted discrepancies between mothers’ and fathers’ perceptions
of their child’s weight; hence, variations in parental percep-
tions exist within the Mexican American cultural group.
Influence of Cultural Health and Growth Beliefs on
Parental Perception of Child Weight
One of the main findings regarding Mexican Americans’
beliefs and cultural perspectives of children’s health and
growth, was that Mexican American parents did not associate
children’s weight status with overall health. A healthy child
was described as an active and happy child who plays well,
eats well, is loved and does not have any limitations in his/her
ability to function in activities of daily living (Guendelman
et al., 2010; Guerrero et al., 2011; Small et al., 2009). Over-
weight was not viewed a health issue, and parents referred to
heavier babies as healthy; younger children were believed to
“outgrow their fat” (Guendelman et al., 2010). On the other
hand, parents perceived thin children as unhealthy and
expressed more concerns about skinnier children than over-
weight or obese children (Davis, Cole, Reyes, McKenney-
Shubert, & Peterson, 2015; Guendelman et al., 2010; Small
et al., 2009; Su et al., 2014). Some parents associated excess
weight with deficient physical and mental health. This state
would occur with poor self-care, which would subsequently
lead to poor-self-esteem (Small et al., 2009).
With respect to nutrition, parents perceived healthy foods as
a way to prevent diseases (Gallagher, 2010; Guendelman et al.,
2010). One interesting finding was the importance of the mean-
ing of words: diet (“dieta”) for Mexican Americans relates to
restriction of food intake, considered inappropriate for chil-
dren’s growth (Gallagher, 2010). American foods were per-
ceived as unhealthy because they were not natural or fresh
(Davis et al., 2015; Gallagher, 2010; Guendelman et al.,
2010). Discipline—eating at regular times—was described as
a necessity to develop good eating habits. Physical activity
considered essential to prevent disease, control weight and help
children grow. Parents indicated that physical activity should
be based on children’s age and development and could be as
simple as play and dance (Gallagher, 2010; Guendelman et al.,
2010; Zhang et al., 2018).
Mothers also expressed feelings of sadness, anguish, anxi-
ety, hurt, despair and guilt when health care professionals iden-
tified their child as overweight or obese. They indicated feeling
responsible for their child’s health and felt judged to be “bad
mothers” (Davis et al., 2015; Small et al., 2009).
11
Parental Knowledge and Perspectives of Causes and
Consequences of Obesity and How to Address It
The studies examined indicated that Mexican American par-
ents are somewhat knowledgeable about the causes and conse-
quences of obesity and have some strategies in place to address
it. A large scale binational study (N ¼ 369) found that most
participants could state at least one health consequence asso-
ciated with obesity whether their child was overweight/obese
or not (Kersey et al., 2010). Parents identified practices around
food intake as associated with excess weight. They viewed
eating “too much food” and/or eating the “wrong foods” and
dining out as potential causes of overweight (Gallagher, 2010;
Guendelman et al., 2010; Guerrero et al., 2011; Zhang et al.,
2018). Studies revealed that parents were managing excess
weight issues by controlling the quantity and the quality of the
food served, such as monitoring lard used in traditional dishes
(Davis et al., 2015; Guendelman et al., 2010; Zhang et al.,
2018). Fathers specified that setting up diet and physical activ-
ity expectations could be a good strategy as well (Zhang et al.,
2018). However, children’s resistance to decreasing the amount
of food and/or modifying the type of food served was described
as an obstacle. Furthermore, mothers indicated that these con-
trolling practices were often a source of tension and arguments
among family members. Grandparents, particularly, were in
favor of maintaining cultural food traditions strictly (Davis
et al., 2015; Guendelman et al., 2010; Guerrero et al., 2011).
Additional causes of obesity included poor role modeling,
poor self-care, and genetic predisposition. Study participants
felt strongly about a mother’s responsibility for her child’s
health including serving as a role model and feeding her chil-
dren appropriate foods (Davis et al., 2015; Guendelman et al.,
2010; Guerrero et al., 2011; Small et al., 2009). Last, parents
indicated that, unless a medical provider brought it to their
attention, they would not know how and where to obtain infor-
mation regarding children with health issues associated with
unhealthy weight (Small et al., 2009; Su et al., 2014).
Discussion
The purpose of this review was to examine the current literature
on Mexican American parental knowledge and perceptions of
childhood obesity. Studies assessed in this review confirmed
some of the previous findings from the literature and revealed
new knowledge specific to Mexican Americans. First, misper-
ceptions of children’s weight as underestimation of the actual
weight was a common finding. However, differences among
parental perceptions of child weight were revealed, and no
significant commonalities were found among studies in terms
of rationale for misperceptions. Parents’ perspectives of a
child’s ideal body size was found to be considerably different
from current medical expectations, and acculturation—the pro-
cess of social, psychological, and cultural changes occurring in
immigrants adapting to a new culture—might play a determin-
ing role (Berry, 2003). In fact, research has demonstrated that
acculturation was associated with a change in ideal body size
12
for Mexican Americans of later generations, who had an ideal
body size and weight that was smaller than first generations
from Mexico (McLeod et al., 2018; Rosas et al., 2010). Con-
versely, acculturation also lead to a change in food habits with
families eating larger portions and less fruits and vegetables
than in Mexico (Guendelman et al., 2010). Although this is not
completely new information, the binational studies brought to
light that maternal perceptions of children’s body size did not
vary by country of residence. While mothers living in Califor-
nia had a smaller ideal body size than mothers living in Mexico,
all had a preference for larger babies (Guendelman et al., 2010;
Rosas et al., 2010).
Only five studies included fathers in their samples, of which
one (Zhang et al., 2018) addressed the cultural meaning of
paternal roles in the Mexican American culture. The role and
place of fathers needs to be further assessed and discussed to
evaluate how they can support mothers in implementing a
healthy lifestyle for the entire family. This is one of the main
differences with Sosa’s review (2012), which highlighted tra-
ditional gender role differences in Mexican American parents,
with the mother being the main caregiver. The assumption,
based on Bandura’s social cognitive theory including self-
efficacy, was that mothers who perceive childhood obesity as
a health issue would be most likely to engage into preventive
behaviors (Bandura, 2004). Similarly, the extended family,
particularly the impact of grandparents, and the possible cul-
tural pressure they exert, should be further examined.
One novel aspect highlighted in this review was the fact that
parental misperception of child’s weight might not be specific
to Mexican Americans. Societal factors, such as the current
national norms for children’s weight might play a decisive role
in parental perceptions as outlined by the concept of oblivobe-
sity by Katz (2015). Few qualitative studies (n ¼ 5) addressed
Mexican American perceptions of childhood obesity and how
to prevent it from a cultural perspective. This indicates a need
for subsequent qualitative research to gain a deeper understand-
ing of Mexican Americans’ cultural perspectives on this theme
of misperception.
In regard to the cultural perspective, the review did uncover
a major Mexican American cultural difference—the fact that
health did not relate to weight, and excess weight was generally
not considered a health problem. The studies portrayed a hol-
istic Mexican American concept of health. Body and mind
were equally important. Good health was part of one’s success.
Nevertheless, parents were genuinely concerned about their
child’s health.
Contrary to Sosa (2012), this review showed that parents did
understand the causes and consequences of obesity although
they might not always grasp the immediate impact. There was a
disconnect between parents’ knowledge and the way they con-
nected this information with their own children. Parents fre-
quently did not associate this health problem with their children
or thought it did not apply to their children. Yet, studies also
showed that parents felt responsible for their child’s health and
considered the good health of their children a part of their
parental success. These notions require health care
Hispanic Health Care International XX(X)
professionals’ attention. Particularly, mothers’ perception of
being considered “bad mothers” when health care professionals
discuss their children’s overweight status must be taken into
consideration during appointments. Also, Gallagher (2010)
highlighted the importance of terminology and how it can
affect parental motivation and understanding about counselling
for weight management. Mexican American parents did not
follow recommendations for a healthier diet if it meant food
restrictions (“dieta”), considered inappropriate for children.
Additional studies are needed to examine these issues within
the context of the Mexican American culture.
Implications for Nursing Practice and Research
Public health nurses (PHNs) attend to underserved populations,
via home visits, group teaching, outreach, and partnering with
multi-disciplinary agencies. The findings of this review can
assist PHNs in providing culturally congruent care to Mexican
American families and gaining a deeper understanding of fam-
ilies’ obstacles and commitments to healthy lifestyles. With
childhood obesity being a public health focus, PHNs have an
opportunity to develop, implement and lead culturally tailored
obesity prevention interventions. Raising awareness among
providers and community partners about Mexican Americans’
cultural health beliefs and perspectives about childhood obesity
is crucial in tackling this epidemic.
Limitations
Although these findings expanded current knowledge about
Mexican Americans perspectives on children’s health, several
limitations to this review were noted.
The findings cannot be generalized to all Mexican Ameri-
cans as intracultural variations were found among parents
(Bayles, 2010; Su et al., 2014). Also, the number of qualitative
studies was low at 5 out of 13 when, traditionally, qualitative
methods are preferred to capture insights into a phenomenon
(Creswell & Creswell, 2014). Finally, the MQS used by (Sosa,
2012) to assess study quality and utilized here for consistency,
shows a bias toward quantitative studies because the methodo-
logical characteristics evaluated relate more to quantitative
studies than qualitative ones. Similarly, there are no specific
criteria for evaluating mixed methods studies.
Conclusion
This integrative review examined the current state of the sci-
ence about Mexican American parental knowledge and percep-
tions of childhood obesity. A previously recognized finding,
parental underestimation of children’s weight and a preference
for larger size as the ideal was confirmed. However, cultural
variations in parental perceptions existed. These results suggest
that many aspects of the Mexican American culture regarding
children’s health as it relates to body weight have not been fully
examined. Particularly, the roles of different family members
in the Mexican American childrearing tradition and the impact
Confiac et al.
of their associated health beliefs remain largely unknown.
Studies using qualitative approaches are needed to provide
deeper insights to these concepts. Societal factors and accul-
turation should be considered when designing obesity preven-
tion interventions, and caution should be used when attempting
to generalize Mexican Americans’ cultural practices. These
findings represent only a small part of Mexican American per-
spectives on childhood obesity. The identified themes provide
avenues that further expand scientific knowledge on how to
tailor obesity prevention and reduction strategies for Mexican
American children based on parental perspectives and cultural
beliefs.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Nathalie Confiac, MSN, RN, PHN https://orcid.org/0000-0001-
6583-0396
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