OBJECTIVE: In an effort to develop more effective weight-loss interventions, this study examined the daily experiences and personal struggles of Mexican-American adolescent females with morbid obesity.
METHODS: Twenty self-identified, morbidly obese Mexican-American adolescent females and their families were interviewed about their food choices, personal and family barriers to weight loss, sources of support, previous weight-loss experience, and weight-related beliefs. Qualitative responses were coded by using framework analysis.
RESULTS: Four themes emerged from the adolescent and family responses: the impact of normal adolescent development, multiple sources of excess calories, the physical and emotional burden of excess weight for the adolescent, and the magnitude of the family’s personal struggle with weight management. Multiple subthemes were also identified.
CONCLUSIONS: Responses by the adolescents and their families highlighted the intersection of adolescence and Mexican-American culture and the daily challenges of obesity. Recommendations for providers include incorporating knowledge of adolescent development and culturally sensitive care into treatment recommendations.
What’s Known on This Subject:
Obesity is a growing concern for Mexican-American adolescents, with both behavioral and cultural variables that are related to the increasing trend.
What This Study Adds:
These results highlight a patient-centered view of the emotional and physical burden of obesity in female Mexican-American adolescents, the families’ personal struggles with weight-related conditions, and the challenge of balancing family needs with those specific to the adolescent.
Although rates of adolescent female obesity have stabilized in recent years, minority youth continue to be disproportionately affected. An estimated 14.5% of non-Hispanic white females aged 12 to 19 years are obese, compared with 17.4% of Mexican-American females.1 The medical consequences of childhood and adolescent obesity are well documented, with increased morbidity and mortality rates and impaired quality of life.2,3 Adolescents with obesity may also experience comorbid depressive symptoms, weight-based teasing by peers and family members, problematic eating patterns, and issues of negative self-evaluation and esteem.4–6
To date, research has heavily investigated the barriers to children and families making health-related changes: parent-child communication, access to care, affordable healthy food, safe locations for physical activity, and screen time.7 Often, these are quantitative, cross-sectional studies aiming to improve treatment adherence and support program development. Hesketh et al8 conducted a qualitative study in school-aged children and their families, noting the importance of health behavior theories, which include thoughts/perceptions of the patients in the context of their community. Themes identified in that study included the timing of interventions, patient/family-identified factors to healthy change, and contradictions in both implicit and explicit messages children receive. In addition, qualitative studies have considered adolescent views on the importance of health and optimum ways to intervene9 as well as adults’ perceptions of living with obesity.10 These qualitative studies add a depth to the understanding of adolescent obesity; however, they still lack both a focus on overweight adolescents’ thoughts and perceptions as well as a deeper understanding of the daily challenges an adolescent may face regardless of intervention. Understanding these deeper challenges may provide valuable insight into aspects of motivation for change to improve health.
Adolescents have unique developmental considerations that reduce the ability to copy interventions from adult and child populations.11,12 In addition, Mexican-American youth simultaneously navigate the cultures of Mexico and the United States, leading to intergenerational struggles of acculturation within families.13 Research has revealed the importance of generational status and acculturation of the adolescent and family on nutritional intake, quality of food choices, food preparation, obesity status, and food insecurity.14–17 However, to our knowledge, no published study has captured adolescents’ navigation through these unique cultural and developmental struggles in their own words.
Little is known about the daily challenges and experiences of obese Mexican-American adolescent females. This study describes their personal struggle with obesity across family, school, and peer environments and the challenges to adopting a healthy diet. A greater understanding of the world of obese Mexican-American adolescents enables health care providers to better tailor and therefore improve the effectiveness of current treatment approaches.
Twenty severely obese, self-identified Mexican-American adolescent females, aged 12 to 19 years, and their families were recruited from September 2007 through June 2008 to participate in a study of barriers and facilitators to adopting a modified low-glycemic diet. Potential participants were identified by clinic staff as they attended hospital-, community-, or school-based clinics in the greater Houston area. Adolescents were ≥150% of estimated ideal body weight (NHANES II), not due to endogenous (eg, hypothyroidism) or medically based (eg, corticosteroid use) etiologies, and self-reported motivation to lose weight by using a dietary approach. A mix of English- and Spanish-speaking only and bilingual families was purposely selected. A bilingual research assistant described the study to families who spoke only Spanish. Participant characteristics are reported in Table 1.
Strategies to enhance trustworthiness, believability, and credibility were incorporated throughout. Home-based interviews were scheduled at a time convenient to families, often during the evening. Three trained interviewers traveled to each home. Initially, all participating family members were interviewed together (1 interviewer took notes on the home environment and the interview process). Then, the family, mostly parents, and adolescent were interviewed in private. All adolescents were interviewed in English, whereas 8 families were interviewed in Spanish. The Baylor College of Medicine Institutional Review Board for Human Subjects approved all protocols. Informed, signed consent was obtained for adolescent and parent participants; parents provided signed consent for adolescents younger than 18 years.
Interview content was developed from empirical research, clinical experience, and consultation with Mexican-American researchers and adolescents to address barriers to weight loss and adopting a low-glycemic diet (Table 2 contains sample interview questions). Interviews began with general questions about who shops for food, foods typically consumed, including beverages and desserts, and food preparation. Additional questions asked about the frequency and types of meals eaten out of the home and what families knew about health concerns associated with being overweight. A low-glycemic diet was then described, and families were asked to identify aspects of the diet that would be easy or difficult to adopt. Adolescents and families were then separated. Family questions focused on aspects of the low-glycemic diet that would be easy or hard for the adolescent to adopt and what weight loss would mean for her and the family. Three-day food diaries that adolescents completed ahead of the home visit were reviewed during the adolescent interview, with the goals of verifying earlier responses and teaching how to consume lower-glycemic foods. Other adolescent interview questions included foods eaten on the way to and from school, what weight loss would mean to the adolescent and her family, the types of support she could expect from family members, and previous weight-loss attempts. Throughout the interviews, information provided by families was restated or summarized to ensure accuracy and to increase credibility. The portion of the interview with all family members present lasted ∼60 minutes, whereas the separate family and adolescent interviews lasted ∼30 minutes each. The family as a whole received $70 as compensation for their time. As a form of triangulation, the interview team met for 30 minutes after each home visit to process the experience and record observations of the family and home environment.
All interviews were digitally recorded with the participants’ permission. Interviews conducted in English were transcribed by a professional transcription service and reviewed and corrected by a research assistant. Interviews conducted in Spanish were transcribed, reviewed, and corrected by bilingual research assistants. Few errors were found.
Transcripts were reviewed by using framework analysis18 (Table 3), and an audit trail was maintained throughout. The coding team consisted of 6 professionals from psychology, adolescent medicine, public health, nutrition, and Latin American studies. Two coders were linguistically and culturally bilingual. To increase trustworthiness, coding was conducted independently and reviewed during group meetings. Discrepant codes were resolved via group consensus. Atlas.ti 5.2 software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) was used for help organize data during the coding process. Process notes recorded immediately after each interview were reviewed to help in the interpretation of text and validation of themes. Two of the interviewers who did not participate in the coding also reviewed the final themes.
Analyses of transcripts yielded 4 main themes, each with subthemes (Table 4). The themes were adolescent development, multiple sources of excess calories, physical and emotional health burden of excess weight for the adolescent, and the magnitude of the family’s personal struggle with overweight and weight management. Quotations that richly characterize each theme are contained in the Supplemental Information.
Theme 1: Adolescent Development
Interviews revealed aspects of adolescent development and its unique social, developmental, and environmental challenges, such as teasing/bullying, adolescent perceptions/expectations, and school/social experiences. Adolescents and families highlighted the interplay of navigating typical adolescent developmental issues (eg, establishing and maintaining peer support) and weight struggles.
First, many families identified weight-based teasing by peers as a persistent struggle, often tied to feelings of sadness and low self-confidence. Parents believed weight loss, even a small amount, would eliminate teasing and increase motivation and self-confidence. Younger adolescents reported that the quinceañera, a celebration symbolizing a girl’s transition to womanhood at her 15th birthday, was both a source of emotional stress and a major motivator to lose weight. There was high motivation for weight loss for their own quinceañera and for those of their friends.
Several thoughts and perceptions were identified that relate to adolescent response styles: concrete thinking, pickiness, extreme responses to healthier foods, and bravado (perceived overconfidence/simplification of weight-loss process). Adolescents fluctuated between abstract and concrete thinking, especially when asked how often they ate out. Different interpretations of “eating out” resulted in underestimating the number of meals or snacks consumed outside the home with peers. Self-described as being picky eaters, adolescents demonstrated extreme responses to certain healthy foods, such as skim milk and whole-wheat bread, which were frequently associated with such words as “hate” and “nasty.” Adolescents also oversimplified potential barriers to making healthy choices. Most thought changing current eating habits would not be difficult despite having previously responded negatively to diet alternatives. Several voiced an attitude of perseverance (“Once I start, I don’t quit”), which starkly contrasted with previous failed weight-loss attempts.
Also, school-day schedules contributed to meal skipping for many adolescents. The morning rush to get to school on time and the lack of easily accessible healthy school lunch options contributed to skipped meals.
Theme 2: Multiple Sources of Excess Calories
Families varied in their knowledge of good nutrition: some lacked an understanding of healthy meals and how food choices affect weight and health, whereas other families had knowledge of nutrition but struggled with its application. Previous weight-loss attempts and lifestyle changes were reported by all adolescents; maintaining these efforts was reportedly challenging. Families fluctuated between intake of high-calorie foods and adoption of sustainable healthy eating habits. Parents’ inconsistent implementation of lifestyle changes relayed mixed messages to the adolescent as to what was expected and was at times contradictory to previous medical advice.
Similar to many Mexican households, mothers or grandmothers were the primary cooks. Commonly eaten foods, such as taquitos, enchiladas, and gorditas, were fried. Mothers did not understand the general impact of fat calories from cooking oils. Families also reported an abundant intake of liquid calories (“sweet tea” and “Coke”) as discussed during the interview and as answered on the 3-day food diaries/recall.
The consumption of fast foods exemplified the influences of the US culture. Easy access and previously noted schedule challenges made them appealing options. Some families ate out multiple times a week, and, when socializing with friends, the adolescents usually ate at fast-food restaurants and mall food courts.
School breakfasts and lunches were considered by the adolescents and their parents to be high in calories. Sample foods included cinnamon rolls, chocolate milk, pizza, hamburgers, and French fries. High-calorie foods were not limited to meals but also were present in classroom activities, in school vending machines, and at special occasions.
Theme 3: Physical and Emotional Health Burden of Excess Weight for the Adolescent
Adolescents listed common obesity-related medical conditions and affected family members. They connected their family’s medical conditions to problems that they themselves were experiencing or could develop. This knowledge allowed them to understand the importance of losing weight and provided insight into the emotional burden of obesity.
Excess weight placed limitations on movement, physical activities, and exercise. The inability to fit into “normal” or stylish clothing was cited as a physical limitation and was a major source of reported emotional stress. Mothers commented on these sources of stress as frequently as the study participants.
Losing weight represented the opportunity to have a new life, because it would lift the associated physical and emotional burdens of being obese. Phrases such as “reborn,” “born again,” “happy,” “light,” “it means kind of life,” “I’d be thrilled,” “it will change my life,” and “I would live a new life” were used to describe the anticipated impact of weight loss. Parents expressed a similarly intense emotional relief when asked what it would mean for their daughters to lose weight.
Theme 4: The Family’s Personal Struggle With Overweight and Weight Management
All families were aware of weight-related medical problems: diabetes, acanthosis nigricans, hypertension, high cholesterol, cardiovascular disease, and cancer, among others. In our study, 85% of families had these conditions (especially diabetes), and numerous family members were instructed to make health changes.
Adolescents identified their family’s active participation in a diet, with all members adhering to the diet, as the preferred method of support. Families preferred to provide support by reminding her not to eat “bad” foods even if they were available in the home, “drag[ging] her to exercise,” and talking about her health needs.
Tensions reportedly arose when changes were made to balance the adolescent’s needs with those of other family members. Many mothers reported feeling pressured to please all members of the household with the foods she bought and prepared. Older siblings and extended family often brought tempting foods into the home. Families expected participants to exhibit a high degree of self-control, both in and out of the home. Therefore, changes in the food environment were often limited to diet soda, 2%-fat milk, and the elimination of chips. Not all families were successful at adopting and maintaining these healthy eating habits. Mothers expressed guilty feelings surrounding the daughter’s weight and failed attempts at weight loss.
This study describes the daily experiences and personal struggles of obese Mexican-American female adolescents. Characteristics of adolescent development were evident across themes. For example, response styles of abstract versus concrete thinking as well as extreme responses to food changes are congruent with the process of adolescent thought development. In addition, these thought patterns were associated with minimizing perceived barriers to weight management. Adolescents often provided insightful responses suggesting strong motivation but struggled to move from thought to action. Adolescence also gradually shifts influence from family-only to an increased balance of peer and family support. This process was noted throughout the interviews both in the food-centered social activities of peers and the perceived impact of weight-based teasing. These normal maturation processes may impede awareness and self-observation of food intake and exercise.
Research on food acculturation suggests that Mexican-Americans consume greater amounts of calorie-dense foods such as dessert, salty snacks, pizza, and French fries than their Mexican-born counterparts.14,17,19,20 Intergenerational dynamics between parents and adolescents also influence family eating practices.21 Evans et al22 reported that Spanish-speaking mothers are more likely to have traditional Mexican food available in the home. Similarly, in this study, foods prepared in the home were typical Mexican dishes. However, many families also ate out multiple times a week, highlighting the influence of the larger American culture. Thus, the process of acculturation can place an adolescent at risk of obesity due to the variety of calorie-dense and fast food consumed compared with diets consumed by grandparents.14
Although family support of dietary and physical activity changes has been identified as an important predictor of successful weight loss among young overweight children, a growing body of research indicates that family emphasis on dieting during adolescence, especially when associated with weight-based teasing, can lead to higher BMI, body dissatisfaction, unhealthy weight-control behaviors, and binge eating.23 Adolescents in our study preferred their family’s active participation in food changes as a display of support. Yet, in some families, there was a clear disconnect between the type of support desired by the adolescent and what the family could provide. Families may need guidance in how to manage multiple and sometimes competing needs of different family members to provide effective support for adopting healthy lifestyle behaviors. Future research should evaluate how to empower parents in making food changes that are supportive of the adolescent’s health needs.
Our results highlight the emotional and physical health burden of adolescent obesity and the families’ personal struggles with weight-related conditions. Previous studies have revealed a strong association between health-related quality of life and obesity, such that higher levels of obesity are associated with lower health-related quality of life.24 Without significant intervention, many of the adolescents in this study are at considerable risk of developing serious medical comorbidity and additional reduced quality of life as they progress into adulthood. Because many family members also struggle to maintain a healthy lifestyle and weight, the entire family may benefit from education on how food choices and the ability to maintain a healthy lifestyle impact the development of comorbidities.
Providers can use these findings to improve the effectiveness of their current treatments and interventions. First, incorporating knowledge of adolescent developmental stages into practice may improve specific treatment of weight management, as well as overall rapport with the adolescent and family. Inquiring about an adolescent’s personal motivation for improved health, as well as incidents of teasing and bullying, may highlight personal struggles and allow for more effective problem solving. Providers can assist families by going beyond providing education regarding related illnesses by asking how the adolescent feels best supported and by identifying areas for collaboration. Culturally, the 2 to 3 years before the quinceañera may provide an optimal time for weight-loss intervention because motivation is reportedly high. However, as this milestone approaches, a health care provider can redirect the conversation of motivation toward additional factors that will sustain behavioral change. Other suggestions include asking more culturally specific questions concerning food purchases, foods commonly eaten in and out of the home, and how food is prepared. It is at the intersection of culture, adolescence, and obesity that treatment success can occur.
Strengths and Limitations
The results of this study may not be generalizable beyond morbidly obese, Mexican-American adolescent females who are motivated to lose weight and seeking health care. Adolescents and their families may have responded in socially desirable ways; however, because the participants’ stories emerged from the interview process itself, it is unlikely that social desirability played a large role. Strengths of the study included its design aspects, such as inclusion of both English- and Spanish-speaking adolescents/families, and conducting interviews in homes and in private, to maximize participant comfort as well as for analytical considerations (eg, using coders from diverse disciplines, consensus among coders was achieved during face-to-face meetings).
Obese Mexican-American adolescent females are faced with the challenge of navigating both adolescent development and the larger Mexican and US cultures. These results highlight the emotional and physical burden of adolescent obesity, the families’ personal struggles with weight-related conditions, and the challenge of balancing family needs with those specific to the adolescent. Insights provided by the adolescents and families in this study may help improve the effectiveness of current treatment approaches if providers have an understanding of adolescent development, incorporate culturally sensitive care, and extend empathy and patience.25
We acknowledge Mrs Brittan Clark Sweetin for transcription and coding and the researchers from the parent study who were not involved in the coding and development of this particular study.
- Accepted February 25, 2013.
- Address correspondence to Sharonda Alston Taylor, MD, Department of Pediatrics, Section of Adolescent Medicine and Sports Medicine, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin St, Suite1710.00, Houston, TX 77030. E-mail:
Drs Taylor, Garland, Sanchez-Fournier, and Doak and Ms Allen contributed to analysis, interpretation, drafting, and revising the manuscript and provided final approval of the submitted manuscript; and Dr Wiemann conceptualized and designed the study, coordinated data collection, contributed to design, analysis, interpretation, drafting, and revising the manuscript, and provided final approval of the submitted manuscript.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the Women’s Fund for Health Education and Research (C.M.W.) and the Health Resources and Services Administration, Maternal and Child Health Bureau grant 171MC00011.
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- Copyright © 2013 by the American Academy of Pediatrics