RESEARCH

Qualitative Research

Making Tortillas without Lard: Latino Parents’Perspectives on Healthy Eating, PhysicalActivity, and Weight-Management Strategies forOverweight Latino Children

GLENN FLORES, MD; JULIO MALDONADO; PAOLA DURÁN

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ABSTRACTLatinos are among the most overweight racial/ethnicgroups of US children. The study aim was to identifyparents’ perspectives on healthy eating, physical activity,and weight-management strategies for overweight Latinochildren. Four focus groups were conducted of Mexicanimmigrant, Mexican-American, Puerto Rican, and otherLatino families with overweight children. Parents wereasked 33 questions and sampled four healthy substitutesfor traditional Latino foods, including multigrain enchi-ladas and brown rice. Nineteen parents were interviewedin the focus groups. The children=s median body massindex was 23; 60% had a body mass index �95th percen-tile. Parents identified 22 themes regarding the mostimportant things parents can do to help overweight chil-dren lose weight, including encouragement, not makingthe child feel left out, the whole family eating healthy,and the parent setting a good example. Parents identified17 themes regarding the most important things over-weight children can do to help themselves lose weight,including eating healthier, limiting portion size and sec-ond helpings, drinking more water, increased physicalactivity, decreased screen time, children educating them-selves at school, asking parents for help, and participat-ing in interventions that include the whole family. Chal-lenges to getting kids to exercise included expense, timeconstraints, and neighborhood safety. Parents were opento integrating healthy substitutes into traditional Latinomeals/snacks, and found them palatable. One mother

G. Flores is professor and director, Division of General Pe-diatrics, Department of Pediatrics, UT Southwestern Med-ical Center, and Children’s Medical Center, Dallas, TX.J. Maldonado is chief principal executive, Maldonado Con-sulting & Associates, Milwaukee, WI. P. Durán is researchassistant, Department of Pediatrics, Medical College ofWisconsin, Milwaukee.

Address correspondence to: Glenn Flores, MD, Divi-sion of General Pediatrics, Department of Pediatrics, UTSouthwestern Medical Center, 5323 Harry Hines Blvd,Dallas, TX 75390. E-mail: glenn.flores@utsouthwestern.edu

Manuscript accepted: July 27, 2011.Copyright © 2012 by the Academy of Nutrition and

Dietetics.2212-2672/$36.00

fdoi: 10.1016/j.jada.2011.08.041

© 2012 by the Academy of Nutrition and Dietetics

tated, “We have to keep our traditional foods, but realizehat we can make them more nutritious.” Parents re-orted their children would accept high-fiber foods andow-fat dairy. In designing effective weight-managementnterventions for overweight Latino children, the studyndings may prove useful in identifying healthy, well-ccepted foods and beverages; agreeable physical activi-ies; suitable targets for reducing inactivity; and effica-ious strategies for enhancing traditional foods and mealso that there is an increased likelihood of healthy diet andeight loss. Parental input on the most important things

hat children and parents can do to help children loseeight and on challenges faced in trying to get children to

xercise might provide valuable guidance in devising ef-ective, evidence-based interventions that are likely to bedhered to.Acad Nutr Diet. 2012;112:81-89.

Latinos continue to be among the most overweight andobese racial/ethnic groups of children in the UnitedStates. Nationally representative data on 102,353

hildren from the National Survey of Children’s Healthocument that 47% of Latino children are overweight/bese and 31% are obese, vs 35% and 21%, respectively,or white children, and Latino children have 1.4 times thedjusted odds of white children of overweight/obesity (1).ational Health and Nutrition Evaluation Survey data

rom 1999-2008 reveal no substantial change over time inhe high prevalence of overweight/obesity among Latinohildren or in disparities between Latino and white chil-ren (2). In addition, an extremely high prevalence ofuture risk factors for type 2 diabetes was reported amongoor Mexican children in one study, including 60% ofhildren with first- and second-degree relatives with dia-etes, and 38% with unacceptable fitness scores, highbesity prevalence, and diets high in fat and low in veg-table and fruit intake (3). Recent data indicate thatatino sixth graders have a considerably higher preva-

ence of type 2 diabetes risk factors than their white andfrican-American counterparts (4).Not enough is known, however, about what Latino par-

nts consider to be healthy eating, physical activity, andeight-management strategies for overweight and obese

hildren. A recent exhaustive systematic review of inter-entions for treating obesity concluded that a largelynanswered question is, what interventions are most ef-

ective for specific ethnicities or culturally diverse popu-

Journal of the ACADEMY OF NUTRITION AND DIETETICS 81

Mexican subgroups

Eight-grain enchiladas with vegetables and low-fat cheese (above)Frijoles (with no lard) with vegetables Brown rice and beans

Puerto Rican subgroup

Skinless chicken breast with traditional seasoning (above) Baked plantains with wheat germ crust (above) Brown rice with beans (habichuelas)

Other Latinos subgroup

Baked fish with herbs Skinless chicken breast with vegetables Brown rice with black beans (above)

Figure 1. Menu of samples tasted by focus-group participants of healthy substitutions for traditional Latino meal items prepared by a professional Latino chef.

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lations (5)? The study aims, therefore, were to identifyLatino parents’ perspectives on healthy eating, physicalactivity, and weight-management strategies for over-weight and obese Latino children, and examine thepalatability and acceptability of, and obtain constructivefeedback on, healthy, inexpensive substitutions for tradi-tional Latino foods, with an ultimate goal of providinguseful data for developing effective, evidence-based inter-ventions for children, parents, and families that are likelyto be adhered to.

METHODSStudy DesignThis qualitative study consisted of focus groups. Focus-group methodology was chosen because it is consideredone of the most useful mechanisms for in-depth explora-tion of people’s knowledge, experiences, attitudes, andmotivations (6).

Study SampleThe study sample consisted of parents of overweight La-tino children residing in Milwaukee, WI. Parents wererecruited from public schools in Latino neighborhoods.Eligibility criteria included parental identification of thechild as being of Latino ethnicity; a school-aged child (6 to18 years old) in the household with a body mass index(calculated as kg/m2) �85th percentile for the child’s age/ex; and no current or past enrollment in a formal diet/ctivity study or counseling program. Body mass indexas calculated using height and weight measurements

aken during home visits or at the child’s school healthlinic.

ocus Groupsour focus groups were held. Ten parents were inviteder focus group, with three to eight parents participatingn the focus groups. Focus groups were stratified by La-ino subgroup ethnicity and immigration status (for Mex-

Table. Selected sociodemographic features of Latino families andtheir overweight children who participated in focus groups on healthyeating, physical activity, and weight-management strategiesa

Characteristic Median or %

Parental age (y), median (range) 35 (26-61)Child age (y), median (range) 9 (6-17)Parent high-school graduate (%) 79Parent married and living with spouse (%) 84Annual combined family income �$25,000 (%) 42More than one child in household (%) 37Parent undocumented immigrant (%) 26Overweight children (BMIb�85% to 94%) (%) 40Obese children (BMI�94%) (%) 60

aNo significant differences observed among four Latino subgroups (Mexican Ameri-cans, Mexican-American immigrants, Puerto Ricans, and other Latinos) for any char-acteristic.bBMI�body mass index; calculated as kg/m2.

can children). Focus groups thus consisted of Mexican- t

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mericans (defined as both parents born in the Unitedtates), Mexican-American immigrants (both parentsorn in Mexico), Puerto Rican, and other Latino (Centralnd South American and Caribbean subgroups otherhan Puerto Rican).

Each family received a $50 honorarium, free transpor-ation, on-site daycare, and dinner. Focus groups wereonducted by two trained bilingual research personnel innglish or Spanish (according to parental preference).As an integral part of each focus group, parents began

ocus groups by sampling and providing feedback on aeal consisting of healthy, low-cost substitutions for tra-

itional Latino meal items. Each food item was tailored tohe specific Latino subgroup and prepared by a profes-ional Latino chef (Figure 1). Parents were asked to ratehe meals using a scale of 1 to 10, with 1 and 10 repre-enting anchor scores, so that 1 was the worst possiblecore and 10 the best possible score.Focus-group moderators asked parents 33 questions

nd 88 probes addressing the following domains: 1) theost important things parents and children can do to

elp overweight/obese children lose weight; 2) the help-ulness of exercise in children losing weight and barrierso exercise; 3) healthy and unhealthy diet and snacktems for children; 4) high-fiber and low-fat dairy itemsids would eat regularly; 5) the parent’s willingness tohange traditional Latino diet items to emphasize health-er foods and to substitute for unhealthy foods; and 6) thearent’s and children’s palatability assessments of sam-les of healthy traditional Latino menu items served athe start of the focus group. Questions and probes wereeveloped based on a review of the literature on childhoodverweight, and issues raised by children and familiesuring the first author’s 22 years of experience in provid-ng pediatric care to overweight Latino children and ad-lescents. Consistent with customary focus-group meth-ds (7,8), participant discussions for specific questionsnd probes were continued until both thematic saturationthe point at which no new themes are noted in the datand the full range of observations is achieved) and accu-acy (collecting data that are considered sufficient to ful-ll as full a range of observations of the phenomenon asossible) were achieved, regardless of the size of the in-ividual focus group.

nstitutional Review Board Approval and Informed Consenthe Medical College of Wisconsin Institutional Reviewoard approved the study protocol, and all participantsrovided written informed consent.

nalysisach focus group was audiotaped using professional au-io equipment and two microphones (to ensure no com-ents were missed). Verbatim transcripts were then pre-

ared by trained bilingual research personnel. To ensureranscription accuracy, the audiotape for each sessionas compared to the draft transcript, and any transcrip-

ion errors or deletions were corrected.Transcript-based analyses (9-11) were performed, with

ighlighting and margin coding of themes. To validate

he thematic coding, each reviewer analyzed transcripts

nuary 2012 ● Journal of the ACADEMY OF NUTRITION AND DIETETICS 83

Figure 2. Taxonomy of attitudes, beliefs, and practices of parents of overweight Latino children regarding healthy eating, physical activity, and

weight-management strategies.

84 January 2012 Volume 112 Number 1

Figure 2. (continued)

January 2012 ● Journal of the ACADEMY OF NUTRITION AND DIETETICS 85

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independently, and resolved any differences by consen-sus. Themes common to all four focus groups were iden-tified and recorded by three observers. As the customaryprimary aim of focus-group methodology is qualitativetheme identification, it is not considered appropriate toreport frequencies or percentages of specific themes oritem responses (6); thus, theme and response frequenciesand percentages are not reported here. Thematic analy-ses were performed using grounded theory, in which newtheory is generated from the data and appropriate exist-ing theory is modified or refined through comparison withincoming information (9-11). Finally, a taxonomy ofthemes was created to categorize comments that wereconsistent across all focus groups, highlight any inter-group differences, and address three principal study do-mains: healthy eating, physical activity, and weight-man-agement strategies.

RESULTSSample sizes for the four focus groups were: Mexican-American, n�4; Mexican-American immigrant, n�8;Puerto Rican, n�3; and other Latino, n�4. Thematicsaturation occurred in all four groups. The median agewas 35 years for parents and 9 years for children (Table).Most parents were high-school graduates (consistentwith national data on educational attainment in US La-tino parents [1]) and married and living with the spouse.Almost half of households had an annual combined in-come of �$25,000, more than one third had more thanone child, and about one fourth of parents were undocu-mented immigrants. More than one third of children wereoverweight, and almost two thirds were obese.

A variety of healthy-eating, physical-activity, andweight-management themes were identified. Figure 2presents the taxonomy of these themes categorized into15 domains, and Figure 3 presents selected illustrativeuotes. No major intergroup differences were observed inhe themes or taxonomy. Parents identified 22 themesegarding the most important things parents can do toelp overweight children lose weight (Figure 2). These

ncluded encouragement, not making the child feel leftut, the whole family eating healthy, and the parentetting a good example for the child (Figure 3). One par-nt stated, “encouragement from parents, and don’t makehem feel left out. Everyone should eat healthy, not justhe overweight child.” Parents identified 17 themes re-arding the most important things overweight childrenan do to help themselves lose weight (Figures 2 and 3).hese included eating healthier, limiting portion size andecond helpings, drinking more water, increased physicalctivity, decreased screen time, children educating them-elves at school, asking parents for help, and participat-ng in interventions that include the whole family.

Parents identified 11 kinds of exercise viewed as bestor helping overweight children lose weight (Figure 2).wo salient themes were anything that involved thehole body, and activities that the children like. Parents

eported 22 challenges in trying to get overweight chil-ren to exercise (Figures 2 and 3). Several themes cen-ered on lack of time and excessive expense. Additionaloci were programs that were not easily accessible, fam-ly-centered, or designed for teens, and lack of informa-

ion about programs and weekend activities. Winter/cold,

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onflicts with work and homework, unsafe neighbor-oods, and motivating parents also were cited.Parents identified five ways that inactivity contributes

o overweight in children (Figures 2 and 3). Televisionwas cited as a negative influence not only in terms ofexcessive viewing, but also because of exposure to com-mercials about food and snacking while viewing. For ex-ample, one parent remarked, “I think it’s also too manycommercials with food on them. And sometimes they arenot even hungry, but they are watching TV and then theywant something. Even if you tell them, ‘You just atedinner, you know.’ TV is just a big influence, as far aswanting to eat more.” Video games and not exercisingbecause of cold winters were also mentioned as sources ofinactivity contributing to childhood overweight.

Parents identified 19 themes regarding foods that over-weight children should eat to help them lose weight (Fig-ures 2 and 3). These included four general strategies:consuming more healthy foods and snacks, consumingnothing in excess, avoiding carbohydrates, and bakingrather than frying foods. Parents also cited several cate-gories of foods, including vegetables, fruits, high-fiberfoods, dairy, chicken breast, and nuts. The remainingthemes all engendered foods to be limited, including tor-tillas, bread, rice, cold cuts, and hot dogs. Beveragesidentified by parents as those overweight children shoulddrink included water, diluted juice, low-fat milk, andlow-calorie drink mixes (Figures 2 and 3). Parents alsostated that less soda and juice should be consumed.

Parents mentioned eight broad categories of foods thatmake children gain weight, ie, eating in excess, food andsnacks late at night, fatty foods, saturated fats, itemscontaining sugar, desserts, fried foods, and dairy prod-ucts (Figures 2 and 3). Parents also identified 16 specificfoods that make children gain weight, which can be clas-sified as low-nutrient-density carbohydrates, sweets,fatty meats, and lard. One parent commented, “Unfortu-nately, my son likes rice with tortillas. If there are notortillas, then he wants chips. In other words, it is carbo-hydrates with carbohydrates.” Five beverages identifiedby parents as making children overweight (Figure 2)were three sugary beverages, milk, and juice.

Parents identified 22 snacks that help overweight chil-dren lose weight. Four broad categories were unpro-cessed/natural foods, cereals without sugar, desserts/cakes with little added sugar, and seafood (Figure 2). Theremaining 18 specific items included vegetables, fruit,yogurt, baked chips, certain desserts, nuts, and tradi-tional snacks with added fruit. Parents stated that it wascrucial to make healthy snacks convenient and accessiblefor children (Figure 3). Parents cited 19 snacks that makechildren gain weight (Figure 2), including the three broadcategories of large quantities of anything, too much fat,and salty foods. The remaining 16 specific items includedchips, meat, sweets, peanut butter, tacos, pasta, pizza,and cheese.

The eight high-fiber foods that parents said that theirchildren would eat regularly included cereals, beans, flaxseed, and whole-wheat bread (Figure 2). Parents citedfive low-fat dairy products that their child would like andeat regularly (Figure 2), including low-fat yogurt, cheese,and milk; and cottage cheese (uncooked or cooked).

Multiple themes confirmed a willingness of parents to

Figure 3. Focus-group quotes on selected key issues by parents of overweight and obese Latino children.

January 2012 ● Journal of the ACADEMY OF NUTRITION AND DIETETICS 87

change their child’s and family’s diet to have healthier,traditional Latino foods (Figures 2 and 3). Parents citedthe dangers of continuing to be overweight, a desire tochange, the importance of a family-centered approach,and the necessity of maintaining traditional foods whilemaking them more nutritious. One parent said, “Yes,because it is really dangerous to continue with thisweight, and if we don’t change, kids won’t either.” Somereported that it was difficult to change the diet, and thatthe family always returns to bad habits (Figures 2 and 3).Others identified key agents for change, including sup-port from other parents, and the need for education,guides, relevant statistics, and programs.

Parents stated a willingness to substitute healthy forunhealthy food and drinks and to prepare traditionalmeals differently to help their child lose weight (Figures2 and 3). Specific substitutions identified included whole-wheat instead of flour tortillas, brown instead of whiterice, tortillas made with oil instead of lard, reductions inmeat consumption, increasing vegetables and fruits inmeals, and consuming water and low-calorie drink mixesinstead of sugary beverages.

Parents had overwhelmingly positive responses to sam-pling healthy substitutions for traditional Latino mealitems prepared by a professional Latino chef (Figure 1).The Mexican-American and Mexican immigrant sub-groups gave a mean score of 9.3 (including two perfect10s) for the meal consisting of eight-grain enchiladas(using prepackaged, store-bought multigrain tortillas)with vegetables and low-fat cheese, frijoles (without lard)and vegetables, and brown rice and beans. In response tosampling the enchiladas, one parent stated, “they aredelicious.”

The Puerto Rican subgroup gave a mean score of 8.8 tothe meal consisting of skinless chicken breast with tradi-tional seasoning, baked plantains with wheat-germ crust,and brown rice with beans (Figure 1). One parent re-marked, “It tastes good. It tastes like traditional PuertoRican rice and beans.” Another parent, however, stated,“I just like my rice a little bit more suelto” (which trans-lates as moist or loose in English). One of the parents alsonoted that she would have preferred plantains (tostones)instead of sweet bananas (plátanos).

The Other Latino subgroup gave a mean score of 9.3(including two perfect 10s) to the meal consisting of bakedfish with herbs, skinless chicken breast with vegetables,and brown rice with black beans (Figure 1). In response tothe tasting, one parent said, “It’s delicious.”

Parents in all groups stated that they would use therecipes at home, would not modify them, and believedthat their family would enjoy them.

DISCUSSIONThis is the first focus-group study, to our knowledge, tointerview a diverse spectrum of Latino parents to identifyperspectives on healthy eating, physical activity, andweight-management strategies for overweight Latinochildren, including having the parents sample and eval-uate healthy substitutions for traditional Latino mealitems. One particularly salient finding was that the par-ents of overweight Latino children have a fairly extensiveknowledge of healthy and unhealthy nutritional and

physical activity habits. For example, parents identified

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reduced portion sizes; increased consumption of vegeta-bles, fruit, and fiber; drinking more water; and reducedconsumption of fried foods, soda, candy, and “junk food”as effective nutritional weight-loss strategies, consistentwith published recommendations (5,12). Vigorous physi-cal activity was cited as helpful in weight managementfor overweight children, and the contribution to over-weight of such inactive pursuits as excessive televisionviewing and partaking in video games was well recog-nized, also consistent with the published literature (5,12).

Study parents provided unique insights on effectiveweight-management strategies for overweight Latinochildren. Parents underscored that, for an intervention orprogram to be effective, it was crucial for the whole familyto participate. In particular, the whole family eatinghealthy and exercising together were seen as critical tosuccess, and the lack of exercise programs for the entirefamily was seen as a major challenge. Parental motiva-tion, guidance, and assistance were also cited as essentialcomponents of successful childhood weight management.Key specific parent-based strategies identified in the-matic analysis of the focus groups included having bothparents agree about and participate in the plan, teachingchildren to consume vegetables when they are young,controlling and monitoring children’s food and beverageintake, not forcing children to finish everything on theplate, having fathers collaborate by taking kids to dophysical activities, and having parents set a good exam-ple.

A particularly noteworthy study finding was parents’willingness to change their children’s diet to includehealthier traditional Latino foods, including a desire tomake food-item substitutions. Such traditional dietaryalterations as changing from flour to whole-wheat or mul-tigrain tortillas, preparing tortillas with oil instead oflard, consuming brown instead of white rice (although thelonger cook time for brown rice may be a limiting factorfor many), increasing the vegetable content of dishes, andbaking instead of frying were not only viewed with en-thusiasm, but also judged to be flavorful when tried inactual food samples. Parents expressed a wish to main-tain traditional foods and meals, but to make them morenutritious. To accomplish this, however, several expressedthe desire for more education and practical information, andsupport from other parents. The samples of healthy ver-sions of traditional food items were met with enthusiasm,interest, and generally high ratings. Healthy modificationsof traditional foods, therefore, might be a powerful tool foreducation, motivation, and weight management not only forLatino parents of overweight children, but also for parentsof overweight children from diverse races/ethnicities andcultures who desire strategies that integrate the spectrumof traditional dietary preferences and cuisines from aroundthe world.

Certain study limitations should be noted. This quali-tative study was conducted in one urban Midwest loca-tion, so the findings may not necessarily generalize toLatinos in nonurban settings and other US regions. Al-though the focus groups included a diverse cross-sectionof the major Latino subgroups, sample sizes were insuf-ficient to hold focus groups of certain subgroups that maycomprise a large proportion of the Latino population in

particular US regions, such as Cuban Americans and

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Dominican Americans. It is possible that a biased samplemight have resulted from offering a $50 honorarium,child care, and free food, in combination with the Latinonormative cultural value of showing courtesy through apositive response to an invitation.

A major strength of this community-based study wasthe focus on what Latino parents identify as the mostimportant components of healthy eating, physical activ-ity, and weight-management strategies for overweightLatino children. The study findings have the potential tolead to dietary, exercise, and weight-management strat-egies that are highly acceptable, adhered to, and effec-tive, precisely because the data originate from the par-ents of overweight children. For example, the studyresults indicate that the most effective interventions foroverweight Latino children might include a focus onwhole-family approaches to nutritional and physical ac-tivity change, whole-body physical activities that childrenenjoy, low-cost exercise programs that involve minimaltime investment, and healthy but flavorful modificationsof traditional Latino meal and beverage items. The re-sults also suggest that a “one-size-fits-all” approach toweight management for overweight children may not besuccessful for Latinos and other racially/ethnically di-verse populations, because such an approach might notaddress traditional dietary customs and preferences,more family-centered approaches to physical activity, orhealthy and acceptable substitutions for traditional mealitems.

CONCLUSIONS AND IMPLICATIONSThe study findings have several implications for practice,research, and policy. In designing effective weight-man-agement interventions for overweight Latino children,the study taxonomy may prove useful in identifyinghealthy, well-accepted foods and beverages; agreeablephysical activities; suitable targets for reducing inactiv-ity; and efficacious strategies for enhancing traditionalfoods and meals so that there is an increased likelihood ofhealthy diet and weight loss. Parental input on the mostimportant things that children and parents can do to helpchildren lose weight and on challenges faced in trying toget children to exercise might provide valuable guidancein devising effective, evidence-based interventions thatare likely to be adhered to. As an example of how thestudy results might be used and applied, our researchteam has developed a weight-management interventionfor overweight Latino children that consists of a cultur-ally appropriate, increase healthy-food-group diet; partic-ipation in regular, organized, vigorous physical activityprograms (eg, soccer, hip-hop dance, aerobics); and familylifestyle education sessions on healthy nutrition, increas-ing physical activity, reducing sedentary activity, andbehavioral changes that will be led by trained, bilingualLatina registered dietitians, and will include cookingdemonstrations by Latino chefs of healthy dishes consis-

tent with the culturally appropriate diet (13).

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The study findings suggest that soliciting parents’ in-ut on healthy eating, physical activity, and weight-man-gement strategies for overweight and obese children—oupled with families sampling healthy substitutions forraditional meal items—might be potentially valuable ineveloping successful, tailored strategies for managinghildhood overweight, not just for Latinos, but for otheracial/ethnic groups.

STATEMENT OF POTENTIAL CONFLICT OF INTEREST:No potential conflict of interest was reported by the au-thors.

FUNDING/SUPPORT: This work was funded in partby a grant from the Healthier Wisconsin PartnershipProgram.

ACKNOWLEDGEMENTS: Presented in part as plat-form presentations at the 2007 Annual Meetings of thePediatric Academic Societies on May 6, 2007, in Toronto,Canada; American Public Health Association on Novem-ber 5, 2007, in Washington, DC; and Salud America onSeptember 11, 2009, in San Antonio, TX.

We thank René Farías and Ricardo Díaz for their as-sistance in organizing the focus groups and hosting focus-group sessions at the United Community Center, ArturoNápoles for his culinary expertise and preparation of thefood samples, and Kate Carpenter for her helpful input.

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