Overweight, obesity, high blood pressure and lifestyle factors among Mexican children and their parents
Environ Health Prev Med
Overweight, obesity, high blood pressure and lifestyle factors among Mexican children and their parents
Arely Vergara-Castan˜ eda 0 1
Lilia Castillo-Mart´ınez 0 1
Eloisa Col´ın-Ram´ırez 0 1
Arturo Orea-Tejeda 0 1
0 A. Vergara-Castan ̃eda L. Castillo-Mart ́ınez E. Col ́ın-Ram ́ırez A. Orea-Tejeda Asociacio ́n Mexicana para la Prevencio ́n de Insuficiencia Cardiaca AC , Mexico City , Mexico
1 L. Castillo-Mart ́ınez (&) E. Col ́ın-Ram ́ırez A. Orea-Tejeda Heart Failure Clinic, Instituto Nacional de Ciencias Me ́dicas y Nutricio ́n ''Salvador Zubira ́n'' , Providencia 1218-A 402 Col. del Valle, CP 03100 Benito Jua ́rez, Mexico City , Mexico
Objective The objective of this study was to identify associations in the prevalence of overweight, obesity and high blood pressure between children and their parents, as well as their eating and physical patterns. Methods In this cross-sectional study, we obtained data on 83 pairs of school-aged children and one of their parents relating to dietary habits and various physical parameters, including the body mass index (BMI) and blood pressure of the children, which were adjusted by age and gender. Both the children and the parents were asked to complete a questionnaire aimed at providing measures of eating behavior. The questions focused on the consumption of fruit and vegetables and soda drinks as well as on physical activity patterns. Parent BMI was calculated from selfreported height and weight values. Results Obesity was diagnosed in 10.8% of the children, and the prevalence of overweight was 28.9%. There was a relationship between a child's weight status and that of his/ her parent according to the BMI; 45% of overweight/obese children had overweight/obese parents. In addition, a parent's fruit and vegetable consumption was associated with his/her child's fruit and vegetable consumption (r = 0.47, p \ 0.001), and both were associated with soda drink
Children; Eating and physical patterns; Obesity; Parental influence
consumption in both parents and children (r = 0.30,
p \ 0.001).
Conclusion Our results confirmed that there is a
relationship between the weight status, fruit and vegetable
consumption and soda drink intake of children and those of
Overweight and obesity affects 26% of Mexican school
children and the prevalence has continued to increase in
recent years [
]. Childhood overweight and obesity are
associated with a wide range of immediate health concerns,
such as the development of insulin resistance, type 2
diabetes mellitus [
] dyslipidemia, hypertension, and
with an increasing the risk of disease in adulthood [
The results of one study showed that after 6 years of age,
the probability of obesity in adulthood exceeded 50% for
obese children compared with about 10% for non-obese
While there are many factors related to this increasing
trend towards overweight and obesity, energy imbalance
linked with a shift in energy sources and total energy intake
and physical activity are the most important [
increased risk of childhood overweight has been associated
with the increased frequency of inactive leisure time
pursuits, such as watching television and using the computer
The increased consumption of sugar-sweetened
beverages is also associated with a higher energy intake, weight
gain, obesity and diabetes [
]. Current estimations are
that sugary drinks contribute 8–9% of the total energy
intake in both children and adults [
], with 4% coming
from the consumption of soda drinks [
]. In contrast, 2%
of the total energy intake in Mexican families come from
fruit and vegetable consumption. It has been reported that
10.6% of the family income is designated to buying
beverages whereas 16.4% is used to purchase for fruits,
vegetables, legumes and seeds [
Data from industrial sources indicates that Mexico is the
second largest consumer of soda drinks in the world [
and this consumption alone may be an important
contributory factor to the unprecedented increase in obesity [
In Mexico, the percentage of households consuming soda
drinks rose from 48 to 60% between 1989 and 2006. The
percentage of overall daily energy intake from
energycontaining beverages in Mexican adolescents and adults
(22.5%) was higher than that in a nationally representative
survey of the U.S. population (21%) [
The role of the home environment in the development
of childhood overweight and obesity has been recognized
for a long time, and parental obesity is believed to
increase the risk of adult obesity in children [
Some studies originating in Europe and North America
support the findings that the degree of tracking of weight
status from childhood to early and mid-adulthood is
related with parental weight status, suggesting that the
body mass index (BMI) of sons are significantly correlated
with those of both their mothers and fathers at every age
]. There have also been reports suggesting that the
risk of becoming obese in young adulthood is three- to
fivefold higher if either the mother or father is obese
compared with the parent not being obese [
6, 20, 23
However, other findings suggest that parental behaviors
shape many aspects of a child’s development; as such, a
parent’s diet history and eating habits would influence the
development of children’s eating behaviors and weight
Family, friends, school and media also influence
children’s eating behavior [
]. Healthier choices at one stage
in life are associated with healthier choices at a later stage
] because habits acquired in childhood are critical to
the acquisition of healthy habits  and prevention of
sedentary behavior [
]. However, there is as yet
comparatively little evidence that dietary habits persist into
adult life, principally because there have been very few
longitudinal studies. In particular, few investigations have
included hypertension in children and parent’s eating and
physical behavior in their study design [
To clarify the relationship between parental eating
patterns and those of children and also to consider
cardiovascular risk factors, we studied 83 pairs of children and
one of each child’s parents for associations in the
prevalence of overweight, obesity and high blood pressure. We
also analyzed the relationship between the parent’s
physical activity patterns and those of the child.
This cross-sectional descriptive study included 83 pairs of
children and one of their respective parents from a
convenience sample of children attending one of five public
schools in an area of low socioeconomic status in Mexico
City; the schools were located in five districts: Tlalpan,
Xochimilco, Coyoaca´n, Benito Juare´z and A´ lvaro
Obrego´n. To guarantee the homogeneity of the sample, we
recruited all children from public schools considered to be
marginalized, based on an index which groups nine
indicators of social exclusion, revealing the relative
disadvantages that faces a population as result of its geographic,
economic and social situation [
Participating schools were selected randomly by the
Secretar´ıa de Educacio´n Pu´blica in an approach ensuring
that the sample was proportionally selected for each area.
All fifth- and sixth-grade students enrolled in the five
elementary schools were invited to participate in the study,
and their parents were asked to attend a meeting in their
children’s school where they received information on the
study; the children of parents who provided written
informed consent were recruited.
The study is in accordance with the ethical standards of
the Ethics and Investigation in Humans Committee of the
Secretar´ıa de Salud del Gobierno del Distrito Federal, a
federal institution who approved the entire study to ensure
the protection of all the participants. Children were
included only if they and their parents signed a written and
informed consent form before all measurements were
made. In addition, parents were also asked to sign a
personal consent form when completing the questionnaires,
which is in accordance with the Helsinki Declaration.
Anthropometric, blood pressure (BP), physical activity and
dietary patterns evaluations were performed on all children.
All data were collected in the morning immediately after
the children arrived at school.
Anthropometric data on the children were collected by a
group of trained nutritionists during the first hours of
classes. Weight (SECA professional scale model 750; Seca
North America, Hanover, MD) and height (SECA model
280 portable stadiometer; Seca North America) were
measured in accordance to the reference manual of
anthropometric standardization [
]. All measurements
were taken with shoes and heavy outer clothing removed.
The BMI was calculated by dividing the total body weight
(kg) by the squared height (m2) and then making
adjustments for age and gender according to the National Health
and Nutrition Examination Survey (NHANES) I [
Obesity was defined as a BMI [95th percentile for age and
gender, and children were considered to be at risk of
obesity if the BMI [85th and \95th percentile, which is in
agreement with the international obesity task force (IOFT)
cut-off points [
]. The BMI of the children was
categorized into group: ‘‘underweight/normal’’ versus ‘‘at risk for
Blood pressure evaluations were performed in all
children according to the standardized technique described by
the American Heart Association (AHA) [
]: levels were
measured in the right arm, with the child in the seated
position, by auscultation and mercury sphygmomanometer
using the appropriate cuff size. The first Korotkoff sound
was used to determine the systolic BP (SBP) level, and the
fifth Korotkoff sound was used to determine the diastolic BP
(DBP). High blood pressure (HBP) was classified as SBP or
DBP C95th percentile for age, gender and height of children
without taking pre-hypertension into consideration.
Parents were assessed with a self-administered survey at
their children’s school under the guidance of a trained
research assistant. Completion of the questionnaire took
30 min and included questions on age, gender, parental
marital status and occupation. The parents were also asked
to report their actual weight and height. Previous studies in
adults have reported correlations between actual and
reported height and weights that typically range between
0.96 and 0.99 [
]. Parental BMI was categorized as
underweight (BMI \18.5), normal (BMI 18.5–24.9),
overweight (BMI [25) and obesity (BMI [30).
Another section of the parent’s questionnaire focused on
the presence of cardiovascular risk factors, such as
diabetes, hypercholesterolemia, stroke or any cardiovascular
disease, HBP or hypertension and the use of medications to
control these diseases.
Diet patterns were assessed with a questionnaire that
focused on the intake of fruit, vegetables and soda drinks
and was completed by both parents and children. For the
children, we used the Spanish version of The School
Physical Activity and Nutrition questionnaire (SPAN),
which had been tested previously for validity and reliability
in a Hispanic population [
]. For the parents, there was a
special section on their questionnaire that focused on the
same eating behaviors.
Both groups (children and parents) were assisted in
completing the questionnaire by a trained nutritionist who
also gave an explanatory lecture about the questionnaire
and verified that the participants understood the items. The
SPAN includes six questions, such as ‘‘Yesterday, did you
eat vegetables? Vegetables include all kinds, raw or
cooked, and salads. Don’t consider potatoes cooked or
fried’’. ‘‘Yesterday, did you eat fruit? Don’t consider fruit
juice’’; the response categories for such items included
1 = yes, 2 = no. For questions focusing on consumption
portions, such as ‘‘Yesterday, how many times did you eat
fruit? Don’t consider fruit juice’’, ‘‘Yesterday did you drink
any soda drink of sweetened beverages? (Not diet ones)’’,
the response categories for each item included 0 = no, I
didn’t drink any soda drinks, 1 = yes, I drank one soda
drink or sweetened beverage (not diet), 2 = yes, I drank
two soda drinks or sweetened beverages (not diet) and
3 = yes, I drank three or more soda drinks or sweetened
beverages (not diet). Parents were asked about their diet
patterns using eight questions, such as ‘‘How many glasses
of soda drink do you drink during a day?’’ (1 glass is equal
a 240 ml); response categories include 0 = any glass,
1 = 1 glass, 2 = 2 glasses, 3 = C3 glasses and 4 = Don’t
know or don’t remember.
Assessments of physical activity behavior included
recording the usual physical activity patterns of the
children by assessing light and moderate physical activity and
leisure activities, such as watching TV, using the computer
and playing videogames. Eight questions in the SPAN
included, ‘‘Yesterday, how many hours did you watch TV
or video games away from school?’’, ‘‘How many hours
per day do you usually spend on the computer away from
school?’’; response categories for each item included
1 = none, 2 = 1–3 h and 3 = [3 h. Information on
moderate to vigorous physical activity was obtained by
asking, ‘‘In the last week, how many days did you exercise
or participate in an activity that made your heart beat fast
and made you breathe hard, for at least for 20 min (for
example: basketball, jogging, skating, fast dancing,
swimming laps, tennis, fast bicycling, or aerobics)?’’; response
categories for each item included 1 = 1–3 days and
2 = more than 3 days.
Parental physical patterns were assessed using The
Rapid Assessment Physical Activity Scale (RAPA). This
scale involves nine yes/no items assessing the type and
amount of physical activity in which adults engage [
The major advantage of using the RAPA is that it is a quick
and easy scoring sheet, available in different languages,
which enables respondents to visualize differences between
All statistics were performed with commercially available
software (SPSS ver. 12.0 for Windows, 2003; SPSS,
Chicago, IL) Continuous variables are given as means ±
standard deviation (SD), and categorical variables are
presented as absolute and relative frequencies. Descriptive
statistics are presented by gender. Spearman’s correlation
coefficients were calculated to assess the association
between child weight and BP status variables and potential
parent-associated factors (parental BMI, presence of
cardiovascular risk factors, eating and physical patterns). To
identify the parental factors associated to obesity, children
were divided into overweight/obese and normal classes,
respectively. The Mann–Whitney test was used to compare
groups. The results were considered to be statistically
significant at p \ 0.05.
A total of 83 pairs of children and their parents were
included in the study; the mean age of the recruited
children was 9.4 ± 0.6 years old, and 54% were male. Table 1
presents the descriptive characteristics of the children. The
mean BMI of the children was 18.8 ± 3.2 kg/m2. Almost
11% (10.8%) were obese, with a mean BMI of 24.5 kg/m2;
of these obese children, 13.3% were boys. The proportion
of children in the total sample assessed as at risk of obesity
or as being overweight was 28.9%, with a mean BMI of
21.2 kg/m2; there were more males than females in this
group (31.3 vs. 26.3%, respectively). Mean SBP and DBP
were 110.53 ± 15.5 and 74.1 ± 15.8 mmHg, respectively.
The prevalence of systolic and diastolic HBP in this group
was elevated by 34.9 and 39.8%, respectively, and was
much higher in males than females (51.1 vs. 44.7%,
In total, 62.2% of the children considered to have
systolic hypertension belonged to the overweight/obese group
(p = 0.003); in comparison, of those children who
presented with diastolic hypertension, 54.5% were overweight
or obese (p = 0.02) (data not shown).
Of the parents recruited, 90% were females, most
respondants reported that they were married (79%) and the
most common occupation was working at home (43.9%)
(data not shown). The parent’s cardiovascular risk factors
are shown in Table 2. Based on the assessment of parental
weight status (self-reported), 43.2% were overweight and
19.3% were obese. In addition, 94% of the parents reported
not to have problems with their BP, while the prevalence
reported for diabetes mellitus, cholesterol or cardiovascular
disease was 9.2%.
The results of the evaluation to determine whether there
were relationships between the dietary habits of the children
and their weight and BP status were inconclusive in terms of
fruit and vegetable consumption. However, of those
children who reported that they did not consume soda drink
beverages, 71.1% were considered to fall in the normal
weight group (p = 0.51), and 44.7% presented systolic or
diastolic hypertension (p = 0.70). Among those children
who reported performing regular moderate physical
activities, only one out of four were considered to be overweight/
obese, and almost 42% presented HBP; however, these
results were not statically significant (p = 0.23).
In terms of eating patterns in Table 3, in general, the
children had a low consumption of fruit and vegetables:
Values are expressed as the mean ± SD, or as a percentage, where appropriate
F/V fruit and vegetables, HBP high blood pressure; classified according to height and gender percentiles
a Mann–Whitney U test
b Including systolic or diastolic HBP
c Showing trend for increased number of portions of fruit consumed by children and parents with a normal weight
1.0 ± 0.82 portions per day. Of the children who reported
not to consume any fruit or vegetables, 100% presented the
same behavior as their parents, who also did not consume
fruit or vegetables (p = 0.20) (data not shown). The
proportion of children who reported consuming fruit and
vegetables was higher in those children whose parents were
classified as have a normal weight status compared with
those who were overweight/obese (4.8 vs. 0%,
respectively; p = 0.2); The same trend was observed for the
number of portions of fruit and vegetables consumed per
day (1.23 vs. 0.85 portions per day, respectively;
p = 0.09). With respect to the consumption of soda drinks,
the mean number of glasses drunk by the parents and
children was 2.49 ± 1.13 and 0.70 ± 0.9 glasses/day,
respectively. The proportion of children and parents who
were accustomed to drinking these kinds of beverages was
10.2 and 71.7%, respectively.
In terms of physical activity patterns, most of the
children (91.8%) reported practicing some form of moderate
physical activity for an average length of time of 3.7 h/
week; in comparison, 89.8% of the children reported
spending 4.6 h/day watching TV. Among the parents,
37.5% reported doing some form of moderate physical
activity at least three times per week.
The proportion of overweight or obese children was
higher among those whose parents were also overweight or
obese versus those classified as having a normal weight
status (45 vs. 35.7%, respectively; p = 0.46). Figure 1
presents the distribution of the children’s BMI according to
parental weight status; the median value for the children’s
BMI was higher if the father or mother was considered to
be overweight or obese compared with those considered to
have a normal weight (19.08 vs. 16.93 kg/m2, respectively)
even though there was no statistical difference for means
between these groups (19.31 vs. 18.26 kg/m2, respectively;
p = 0.201).
Values are presented as r, with the p value in parenthesis
PA Physical activity
* p \ 0.05
a Including systolic or diastolic HBP
b Watching TV [4 h/day
The results were not conclusive for the children in terms
of intake of soda drinks, but a trend was identified; those
whose parents presented with overweight/obesity consumed
more portions of this kind of beverage (0.78 vs. 0.47;
p = 0.20), and the proportion was higher (14.3 vs. 4.8,
p = 0.28) compared with parents with a normal weight.
Table 4 shows the bivariate associations between the
diet and activity patterns of the parents and those of their
children. It can be seen that the fruit and vegetable
consumption of the parents is associated with that of their
children (r = 0.47, p \ 0.001), as is the consumption of
soda drinks (r = 0.30, p \ 0.001). No significant results
were found for physical activity.
The prevalence of overweight and obesity among the
children participating in this study, 37%, is higher than that
reported previously, 26.6%, by the National Survey of
Nutrition in Mexico in 2006. The pathogenesis of obesity
suggests that environmental factors are implicated in the
rapid increase in prevalence of childhood overweight and
obesity that has occurred in the past years. One of these
factors is a low socioeconomic level in developed countries
], where the increasing of obesity has been related to
increasing of poverty [
]. Our findings, based on
schoolage children from a low socioeconomic population in
Mexico City considered to be a high risk group, support
Available data reveal sex differences in trends in the
prevalence of overweight and obesity among school
children, with girls showing a much more dramatic frequency
in obesity than boys [
]. The greater prevalence of
overweight and obesity in the boys of our sample is
striking, but the use of a small sample limits the
generalization of our findings. In terms of the greater number of
cases of HBP found in our sample, both systolic and
diastolic, it is important to realize that we used duplicated BP
measures and that, in general, the prevalence of HBP
decreases when more than two readings are taken during
one visit (the first reading is ruled out and the last readings
are averaged) and when subsequent visits are paid to an
already reported case of pre- or hypertension [
A significant correlation between the BMI of the parents
and their children was found (r = 0.264, p = 0.030),
which is in agreement with the consistent correlations in
subjects in a British study between both the mother and
father and their children, although in the latter study the r
values ranged from 0.20 between fathers and sons to 0.49
between mothers and daughters [
]. In general, most of
the reported correlation coefficients were around 0.35 [
One of the primary study goals of our study was to
examine the influence of the diet and physical activity
patterns of the parent on those of the child. Despite most of
our observed relations being non-significant, our findings
suggest a positive trend in the relation between a parent’s
BMI and his/her son’s weight status and eating and
physical patterns, suggesting that such patterns in parents are
highly correlated to patterns in children. Consequently,
such patterns can be considered as part of the process
whereby a risk of obesity is transmitted to the children,
possibly subsequently affecting their weight status. These
findings are consistent with those reported in previous
studies which found that parents play a pivotal role in the
development of their child’s food preferences and energy
] and also affect the levels of their children’s
physical activity [
Our findings on diet patterns (fruit, vegetable and soda
drink consumption) show a trend of unhealthy alimentary
patterns in both groups, suggesting that parents and
children share comparatively few likes and dislikes. There is
evidence that parenting practices affect what a child eats
and how much; however, few studies to date have used the
appropriate experimental designs to provide causal
evidence for the indirect effect of parenting on weight status
and eating patterns of children. Children are dependent on
parents and caregivers for food, which ultimately results in
the parent’s choices on diet being key determinants of
children’s eating patterns. These choices include when
eating will occur, the type of food eaten and the portions
that will be offered, among others. Thus, parents influence
children by shaping their eating environment [
In those children whose parents were overweight or
obese, there was a modestly lower consumption of fruit and
vegetables and a higher consumption of soda drinks. These
results are consistent with existing data on obese children
and adults, which indicate that fruit and vegetable
consumption is lower among these individuals than
recommended (4 servings per day) for the general population [
]. Moreover, the diet pattern observed in our sample has
been documented in previous studies, in which individuals
with a low consumption of fruit and vegetables and a
higher consumption of high-energy dense foodstuffs, such
as soda drinks, are related to a higher risk for obesity .
In our sample, the average consumption of soda drinks
among children whose parents were considered to be
overweight or obese was higher than that among those
whose parents were considered to be of normal weight,
independent of the high proportion who report consuming
these kind of beverages every day, thus increasing the
former’s risk for developing childhood obesity. A study in
a Mexican population found that a higher intake of soda
drinks, juices or sugar-sweetened beverages may promote
weight gain and obesity by increasing overall energy intake
]. What is more, subjects consuming three daily serving
of soda drinks face a 2.1-fold greater risk of proportional
excess body fat than those who consume \1 serving a day.
A 12-ounce serving of these products provides 150 kcal;
consequently, if these calories are added to the typical diet
without reducing intake from other sources, 1 soda/day
could lead to a weight gain of 6.75 kg in 1 year [
Although only a limited number of children were
studied, we found that most of the children reported
participating in moderate physical activities on a regular basis,
watching TV and playing videogames. Our data
demonstrate that the total time dedicated to physical activities per
week was less than that expended watching TV or playing
videogames. The mean time spent watching TV in our
children cohort was 4.6 h/day, which correlates with
published results. A study conducted among low- and
middleincome children in Mexico City reported that the average
time for this specific leisure activity was 4.1 h/day, with a
12% greater risk for obesity for each additional hour of
viewing TV programs [
The patterns and levels of physical activity described
herein are comparable to those reported in other larger
studies, in which it was demonstrated that most children
are largely sedentary. As in our study, in those studies that
measured this variable, the average number of hours spent
watching TV was viewed as a marker for sedentary
Despite the low proportion of parents who reported
participating in regular moderate physical activity at least
three times per week, our findings are higher than those
reported by the National Survey of the Use of Time in
Mexico. This National Survey found that 22.1% of the
population aged [12 years participate in some form of
physical activity or exercise for 5.5 h per week and that
81.2% expend 12.8 h per week watching TV and 6.9 h per
week using the computer [
]. It should be noted that there
always exists the possibility of overestimating physical
activity, as has been documented in previous studies among
women who were overweight or obese [
This study is limited by the small sample size. Subjects
were recruited in elementary schools by the principal’s
invitation and by advertisement. It was challenging to
recruit parents because most of them stated that they did
not have enough time to fill out the questionnaire or they
did not want to attend to the planned meetings. Moreover,
our measures of the anthropometric variables of the parents
are limited to the information reported by the parents
themselves. Despite these limitations, there were several
strengths to our study. The information derived is valuable
as it documents the association between weight status
among parents and their children and helps identify groups
with a higher risk for obesity based on the parent’s weight
status. In addition, our measure of diet and physical
patterns in parents provides additional evidence for the
important role played by parents in influencing the risk of
obesity in their children. Our data augment those of
previous studies by examining parenting patterns in an older
group of children. Previous studies in Mexico on parental
influence on children’s eating patterns have largely
included older children or BP measures.
The relationship between overweight or obesity in a child
and obesity in a respective parent was confirmed in this
sample of school-aged Mexican children. Eating patterns of
the parents and their children, such as the consumption of
soda drinks, fruit and vegetables were also associated.
The association found in our obese children and their
obese parents identifies a group for targeted intervention.
If replicated and confirmed, the findings of our study may
help healthcare givers to develop interventions that focus
on teaching parents how to increase the physical activity
levels of their children, decrease their children’s periods of
inactivity and improve the diet of their children to include
enough fruit and vegetables, all with the aim to prevent the
development of overweight or obesity. It is crucial that
interventions focus on the home environment, as parenting
patterns influence children’s dietary and physical habits.
In view of the recognition that diet can make a
substantial contribution to variations in health and disease and
that making healthy food choices is primordial, further
research is needed to evaluate family-based interventions
that target the promotion of fruit and vegetable
consumption and the practice of physical activity, not just in
children but also in their parents, in order to reduce the
prevalence of cardiovascular risk factors, such as obesity
and hypertension. This kind of intervention is
cost-effective because it can influence multiple members of a family.
Acknowledgments A. V. C. is supported by a post-graduate
CONACYT scholarship, no. 176239.
Conflict of interest statement No conflict of interest was reported
by the authors.
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