Perceptions of Healthy Eating Among Hispanic Parent

Abstract

Limited research exists exploring the perceptions of healthy and unhealthy eating among Hispanic families, yet understanding their perceptions could inform public health practice with regard to nutrition and obesity prevention. This study conducted an exploratory analysis of interview data collected from 25 parent–child dyads as part of a program evaluation to learn more about both parent and child beliefs and practices regarding healthy eating, and in particular fruit and vegetable consumption. Families described an incomplete knowledge regarding healthy eating, specifically how to increase fruit and vegetable consumption, and the benefits of healthy eating as well as risks of unhealthy eating. Parents in particular seemed to identify many of the foods to avoid but were unclear about healthier alternatives. Children focused more on the benefits of healthy eating, while parents spoke more about the risks of unhealthy eating and the challenges of eating vegetables, particularly among families where child weight was also raised as a concern.

Keywords

childhood obesity qualitative research dyads Hispanic healthy eating

Introduction

Hispanic families have a higher prevalence of childhood obesity compared with their White, non-Hispanic counterparts (21.9% vs. 14.7%; Ogden, Carroll, Fryar, & Flegal, 2015), and often live in communities where access to healthy foods and to places for physical activity is more limited (Trust for America’s Health & The Robert Wood Johnson Foundation, 2014). However, it is unclear whether Hispanic families, particularly immigrant families, have different perceptions of nutrition and how these perceptions might influence eating practices.

Background Literature

Parental modeling, home environment, and beliefs affect child-eating behaviors and child weight among Hispanics and non-Hispanics alike. For example, parental rules and limits on unhealthy food choices and parental modeling of healthy eating influence child eating behaviors (Arredondo et al., 2006; Kumanyika, 2008). Additionally, use of an authoritarian parenting style regarding eating, such as using food as a reward or requiring clean plates, can lead to unhealthy behaviors such as overeating (Arredondo et al., 2006; Gable & Lutz, 2000; Patrick, Nicklas, Hughes, & Morales, 2005).

Specifically among Hispanic families, Kaufman and Karpati (2007) describe a cultural conceptualization of a fat or gordito child as a happy, healthy child. While families of all races and ethnicities struggle to recognize overweight in children, Hispanic families are less likely to be able to recognize their own children as overweight and are more likely to choose overweight images of children as ideal representations (Gauthier & Gance-Cleveland, 2016; Sosa, 2012). This occurs because Hispanic families have different norms and beliefs, and because family members are often overweight too (Kaufman & Karpati, 2007). A qualitative study found that Hispanic parents perceived overweight as concerning for other families but not their own, as they did not recognize their own children as overweight, and concluded that more emphasis should be on health than on weight (Goodell, Pierce, Bravo, & Ferris, 2008).

Acculturation has also been associated with unhealthy eating behaviors among Latinos (Evans et al., 2011), but evidence is mixed (Lara, Gamboa, Kahramanian, Morales, & Bautista, 2005; Ward, 2008). Previous research has found that acculturation and increased work demands influence food consumption patterns both positively and negatively (Edmonds, 2005; Gray, Cossman, Dodson, & Byrd, 2005). Additionally, language and cultural acculturation factors may be more influential on consumption habits than time in the United States (Sussner, Lindsay, Greaney, & Peterson, 2008). However, most prior research in this area focuses on changes in eating patterns (Edmonds, 2005; Kaufman & Karpati, 2007).

Although research exists regarding perceptions of weight and overweight, and the role of acculturation, there is a dearth of research examining how Hispanic families, and specifically parent–child dyads, understand and implement healthy eating practices, particularly increased consumption of fruits and vegetables, which is associated with the prevention of chronic disease. This article describes an exploratory analysis of qualitative data on healthy eating, collected as part of a program evaluation, using a novel approach that captures the perceptions of children and their parents or caregivers by interviewing them both together and separately. This article also provides findings that can inform health promotion practice related to healthy eating among Hispanics.

Method

We conducted semistructured interviews using a modified grounded theory approach (Charmaz, 2011) to generate explanations of constructs and behaviors related to healthy eating among Hispanic children and their parents or primary caregivers. We combined preexisting knowledge of healthy eating and eating behaviors with concepts and ideas that were offered by interviewees.

Inclusion

Children were eligible to participate if they were students from elementary schools implementing the Eat Smart to Play Hard (ESPH) intervention and were in at least third grade. Children were not required to have participated in the intervention to participate in the interviews. Adults were eligible if they were the parent or primary caregiver of a child who met eligibility criteria. Throughout this article, adult interviewees will be referred to as parents. Parents were invited to participate in the interviews while dropping their children off at school.

The school intervention combined a cooking program, Cooking With Kids, and a social marketing campaign, ESPH, with the goal of increasing fruit and vegetable (FV) consumption among Hispanic children, aged 8 to 10 years, and their families. The intervention was implemented during spring 2015 in three elementary schools located in a New Mexico community with a large immigrant population from Mexico. The results of the intervention evaluation are reported elsewhere (Cruz, Lilo, Cuddy, & Solomon, 2015).

Data Collection

Interviews were conducted in three parts. The parent and child were first interviewed together. Then, two interviewers interviewed the parent and child separately but simultaneously. An interview guide, approved by the University of New Mexico Health Sciences Center Human Research Protections Office, was used by two English–Spanish bilingual interviewers trained on the instrument and protocol.

Interviews were conducted at a location convenient for families. Interview questions focused on eating habits and perceptions of healthy eating, as well as the ESPH intervention. Interviews were audio-recorded and lasted between 25 and 75 minutes. Audio-recordings were translated, transcribed, and reviewed for accuracy by a bilingual team member. Interview text was imported into NVivo 10 software (QSR International) for analysis.

Analysis

The team conducted deductive and inductive thematic analysis (Saldana, 2009) using a single coding schema to code parent, child, and dyad interviews. First, we employed deductive strategies, coding themes based on interview questions and prior research. We then used an inductive approach, to identify emergent themes both within and across interview types. The interviews were independently coded by two researchers and reconciled throughout if there was disagreement. The five main themes included were as follows: unhealthy eating makes you sick, my child is overweight, healthy eating makes you strong, children do not like eating vegetables, and what healthy eating should be. Based on the emergence of a discussion on weight during some of the interviews, we also conducted a post hoc analysis of those who discussed weight as compared to those who did not. We analyzed the themes for consistency, patterns, and subthemes. We also explored the data for interconnections between themes, and although we used a single coding schema for all interviews, we allowed for differences in themes between interview types.

Results

Three interviews were conducted with each of 25 families: one adult interview, one child interview, and one interview with the adult–child dyad. Nearly all adult interviewees (92%) were parents. The remaining 8% were other primary caregivers, for example, grandmothers (Table 1). In two instances, a second eligible parent or primary caregiver was also present and wished to participate in the interview. Three quarters of adult interviewees reported Spanish as the language most often spoken at home. Adult interviews were conducted in Spanish (20), English (4), and a combination (1); child interviews were conducted in a combination of the two languages. When dyads were interviewed together, we used the parent’s primary language. The majority of families (80%) reported a household income of less than $30,000 per year, with 24% reporting an income of less than $10,000 per year. Two thirds of adults (68%) were between 35 and 44 years old. Nearly two thirds of children (64.0%) reported participating in at least some of the ESPH activities, which are described elsewhere (Cruz et al., 2015).

Table 1

Demographic Characteristics of Interview Participants From 25 Dyads

Demographic Variables	Frequency	%
Child gender
Female	11	44.0
Male	14	56.0
Child grade
Third	20	80.0
Fourth	3	12.0
Fifth	2	8.0
Household language^a
Spanish	20	80.0
English	4	16.0
Both	1	4.0
Yearly household income ($)
<10,000	6	24.0
10,000-29,999	14	56.0
30,000-49,999	2	8.0
≥50,000	3	12.0
Adult relationship to child
Mother	17	68.0
Father	4	16.0
Mother and father	1	4.0
Mother and grandmother	1	4.0
Grandmother	1	4.0
Other	1	4.0
Primary parent/caregiver age-group (years)
25-34	5	5.0
35-44	17	68.0
45-54	3	12.0

Household language refers to the primary language of the parent and language most commonly used at home.

Unhealthy Eating Makes You Sick

Families described eating unhealthily as a cause of long- and short-term health consequences such as obesity, diabetes, and a lack of energy, strength, and vitality. For most, there was an internalization of personal responsibility, rather than an attribution of socioecological factors that might limit food choice. The exception was school food, raised repeatedly as an unhealthy food source harming children. Some parents felt it was their responsibility to make healthy choices for their children to be healthier. Parents focused on the need to eat less junk food. Children discussed negative consequences of eating unhealthily in terms of lacking energy, being sick, or being unable to participate in activities, as exemplified in Table 2.

Table 2

Themes and Example Quotes From Interviews With Children, Parents, and Child–Parent Dyads

Theme	Child Example Quote	Parent Example Quote
Unhealthy eating makes you sick	“If you eat other food like junk food you won’t be healthy and you will be in a bed, sick, laying down, not being able to do anything.”	“If one, as a parent, doesn’t stop them and show them how to eat appropriately, then we ourselves are rotting them, and not showing them, since they are little, because then when they are older they can’t anymore, they struggle.”
Healthy eating makes you strong	“If you eat vegetables, you can be healthy and strong and do whatever, like play outside.”	Theme not described by parents
My child is overweight	“Because if you eat a lot of vegetables you can be healthy and . . . like that you can lose a lot of weight.”	“I’ve put him on a diet [now] and he has lost a lot of weight. He used to be bigger . . . but he doesn’t want to do it, he doesn’t want to eat the things we make for him.”
Not liking vegetables	“Like sometimes, for some people it is hard, it is hard to eat healthy and sometimes you don’t want to . . . sometimes [vegetables] taste bad . . . ”	“He doesn’t make a face with the fruit. He is happy eating fruit. But the vegetables, I tell you, I struggle with the vegetables.”
What healthy eating should be	“We need to eat healthy so you won’t get sick or because you eat a lot, of how do you say it . . . A lot of junk food and that can’t be good for your health.”	“It is because I took him to the doctor and the doctor told him that he had to lose weight. So, yes now he takes better care of himself a little more. Like for example, in the night he ate more bread now he eats less and also milk he tries to drink less milk. But, yes I have to keep telling him. (To son: “The doctor told you.”). Even if sometimes he makes his faces.”
Other barriers to healthy eating	“Sometimes, we don’t always have fruits and vegetables at home.”	“I think that it is very convenient to not [eat healthy], it is really easier to grab an unhealthy snack as opposed to, well depending on what you have at home . . .”

Healthy Eating Makes You Strong

Children saw a clear, positive value in eating healthily. Some had a complex conceptualization of healthy eating, but most centered on the importance of eating FVs and not eating “junk food.” Unprompted, many children listed FVs among the foods they liked to eat. Children reported that eating FVs makes you strong and energetic and allows you to be healthy and play.

The children connected healthy eating to preventing obesity and diseases. One child stated, “I think it is important because it makes you live longer and with junk food it won’t make you live longer so I think fruit and vegetables are important.” Children also discussed the concrete, short-term effects of healthy eating such as having energy. One child stated, “Because vegetables are good for your health. They give you more energy, and like the carrots, those help you see better . . .”

My Child Is Overweight

Of the 25 dyads, 10 initiated discussions of excess weight during the interviews, although the topic was neither included in the interview guide nor introduced by interviewers. All of the parents who raised the issue of weight were female. These women directly spoke about their children being overweight in the child’s presence. Some spoke of the overweight status of their children as the reason the family was trying to eat more healthily. Several participants acknowledged a precipitating event (e.g., physician concern) that identified the problem for the family.

Families provided examples of how they tried to eat more healthily, including cutting out sweets, chips, sodas, breads, and processed foods and trying to eat more FVs. Some parents blamed their child’s doctor for not warning children about the need to eat healthily or blamed the child for being unwilling to make recommended changes. Most parents did not acknowledge that the home environment or parental choices contributed to their child’s overweight status. One parent said, “The doctors, they just give them medicine. They don’t tell them, ‘eat healthy so you won’t get sick.’” Only one parent discussed being concerned because her child was too thin. She explained that in the United States, doctors are not concerned if a child is thin, which she found troubling.

Among the children who discussed weight, several made statements about eating FVs to lose weight. Children were also concerned about being ridiculed. One stated, “If we don’t eat fruit or vegetables we’re going to be fat and they will make fun of you.” This internalization of the label of being overweight was expressed as motivation for eating FVs. Those children who discussed being overweight without their parents being present were concerned and had a strong desire to lose weight.

Not Liking Vegetables

When interviewed alone, many parents stated that their children disliked eating vegetables and said this was the reason the family did not eat more healthily. Some parents stated that they had stopped trying to get their children to eat vegetables. However, child dislike of vegetables was expressed more often in the group that discussed weight, and was discussed in front of the children. Parents described getting their children to eat vegetables as a “battle,” “struggle,” or “impossible.” Parents who discussed weight, when interviewed alone, admitted that they themselves also struggled to eat FVs or did not eat enough FVs. Among parents who did not discuss weight, only fathers said it was difficult to eat FVs. Parents in both groups reported an interest in recipes and suggestions for increasing child vegetable intake.

Despite most parents remarking that their children disliked vegetables, almost all of the children listed at least two vegetables that they liked to eat when they were interviewed alone. Only one child reported not eating vegetables. Children were asked, while with parents, to provide suggestions for how their families could eat more FVs. Responses included, “buying less cokes and more fruits and vegetables” and “making more recipes with more fruits and vegetables.” Parent responses to these suggestions included, “If I buy it, will you eat it?” and “You don’t eat them when I make them.” Other parents joked that the child was asking too much, expecting their parents to give up sodas or sweets.

Some children talked about their efforts to get their parents to make healthier food choices. One girl explained,

Because my dad . . . he just works in construction and he doesn’t really know how to cook. And also, like, sometimes he doesn’t like too much vegetables. But, I told my dad that he had to eat vegetables, so now he is eating vegetables.

What Healthy Eating Should Be

Families were able to describe benefits of healthy eating and concerns about eating unhealthily. However, parents most often described what they should not eat (e.g., fat, sugar, salt, and processed foods), as opposed to specifically what they should eat. One parent reported that her husband had stopped buying take-out burritos and pizza. Other families spoke of foods they continued to eat, despite knowing they were unhealthy (e.g., junk food, soda). Families also described natural versus added sugars, and fruit juice being not as healthy as whole fruit. Carbohydrates were described as unhealthy foods that should be restricted. No one discussed the health benefits of whole grains.

When parents were asked directly about daily FV recommendations, their responses about serving sizes and quantities varied. Responses ranged from a total of one apple-sized portion daily, to at least three to four servings each of FVs daily. Regardless of whether they accurately reported FV recommendations, only about one quarter of parents reported eating five or more servings of FVs daily. Almost all parents stated that their children ate fewer than five servings of FVs daily. Three families spoke about the MyPlate recommendations (U.S. Department of Agriculture, 2015), but only one parent knew that half the plate should be FVs.

Other Barriers to Healthy Eating

Additional barriers to healthy eating included not knowing how to prepare FVs, time and money constraints, and cultural factors. Families described buying FVs when they were in season because they were cheaper, and not wanting to buy foods that would go to waste. Others described healthy eating as more expensive. One parent stated, “I find it a lot easier to get unhealthy foods a lot cheaper.” No one specifically mentioned food insecurity. Families also discussed how preparing healthy foods requires more time and effort than fast food/take-out. One parent stated,

Sometimes you are in a hurry and do not have enough time to arrive and prepare a good meal. Sometimes you arrive and . . . on the way [you] buy something and arrive, and eat, that’s the truth.

Cultural norms were also reported as barriers. Specifically, one adult discussed how family gatherings are a staple of Hispanic culture. The gatherings commonly include heavy, rich foods, such as meats, cheeses, cakes, and sodas. One parent said,

Just in the close family, they get married, birthdays, this and that. So now, I tell [my son] just a taste, just think about the food if it is doing us good, or is it harming us? So then, I tell him if we know that it isn’t good for us then just a little, just so he can take away the idea, the flavor. Just that bit, not like before. Because, all of the bad things taste very good but they are not good for the health, not good at all.

Others described eating healthier foods growing up; raised on farms or ranches they ate more of what they grew. They recognized that now they buy everything and cook less at home. They worried that their children no longer wanted traditional foods such as soups and beans.

Discussion

This study describes the perceptions of Hispanic parents and their children regarding healthy eating and related barriers. While other interviewers have worked with parent–child dyads (Colby, Morrison, & Haldeman, 2009; Ungar et al., 2012), to our knowledge, this is the first study to use this joint-and-separate, simultaneous strategy.

Children focused on benefits of healthy eating, particularly eating more FVs. This contrasted with more negatively oriented parental perspectives, specifically the harms of eating unhealthily, being overweight, and foods to avoid. Parents often blamed children for eating too much junk food or not enough FVs, seeing the issue in terms of personal responsibility. There was a limited understanding of the socioecological factors (e.g., health care system, food system) that affect food consumption. However, some parents described school food as unhealthy, and some with overweight children considered health care providers responsible for not educating their children sufficiently about healthy eating. Many parents failed to acknowledge that parental food practices had contributed to the eating habits and weight of their children, although the literature indicates the importance of parental roles and the family environment (Arredondo et al., 2006; Fisk et al., 2011).

Parents who discussed weight emphasized that their children disliked vegetables and that it was a struggle to get them to eat vegetables. In contrast, all but one of the children discussed vegetables that they liked to eat. This discrepancy may have been a result of interviewer bias, as the children may have been aware of the dominant discourse that FVs are healthy, particularly among those children who participated in ESPH.

The emphatic negative statements about vegetables made by parents in front of their children may also contribute to child expectations regarding acceptable eating practices. Research on expectations and labeling biases (Darley & Gross, 1983; Harris, Milich, Corbitt, Hoover, & Brady, 1992) has found that by telling others that their children do not like vegetables, parents may be unintentionally providing tacit consent, making their children less likely to eat vegetables.

These parents may also be projecting their own preferences onto their children, or modeling unhealthy practices since many parents admitted to disliking FVs themselves. Parents were also hesitant to incorporate child suggestions for ways family eating could be improved. Studies have shown that children need multiple exposures to a new food before accepting it (Anzman-Frasca, Savage, Marini, Fisher, & Birch, 2012; Johnson, 2016). Several children reported that their opinions of FVs changed during the ESPH campaign after trying new FVs. If parents provided more opportunities to taste FVs, encouraged their children, asked them about FV preferences, or experimented with them, they may have more success (Scaglioni, Salvioni, & Galimberti, 2008).

Parental perceptions of healthy weight may also play a role. As with previous research, we also found that Hispanic mothers are inclined to see chubbiness as a sign of a healthy child whereas being thin was concerning (Sosa, 2012). Ward (2008) found that Mexican American families are often not concerned about weight. Our findings contradicted this. Among the 10 families (40%) that discussed overweight specifically in their children, as opposed to general chubbiness in children, all were concerned about it. They were making the connection between eating and weight and indicated that doctors had discussed overweight and health with them.

The majority of parents did not know how many FVs they should be eating, discussing instead vague generalizations of needing to eat more FVs and needing to eat “healthier,” and most stated that their families do not eat the recommended quantities of FVs. Similar to other research, interviewees knew that it was important to eat FVs but were unclear on recommended amounts (Paquette, 2005). Most parents discussed foods they should be avoiding but failed to accurately articulate healthier alternatives. Improved messaging, specifically for this audience—Spanish-speaking elementary school–aged children and their families—may bridge this knowledge gap.

Previous studies have identified cultural influences as a barrier to healthy eating for Hispanic families (Sosa, 2012). In our interviews, participants discussed both leaving the traditional agricultural lifestyle, which included being physically active and eating foods that were grown or raised by the family, and frequent cultural events that included unhealthy foods. This aligns with previous research where Latin American participants described food from their home countries as healthier because it was more natural and less processed, and diets as more subsistence based (Tovar et al., 2013).

Limitations

This study had several limitations. First, it was a secondary analysis of interviews conducted primarily for program evaluation. Therefore, not all data of interest were collected (e.g., time in the United States, acculturation, structural barriers to healthy eating, food insecurity). Specifically, questions regarding immigration status were not collected to protect participant safety and reduce stress among participants, limiting the analysis and findings. Some participants also had participated in the ESPH intervention while others had not. While there were no identified differences in responses between the two groups, participation in the intervention may have increased interviewer bias. In two instances, families were permitted to include a second adult in the interview out of respect for cultural norms regarding family decision making. Responses regarding nutrition and eating practices from the triads were not appreciably different from the dyads. However, in one interview, the mother took nutritional advice and cues regarding responses from the grandmother. Responses from the mother alone may have differed. Last, these qualitative data were collected from a convenience sample in one community and are therefore subject to response bias and have limited generalizability.

Implications for Practice

This research offers insights into the perceptions of eating habits and healthy food knowledge among a group of low-income, primarily Spanish-speaking, parents and children. It demonstrates the importance of including both parents and children in the interview process to obtain a more complete picture of the dynamics involved in healthy eating. While these data are exploratory, there is support for the following recommendations for practice: (1) include a strong family component in health promotion interventions; (2) encourage parents to involve children in choosing FVs and provide them with repeated opportunities to try new vegetables, (3) educate parents on providing ready access to FVs, (4) emphasize to parents that the way they discuss and model FV consumption influences child eating behaviors, (5) consider providing parents with recommendations for FV consumption and portion sizes for children, (6) provide families with strategies for making family gatherings healthier, and (7) consider cultural norms and family traditions when designing communication materials and messaging for families.

Footnotes

Acknowledgements

We would like to thank Lynn Walters, Anna Farrier, and Jane Stacey with Cooking With Kids; Glenda Canaca and Jennifer Johnston with the University of New Mexico Eat Smart to Play Hard social marketing project; and the teachers, staff, and administrators of participating elementary schools for their assistance in this project. We appreciate the families that took the time to share their thoughts and opinions with us during the interviews. This work was conducted by the University of New Mexico Prevention Research Center with support from the New Mexico Human Services Department.

This work was funded by U.S. Department of Agriculture’s Supplemental Nutrition Assistance Program (SNAP).

The conclusions in this report are those of the authors and do not necessarily represent the official position of the New Mexico Human Services Department or SNAP.

ORCID iD

Emily A. Lilo

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Perceptions of Healthy Eating Among Hispanic Parent–Child Dyads

Abstract

Keywords

Introduction

Background Literature

Method

Inclusion

Data Collection

Analysis

Results

Unhealthy Eating Makes You Sick

Healthy Eating Makes You Strong

My Child Is Overweight

Not Liking Vegetables

What Healthy Eating Should Be

Other Barriers to Healthy Eating

Discussion

Limitations

Implications for Practice

Footnotes

Acknowledgements

ORCID iD

References