The Role of Culture in the Context of School-Based BMI
Screening
abstract
CONTRIBUTORS: Marian L. Fitzgibbon, PhDa,b and Bettina
M. Beech, DrPH, MPHc
The high prevalence of overweight and obesity is a significant public
health concern in the United States. Minority populations are disproportionately affected, and the impact of obesity on minority children is
especially alarming. In this article we discuss school-based BMI reporting, which is intended to increase parental awareness of their children’s weight status. This information could potentially lead parents of
overweight and obese children to carefully examine and possibly
change their children’s diet and activity patterns. However, any program related to child weight status must consider culturally defined
aspects of body size and shape. In other words, the cultural context in
which information on child BMI is presented to and received by parents
must be considered. In this article we review parental perceptions of
child weight. Multiple studies have shown that parents of overweight
or obese children often fail to correctly perceive their children as
overweight. Possible reasons for, and implications of, this misperception of child weight status among minority parents are then explored
within a cultural framework. The PEN-3 model is used to examine influences on health behaviors and could help inform the development of a
culturally sensitive BMI-notification program for minority parents. Reporting materials congruent with the social and cultural values and
practices of the target audience are likely to maximize program effectiveness. A culturally based BMI-notification program should be conceptualized as a small step in a comprehensive plan to reduce childhood obesity and improve the current and future health of minority
children. Pediatrics 2009;124:S50–S62
a
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FITZGIBBON and BEECH
Department of Medicine, University of Illinois, Chicago, Illinois;
Center for Management of Complex Chronic Care, Jesse Brown
VA Medical Center, Chicago, Illinois; and cDivision of General
Internal Medicine and Public Health, Vanderbilt University
School of Medicine, Nashville, Tennessee
b
KEY WORDS
weight status, weight perception, minorities, overweight, African
Americans, Latinos, PEN-3 model
ABBREVIATIONS
NHANES—National Health and Nutrition Examination Survey
WIC—Supplemental Nutrition Program for Women, Infants, and
Children
www.pediatrics.org/cgi/doi/10.1542/peds.2008-3586H
doi:10.1542/peds.2008-3586H
Accepted for publication Apr 29, 2009
Address correspondence to Marian L. Fitzgibbon, PhD, University
of Illinois, Department of Medicine M/C 275, Section of Health
Promotion Research, 1747 W Roosevelt Rd, Room 558, Chicago, IL
60608. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
SUPPLEMENT ARTICLE
Although overweight and obesity pose
a significant public health concern for
the US population as a whole, ethnic
minority populations are disproportionately affected.1 The impact of obesity on ethnic minority children is especially troubling.1 The significant
increases in obesity-related chronic
diseases among children and adolescents serve as both disturbing and sobering sequelae to this relatively recent national public health crisis.
Our culture, preoccupied with weight,
food, diets, and thinness, is demanding
a simple solution to this complex problem. A disturbing array of organizations and individuals are pleased to
comply and offer products, pills, and
diets as an overall “quick fix” to this
multifaceted problem. It is a challenge
to address this issue with scientific
rigor and input from the diverse
groups of stakeholders that it requires. Clearly, no single strategy will
be sufficient to address this health
problem.2 Research has suggested a
variety of contributory factors, including excessive portions,3 fast food,4,5
skipping breakfast,6 sweetened beverages,7 excessive fruit juice consumption,8 irresponsible food marketing,9
sedentary lifestyles,10 insufficient
sleep,11,12 television viewing,10,13 reduced breastfeeding,14 and lack of dietary calcium.15 However, it remains
unclear why some individuals are
more prone to weight gain,16 why
weight loss maintenance is so difficult,17,18 and what individual, institutional, and environmental changes
need to be made. To add to the challenge, obesity is an emotionally and politically charged condition that continues to stir controversy.19 For example,
some have speculated that the public
health emphasis on obesity contributes to an exaggeration of the health
consequences,19 an increase in discrimination against and stigmatization
of obese people,19 and an increase in
disordered eating behavior.20 Furthermore, some have speculated that the
claim of an obesity epidemic is being
used for economic gain.19,21
Given these issues, it can be difficult to
know how to intervene so as to best
prevent and treat obesity, in general,
and childhood obesity among minority
children, specifically. Ultimately, a multifaceted approach is required. However, a recommendation in a recent Institute of Medicine report, “Preventing
Childhood Obesity: Health in the Balance,”22 was for schools to conduct annual assessments of each student’s
height, weight, and BMI (which is calculated as weight in kilograms divided
by the square of height in meters). The
report indicated that schools have traditionally taken the height and weight
of children as part of an overall health
screening.23 Although this may be true,
using these data to calculate BMI and
then reporting the BMI percentile to
parents has not been a customary part
of the process.23
Nonetheless, sharing child weightstatus information is thought to be one
strategy for raising parental awareness of their children’s weight and related health risks.24 Parents have a significant influence on the development
of lifestyle habits in their children, including those that may contribute to
the maintenance of a healthy weight.
For example, parents’ knowledge of
nutrition, food-purchasing practices,
home eating patterns, and activity
choices provide models for their children’s knowledge and behavior.25
Thus, parents need to be armed with
the knowledge of and, more importantly, the ability to use this information to make informed decisions.
The goal of BMI reporting is to encourage parents to assess and potentially
change the diet and activity patterns of
their children. To achieve this goal, it is
imperative that careful thought be
given to crafting a message with par-
ents in mind. Given the higher prevalence of obesity among minority adults
and children, this is especially true for
messages sent to minorities. Cultural
influences may be particularly salient
for schools to consider in developing
these programs, because culture
shapes perceptions and practices related to health.26,27 In this article we focus on aspects to consider in the BMInotification process, with an emphasis
on the importance of culture, obesity
prevalence among minority children
and the role of schools, parental perception of child weight status, how culture affects weight perceptions, and
BMI notification and behavior change.
OBESITY PREVALENCE AMONG
MINORITY CHILDREN AND THE ROLE
OF SCHOOLS
Between 1980 and 2004, the prevalence of overweight in children (6 –11
years) increased from 6.5% to 18.8%
and in adolescents (12–19 years) increased from 5.0% to 17.4%.1,28,29 In the
United States, “overweight” in children
has generally been defined as a BMI at
ⱖ95th percentile for age and gender
on the basis of the 2000 Centers for
Disease Control and Prevention
growth charts. “At risk for overweight”
has been defined as a BMI between the
85th and 95th percentiles. However, an
expert committee convened by the
American Medical Association recently
recommended classifying children
with a BMI at ⱖ95th percentile as
“obese” and those with a BMI between
the 85th and 95th percentiles as
“overweight.”30
Unfortunately, there is no one data
source that reports information on
child weight status for all major ethnic
groups in the United States. The National Health and Nutrition Examination Survey (NHANES), a nationally representative survey, has conducted
surveys since the early 1970s and has
a large enough sample of white, black,
PEDIATRICS Volume 124, Supplement 1, September 2009
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TABLE 1 Prevalence of Risk of Overweight and Overweight in Children and Adolescents Aged 2 to
19 Years According to Gender and Racial/Ethnic Group for 2003–20041
Male, % (SE)
Non-Hispanic white
Non-Hispanic black
Mexican American
a
b
Female, % (SE)
At Risk or
Overweighta
Overweightb
At Risk or
Overweighta
Overweightb
35.4 (2.7)
30.4 (2.7)
41.4 (1.9)
17.8 (2.2)
16.4 (1.5)
22.0 (1.6)
31.5 (2.6)
40.0 (1.9)
32.2 (2.5)
14.8 (1.9)
23.8 (1.4)
16.2 (2.3)
BMI for age and gender at ⱖ85th percentile.
BMI for age and gender at ⱖ95th percentile.
and Mexican American children to calculate overweight and obesity rates
and changes over time.1 The genderspecific BMI-for-age growth charts
were created by using data from national surveys conducted between
1963 and 1994, although data collected
after 1980 were only used for children
younger than 6 years.31 In 2003–2004,
19.2% of Mexican American children,
20.0% of black children, and 16.3% of
white children were overweight
(BMI ⱖ 95th percentile) according to
NHANES data (see Table 1). Mexican
American children of both genders
were more likely to be overweight than
white children. However, although
black girls were more likely to be overweight than white girls, black boys
were not more likely to be overweight
than white boys.1 The higher prevalence of overweight among ethnic minority children parallels the higher
prevalence of obesity among ethnic
minority adult women.1 In 2003–2004,
53.9% of non-Hispanic black women,
42.3% of Mexican American women,
and 30.2% of non-Hispanic white
women were obese (BMI ⱖ 30 kg/m2).1
Other ethnic groups, such as American
Indian people, also have higher rates
of childhood obesity than white people.32 For example, a recent study of
⬎11 000 American Indian school-aged
children reported that at 5 years of
age, 47% of boys and 41% of girls were
overweight (defined as BMI ⱖ 85th
percentile), and 24% of the children
were obese (BMI ⱖ 95th percentile).33
In this article, we attempt to highlight
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FITZGIBBON and BEECH
the role of culture in the context of BMI
screening for minority populations in
the United States. However, because
there is significantly more information
available on black and Latino populations than on other populations, we focus predominantly on these 2 ethnic
groups.
Although BMI is a convenient and
widely used measure of obesity, there
are few or no reliable data on the association between BMI at any given age
and future health.34 Therefore, in 2005,
the Childhood Obesity Working Group
of the US Preventive Services Task
Force reported that “[w]e do not know
the best way to identify children who
are at risk for future adverse health
outcomes due to obesity or overweight.”35 A review of the evidence
showed a number of areas in which
information is lacking on the links between children’s weight and future
health outcomes.36 In terms of health
outcomes, the US Preventive Services
Task Force did not find enough evidence to recommend screening for
BMI among children and adolescents.
This finding does not negate the utility
of screening, but it does underscore
the need for additional evidence to
draw firmer conclusions. In addition,
researchers, legislators, and the popular press are increasingly interested
in the idea of measuring the BMI of students in schools.34,37–39
Schools and parents have an established tradition of communication with
each other concerning student-related
health matters such as delivery of
medication to children with chronic
health conditions and immunization
needs.22,40 Schools also offer health
screenings, which have most often included vision and hearing screening
and height/weight measurement.
Therefore, schools could potentially
screen students for overweight and
communicate potential risks to parents. This could place schools in a pivotal role to partner with parents, and
parents who perceive their child’s
weight as a concern may be more
likely to take ameliorative action.41
PARENTAL PERCEPTION OF
CHILDRENⴕS WEIGHT STATUS
Children who are obese are more
likely to become obese adults than
normal-weight children.42,43 Moreover,
obese adults are more likely to suffer
from hypertension, type 2 diabetes,
coronary artery disease, and high cholesterol levels.43,44 This has led to an
increasing focus of study on obesityprevention efforts in childhood.22,45,46
However, weight-status misperception
may make prevention efforts more difficult. Parents are unlikely to initiate
action to prevent overweight or obesity if the weight status of a child is not
perceived as problematic or if parents
do not consider the link between obesity and the possibility of current or
future adverse health outcomes for
their children.
Notwithstanding the higher prevalence of obesity among black and
Latina women in the United States, a
large body of research suggests that
the desire to be thinner is stronger
among white women.47 This does not
mean that minority women are not attempting to lose weight or have uniformly positive body images.48 However, on average, ethnic minority
women have a greater acceptance of
overweight49 and have higher rates of
body-image satisfaction independent
SUPPLEMENT ARTICLE
of body weight than white women.50
Data also suggest that black women do
not report a discrepancy between
their current and ideal body image until they are obese.51 Other research has
shown that black and Mexican American men and women are less likely to
perceive themselves as overweight
than white men and women.52 These
findings could certainly have implications for how minority parents perceive the weight status of their children.
Parents frequently fail to perceive that
their children are overweight.53 Table 2
contains a list of articles published between 2000 and 2007 that report on
studies of parental perception of overweight in children. Only studies conducted in the United States are listed,
although a number of similar studies
have been conducted outside the
United States.54–58 Some of the studies
focused specifically on minority children,59–64 whereas others included
multiethnic samples.65–70 Many researchers selected participants from
within a fairly narrow age range (eg,
2–5 years, 4 – 8 years), whereas a few
included a broader age range.53,66,67 A
number of studies focused on lowincome parents, recruiting participants from the Supplemental Nutrition
Program for Women, Infants, and Children (WIC) or Head Start.59,63,65,69 Income was not a criterion for participation in most of the other studies,
although Baughcum et al70 specifically
recruited both low-income and higherincome participants.
Despite the diversity of the samples,
the results of these studies were remarkably consistent. Many parents of
overweight or obese children did not
perceive their child to be overweight.
Among NHANES participants, only 67%
of obese children were perceived as
overweight by their mothers, and only
14% of overweight boys and 29% of
overweight girls were perceived as
overweight.53 In other studies, participants were even less likely to identify
their obese child as overweight. In a
study of WIC clients, only 21% of obese
preschoolers were identified as overweight by their parents.65 In a study of
Native Americans living on reservations, only 15% of the obese children
were perceived as overweight, and the
children who were perceived as overweight had a mean BMI at ⬎99th percentile.60 Even some parents who had
brought their child to a weightassessment clinic said that they were
not especially concerned about their
child’s weight.66 Similarly, very few of
the parents who brought their obese
child to be screened for a weightmanagement program thought that
their child was very overweight, although 62% did say that their child was
a little heavy.64
overweight or very overweight were
classified as perceiving their child was
overweight.70 Overweight in this study
was defined as a weight-for-height percentile at or above the gender-specific
90th percentile based on the Centers
for Disease Control and Prevention
growth references for children.71,72
In general, ethnicity did not seem to be
a predictor of parents’ perception of
their child’s weight status.53,65,67,68,70 In
studies that included a broad age
range, parents of older children were
more likely to correctly identify a child
as overweight than parents of younger
children.53,67 Baughcum et al70 found
that mothers with a high school education or less were less likely than mothers with education beyond high school
to correctly identify their children as
overweight. To assess the mothers’
weight perception in this study, each
mother was asked to complete a statement asking about her perception of
her child’s weight. The possible responses were “very underweight,” “a
little underweight,” “about the right
weight,” “a little overweight,” and “very
overweight.” The overweight and underweight categories that included 2
responses were then collapsed. Mothers who answered either very underweight or a little underweight were
classified as perceiving their child as
underweight, and mothers who responded that their child was a little
WEIGHT-RELATED PERCEPTIONS
AND ATTITUDES: THE ROLE OF
CULTURE
It seems that inaccuracy in assessing
weight status is not necessarily specific to ethnic minority populations.
However, the consequences of the misperception may be greater for minority children, given the disparities in
weight status and weight-related comorbidities between ethnic minority
and white people in the United States.1
Therefore, factors that underlie the
misperception and the cultural context
in which they develop and are maintained need to be examined.
As shown in the previous section, overweight children are frequently not perceived as such by their parents, and
the misperception of a child’s weight
status does not seem to be specific to
any one ethnic group. However, data
from the NHANES III showed that,
among adults, overweight and obese
black and Latino men and women were
more likely to misperceive their own
weight status compared with white
men and women,73 which could pose
an impediment not only for their own
weight control but also for that of their
children.
It is noteworthy that in an article by
Baturka et al74 the authors reported
that among a sample of black women
from all weight categories, most reported feeling dissatisfied with their
weight. However, they also reported
that their dissatisfaction was not consistent with their cultural belief in selfacceptance and placing character
above appearance. Therefore, among
PEDIATRICS Volume 124, Supplement 1, September 2009
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FITZGIBBON and BEECH
Total: 192; obese: 35;
overweight: 31
Total: 366; obese: 86
Total: 76; weight for length
ⱖ 95th percentile: 76
(all)
Total: 80; WFH ⱖ 95th
percentile: 26%
Total: 755; obese: 16.5%;
overweight: 19.9%
Killion et al59 (2006)
Adams et al60 (2005)
Rich et al61 (2005)
95% H
100% AA
2–11 y
26–56 mo
23–60 mo
2–5 y
5–10 y
Total: 5500; obese: 570;
overweight: 682
Total: 18; WFH ⱖ 90th
percentile: 15
Total: 622; WFH ⱖ 95th
percentile: 66; WFH ⱖ
90th percentile: 99
Total: 200; child WFH ⱖ
95th percentile: 200
Total: 111; obese: 100
Jain et al69 (2001)
Baughcum et al70
(2000)
Myers and Vargas63
(2000)
Young-Hyman et al64
(2000)
Site
Primary care offices
9 WIC clinics in Kentucky and 3
pediatric practices serving
middle- and upper-middle–
income families in Ohio and
Indiana
WIC clinic in Arlington, VA
WIC clinic in Cincinnati, Ohio
Nationally representative
sample of US residents
(NHANES III, 1988–1994)
3 churches in North Carolina
participating in an obesityprevention pilot program
Private pediatric faculty
practice in Westchester, NY
2 inner-city public schools in
Chicago, IL
Middle and high schools in the
Minneapolis/St Paul, MN,
metropolitan area
5 WIC clinics in Dallas, TX
3 reservations in Wisconsin
10 Head Start centers in
southeast Texas
7 pediatric practices in or
near Chicago, IL
Weight-assessment clinic,
University of Michigan
4 WIC clinics in Minnesota
W indicates white; AA, black/African American; H, Hispanic; O, other; WFH, weight for height.
a Obese children: BMI for age and gender at ⱖ95th percentile; overweight children: BMI for age and gender at ⱖ85th percentile but ⬍95th percentile.
81% W, 13% AA, 4% O, 2% H
72% AA, 28% W
W, AA, Mexican American
Not shown
Maynard et al53
(2003)
4–8 y
Total: 83; obese: 19
100% AA
33% W, 24% AA, 17% Asian,
13% H, 13% O
100% H
87% H, 9% AA, 4% W
94% Native American
57% H, 43% AA
42% W, 35% H, 17% AA,
7% O
Multiethnic, majority white
Etelson et al116 (2003)
6–9 y
Adolescents, mean
(SD): 14.6 (1.7) y
5–6 y
14–47 mo
4.5–8.5 y
3–5 y
2–17 y
2–20 y
Ethnicity
79% W, 15% H, 6% AA
Total: 35 girls; obese: 13;
overweight: 7
(2004)
Age
24–59 mo
Katz et al62 (2004)
Boutelle et
al68
Ariza et al115 (2004)
Total: 223; obese: 45;
overweight: 43
Eckstein et al67 (2006)
Total: 967; obese: 108
Total: 74; obese: 74 (all)
(2007)
N (Children)a
Watkins et al66 (2007)
May et
al65
Authors
TABLE 2 Studies of Parents’ Perception of Children’s Weight, US Studies Only
Results
Parents classified 30% of overweight adolescents as somewhat or very overweight. Only
14% of obese adolescents were described as very overweight. In a multivariate analysis,
adolescent and maternal race/ethnicity were not related to accuracy, although each
was related to accuracy in a bivariate analysis.
Each caregiver was asked to choose the figure that resembled her daughter’s current body
size. There was a statistically significant correlation (r ⫽ .50, P ⫽ .002) between
perceived body size and the girls’ BMI.
Parents were asked to place their child on a 10-cm linear scale from “extremely
underweight” to “extremely overweight.” All parents of obese children underestimated
their child’s BMI percentile by at least 10 points, and only 11% underestimated it by ⬍30
points.
Sixty-seven percent of the mothers correctly identified their obese child as overweight;
14% of overweight boys and 29% of overweight girls were perceived as overweight.
Younger obese children were less likely to be perceived as overweight. Among
overweight children, boys, younger children, and children of heavier mothers were less
likely to be perceived as overweight. Ethnicity was not a predictor of the mothers’
perceptions.
Sixty-seven percent of the children with WFH at ⱖ90th percentile were perceived as a little
or very overweight. However, only 2 of the 15 mothers worried about their child’s
present weight, and only 5 worried about their child’s weight in the future.
Twenty-one percent of the children with WFH at ⱖ90th percentile were perceived as
overweight; 29% of children with WFH at ⱖ95th percentile were perceived as
overweight. Mothers with a high school education or less were less likely than mothers
with education beyond high school to correctly identify their children as overweight.
Ethnicity was not a predictor of the mothers’ perceptions.
All children selected for the study had WFH at ⱖ95th percentile. Sixty-four percent of the
parents believed their child was overweight.
All children had WFH at ⱖ90th percentile, and parents had brought their children to be
screened for a weight-management intervention. Seventeen percent of the obese
children were perceived as very overweight, and an additional 62% were perceived as a
little heavy. Only 45% of the parents of obese children believed that their child’s weight
was a health problem.
Forty percent of the children with WFH at ⱖ95th percentile were perceived as overweight.
Twenty-one percent of the obese children were perceived as overweight, with no difference
between white and Hispanic children. No obese black children were perceived as
overweight, but the sample was small (N ⫽ 6).
All parents perceived their children as overweight, although 30% did not describe
themselves as concerned about their child’s weight. There was no relationship between
the child’s BMI z score and the parent’s description of the child’s weight (little
overweight, overweight, very overweight, obese). All children had been referred to the
clinic by a physician.
Fifty-one percent of the obese children and 21% of the overweight children were described
as a little overweight or overweight. Parents of older children (ⱖ6 y) were more likely to
correctly perceive a child as overweight, but ethnicity did not influence perception.
When asked to choose the figure that most closely resembled the current size of their
children, mothers, on average, perceived their children to be thinner than they really
were. However, 49% of the mothers of obese children wanted their children to be
thinner. Only 16% of the mothers of overweight children wanted their children to be
thinner.
Fifteen percent of the obese children were described as “already overweight.” Children
whose parents classified them as overweight had a mean BMI above the 99th percentile.
All children were at ⱖ95th percentile of weight for length, but 50% of the parents were not
concerned about the child’s weight.
SUPPLEMENT ARTICLE
Cultural identity
Relationships and
expectations
Person
Extended family
Neighborhood
Perceptions
Enablers
Nurturers
Cultural empowerment
Positive
Existential
Negative
FIGURE 1
The PEN-3 model. (Used with permission from
Collins O. Airhihenbuwa, PhD.)
minority populations, strong selfimages may transcend weight issues
and serve to buffer some people
against mainstream weight discrimination.48 This is a dilemma that is not
easily resolved when making day-today eating and physical activity decisions, particularly when being overweight and obese may be normative in
one’s own community.1,74
With a focus on understanding the cultural influences on health behaviors,
this section discusses the PEN-3
model, which could potentially inform
the development of a BMI-notification
program.75,76 The PEN-3 model was developed to help align health education
programs with a culture’s existing beliefs and practices.76 The model consists of 3 dimensions of health beliefs
and behaviors that are interdependent
and interrelated. These dimensions include (1) cultural identity, (2) relationships and expectations, and (3) cultural empowerment. Within each of
these 3 dimensions, there are 3 categories that form the acronym PEN. The
model is illustrated in Fig 1.
The 3 categories of the culturalidentity dimension include “person,”
“extended family,” and “neighborhood.”
This first dimension recognizes that
health promotion can occur at the person (individual), extended-family, and
neighborhood (community) levels. That
is, the target audience is potentially
larger than just the individual. This
conceptualization is in contrast to a
number of health behavior-change
models that focus predominantly on
the individual (eg, theory of reasoned
action, health belief model). Targeting all 3 levels (ie, person, extended
family, and neighborhood) is particularly salient when designing healthinformation programs for cultures in
which health decisions are more likely
influenced by a collectivist rather than
an individualist perspective.76 For example, in black families, women are
often heads of household, have extended roles that bridge several generations, and influence large networks
of family members.77 This could include roles related to food purchasing
and preparation that are integral to
their role in the family, extended family, and community.16 An equivalent
concept in Latino families is that of
“familismo” or familism, a term that
refers to the significance of the family.78,79 Also, the central role of men in
the decision-making of the family in
Latino culture should not be underestimated.80 The family, both nuclear
and extended, plays a pivotal role as
a supportive network for both healthful and unhealthful behaviors. In this
way, the family as a group may take
precedence over individual interests.81
For example, if a child’s BMI percentile
is high, but the grandparents insist
that the child is not overweight, the
parents may feel compelled not to
make any substantive changes. In
this case, the extended family would
need to be involved before any action is
taken. Stressing family-centeredness
rather than individual self-management
in providing information about children’s weight may facilitate acceptance
and consideration of the information
by parents and family members.82
Related to this is the possible involvement of neighborhood or community
leadership, such as spiritual leadership,
when designing health-related messages for minority parents that could
include educating families about the
significance of excessive weight, risk
factors, and prevention.
The second dimension, relationships
and expectations, focuses on determining the factors that influence the person, family, or neighborhood through
the 3 categories of “perceptions,” “enablers,” and “nurturers.” Perceptions
refer to the knowledge, attitudes, and
beliefs that contribute to or impede engaging in a particular health behavior.
For example, the concept of “fatalismo” (fatalism), which is part of the
Latino culture, refers to the acceptance of a chronic disease because it is
determined by God.83,84 Fatalism is also
thought to be prominent among some
communities within black culture.85 In
such communities, obesity among children and adults may be viewed as inevitable and not under one’s control.
Adapting best practices in health communication to minority populations to
convey BMI results and their meaning
should be considered.
Enablers are cultural or structural influences that may enhance or impede
behavior change, such as the availability or accessibility of resources. For example, schools must provide a supportive food and activity environment
if a BMI-notification process is to have
credibility. Schools can also develop a
family approach to BMI notification
and combine weight issues with academic and athletic issues. Schools
could stress the importance of a
healthy breakfast for brain acuity and
attentiveness. Structural impediments
such as a lack of health insurance
could pose a challenge to seeking further assessment after a school-based
BMI screening. These factors must be
considered when delivering BMI results that imply a need for further evaluation and altering eating and activity
patterns.
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The third category, nurturers, refers to
the extended family, friends, the neighborhood, and often the spiritual community, who can reinforce or nurture
health beliefs, attitudes, and behaviors.76 Within both Latino and black
communities, belief in the importance
of family, God, and spirituality needs to
be considered in predicting how parents may interpret BMI results.80,86
Within the black community in particular, the church has a long tradition of
disseminating health information to
the congregation and its surrounding
community in addition to meeting the
spiritual needs of its membership.87–89
Similarly, among Latino populations,
reliable sources of health information
such as churches90 and lay health
advisors (eg, promotoras or consejeras)91,92 have often been trusted as
sources of community information.
Overall, these individuals often serve
as mediators between the community
and formal institutions and offer social support to those in the community.93–95 BMI and weight information
given to parents may go unheeded unless it is also sanctioned by trusted
sources in their community.
Although minority populations often
have trust in their churches and community leaders, there may be distrust
or negative attitudes toward the medical profession and scientific authorities.96 For example, data suggest that
Latinos with low educational attainment are more likely to distrust scientific experts on obesity.97 Trust and
credibility are critical when delivering
information on health risks, especially
on controversial and sensitive topics
such as childhood overweight and
obesity.19 Science is an evolving process and at times seems contradictory. This has led some people to feel
confused and skeptical about how to
integrate research findings that may
affect health care decisions.98 This confusion may lead to added distrust
S56
FITZGIBBON and BEECH
among communities that may feel marginalized or are linguistically isolated,99
which highlights the importance of
crafting messages that engender trust
by recognizing and responding to culturally based beliefs and attitudes.
The final, and possibly most critical,
dimension of the PEN-3 model is the
cultural-empowerment dimension, which
emphasizes the central role of cultural appropriateness in any healthpromotion program. According to Airhihenbuwa and Webster,75 the terms
“culture” and “empowerment” are typically not used together; culture is often seen as a barrier, whereas empowerment is seen as a strength. The PEN-3
model, therefore, illustrates the full
range of the possible influences of
culture, from positive to negative. The
perceptual and structural considerations gleaned from the relationships
and expectations dimension should
be evaluated within the 3 categories of
this domain, which include “positive
behaviors,” “existential behaviors” (culturally based but benign behaviors),
and “negative behaviors.” The “positive” category refers to perceptions,
enablers, and nurturers who serve to
facilitate engagement in the healthful
behavior. In contrast to a deficit model
of health behavior, in which negative
behaviors are often emphasized and
highlighted, the PEN-3 model proposes
that positive behaviors and cultural
strengths should be promoted initially.75 For example, when delivering BMI
information that includes recommendations for healthy eating, positive aspects of the traditional Latino diet such
as the consumption of foods high in
fiber should be reinforced. Similarly,
the use of greens and other healthful
vegetables in traditional black dishes
should be emphasized.
The “existential” category refers to
practices that are culturally based and
have no harmful health consequences.
For example, eating cooked rather
than raw vegetables, not eating certain foods after sunset, or considering certain foods inappropriate at certain meals would have no effect on
weight control. These are benign eating practices preferred by some black
people.85 The negative category refers
to perceptions, enablers, and nurturers that impede engaging in healthful
behavior and lead individuals to engage in harmful behavior. However, although some behaviors are known to
be harmful to health, they still need to
be understood within a cultural context. For example, behaviors that are
often consistent with weight gain include having meat as an integral part
of a meal, drinking whole milk rather
than low-fat milk, and eating chicken
with the skin.85 BMI-notification programs that include recommendations
for healthy eating choices need to address the cultural context in which
some of these long-standing behaviors
were developed and are maintained.85
Incorporation of the PEN-3 model in
planning a BMI-notification program
for minority parents could be conducted in 3 planning phases. In the
first phase (cultural identity), school
administrators should give thought to
who should comprise the target audience. Should the program target the
parent/child or the extended family, or
should it be a neighborhood or community effort that requires “buy-in”
from trusted sources of health information? In the second phase (relationships and expectations), school personnel should be aware and respectful
of the attitudes and beliefs related to
perceptions, enablers, and nurturers
and how personal actions can be examined as a function of a broader social context. On the basis of this information, in the third phase (cultural
empowerment), the attitudes and beliefs related to perceptions, enablers,
and nurturers of the individual, extended family, or neighborhood can be
SUPPLEMENT ARTICLE
considered as culturally positive, existential, or negative.76 With this framework in mind, a potentially more effective BMI-notification program can be
developed and delivered.
BMI NOTIFICATION AND
BEHAVIOR CHANGE
There must be recognition and concern that any study of ethnic groups
runs the risk of overgeneralization, because labels tend to focus on the similarities between sets of people while
ignoring substantial variability within
those sets. For example, the labels of
black, Latino, and American Indian people highlight the differences in backgrounds and experience of groups of
Americans but may also mask withingroup distinctions such as socioeconomic status, educational achievement,
acculturation, immigration status, household size, media exposure, neighborhood characteristics, geographic location, or urban versus rural lifestyles.100
With this caveat in mind, it is important to assess how parents will react
and respond behaviorally to the notification of BMI results. To date, BMInotification programs have met with
some controversy and challenges. Many
potential issues and questions have
been raised: the limitations of BMI
screening34; training of school personnel37; privacy concerns101; self-esteem
concerns37; possible increases in body
dissatisfaction37; where to refer children at high risk56; how to interpret results102; questions regarding schools
as the appropriate screening site37;
parentally imposed food restrictions
on children24,34,38; increased disorderedeating behavior34; increased stigmatization of obese children37,39; and
concerns about the availability of resources103,104 have been voiced. Despite
these concerns and the need for further research on the long-term impact
of the benefits and potential harms of
school-based weight monitoring,105 the
limited data available reflect support
for the school-based screening and
parent-notification programs.24,106,107
Developing BMI-notification programs
that recognize and respond to the cultural values and concerns of families
represents a substantial challenge.
For example, obesity may be so common in some communities that it is
normative and possibly not treated
with high concern, which could mean
that a BMI-notification program might
be perceived as irrelevant.
There are currently no definitive data
on the usefulness of school-based BMImeasurement programs in preventing
or reversing the obesity epidemic, and
controversy over the practice exists.37
Data gathered from clinical settings by
the US Preventive Services Task Force
revealed no evidence that routine BMI
screening improves either behavioral
or physiologic measures of health outcomes.35 In addition, the task force did
not find sufficient evidence for or
against the practice of school-based
BMI screening but also did not find evidence that the practice of screening
negatively affects self-esteem or promotes disordered eating.35 Nonetheless, some states, such as Arkansas,
California, Michigan, Florida, and Illinois, are promoting guidance for families on healthy eating and activity or
have initiated BMI-measurement programs for children and adolescents.108–
110 Since these initiatives began, a
number of studies have shown that
parents either react positively to
BMI-screening programs in their children’s schools24,106,111 or that negative
responses are quelled after the programs are established and parental
concerns are incorporated into the
program.38,112,113 For example, a study
that used focus-group data revealed
that parents are receptive to schoolbased BMI screening if advanced notification is part of the process and if
there is a private and sensitive plan
devised for data collection.111 A followup pilot intervention based on these
focus-group results showed that the
majority of parents believed it was
important to send home BMI results
as part of an annual student health
screening program.106 Importantly,
recent data suggest that informing
parents of their children’s BMI serves
to improve the accuracy of parental
perception of a child’s weight status.24
Although preliminary, this could serve
as a very positive step in addressing
weight-gain prevention and, ultimately,
obesity.
Even if BMI-notification programs improve parents’ perception of their children’s weight status and make them
aware of the benefits of a healthful lifestyle, actually changing diet and physical activity patterns will still present a
challenge. This is a concern for some
minority communities, which face environmental and other barriers to behavior change. Therefore, possible limitations in the ability to make healthful
choices need to be understood in the
appropriate context. Advocacy for environmental changes that support individual behavior change may be a critical complement to a school-based
BMI-notification program.
SUMMARY AND CONCLUSIONS
The high prevalence of obesity among
both adults and children in black,
Latino, and American Indian populations in the United States influences
the context for both obesity-prevention
and BMI-notification programs in these
communities. In designing programs,
there should be an effort to make them
congruent with the target audience, or
they will fail to be effective. Ultimately,
the role of culture, which includes the
history, values, beliefs, language, and
family and community systems of an
individual, will affect overall behavior.
PEDIATRICS Volume 124, Supplement 1, September 2009
S57
Environmental and policy changes
are outside the scope of any BMInotification program. However, they
are part of the larger question of
whether the problems associated with
poor diet and physical inactivity are serious enough to warrant changing our
environment, and the role of schools,
more specifically. Values that transcend ethnicity, such as the value of
childhood vaccinations, the importance of wearing seat belts, child labor
laws, prohibiting purchases of alcohol
and tobacco by minors, and car safety
restraints for children, are now generally well-accepted aspects of our culture.114 Laws that govern some of
these individual choices are now
readily accepted. A compelling argument for sanctions against some individual choices would be that not providing them would fail to protect
children.114 It seems that an analogous
argument can be made for addressing
childhood obesity. The notification of
parents of the BMI status of their child
within a culturally relevant context
should be conceptualized as one small
step in a comprehensive plan to reduce childhood obesity.
ACKNOWLEDGMENTS
We thank Melinda Stolley, PhD, and
Linda Schiffer, MS, MPH, for insightful
comments and suggestions. We also
thank Guadalupe Compean and Beth
Schneider for technical assistance.
REFERENCES
1. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and
obesity in the United States, 1999 –2004. JAMA. 2006;295(13):1549 –1555
2. Wadden TA, Stunkard AJ. Handbook of Obesity Treatment. New York, NY: Guilford; 2002
3. McCrory MA, Fuss PJ, Saltzman E, Roberts SB. Dietary determinants of energy intake and weight
regulation in healthy adults. J Nutr. 2000;130(2S suppl):276S–279S
4. Thompson OM, Ballew C, Resnicow K, et al. Food purchased away from home as a predictor of
change in BMI z-score among girls. Int J Obes Relat Metab Disord. 2004;28(2):282–289
5. Ebbeling CB, Sinclair KB, Pereira MA, Garcia-Lago E, Feldman HA, Ludwig DS. Compensation for
energy intake from fast food among overweight and lean adolescents. JAMA. 2004;291(23):
2828 –2833
6. Siega-Riz AM, Popkin BM, Carson T. Trends in breakfast consumption for children in the United
States from 1965–1991. Am J Clin Nutr. 1998;67(4):748S–756S
7. Mattes RD. Dietary compensation by humans for supplemental energy provided as ethanol or
carbohydrate in fluids. Physiol Behav. 1996;59(1):179 –187
8. Dennison BA, Rockwell HL, Baker SL. Excess fruit juice consumption by preschool-aged children
is associated with short stature and obesity [published correction appears in Pediatrics. 1997;
100(4):733]. Pediatrics. 1997;99(1):15–22
9. Institute of Medicine, Committee on Food Marketing and the Diets of Children and Youth. Food
Marketing to Children and Youth: Threat or Opportunity? Washington, DC: National Academy
Press; 2006
10. Eisenmann JC, Bartee RT, Wang MQ. Physical activity, TV viewing, and weight in U.S. youth: 1999
Youth Risk Behavior Survey. Obes Res. 2002;10(5):379 –385
11. Chaput JP, Despres JP, Bouchard C, Tremblay A. Short sleep duration is associated with reduced
leptin levels and increased adiposity: results from the Quebec Family Study. Obesity. 2007;15(1):
253–261
12. Horne J. Short sleep is a questionable risk factor for obesity and related disorders: statistical
versus clinical significance. Biol Psychol. 2008;77(3):266 –276
13. Crespo CJ, Smit E, Troiano RP, Bartlett SJ, Macera CA, Andersen RE. Television watching, energy
intake, and obesity in US children: results from the third National Health and Nutrition Examination Survey, 1988 –1994. Arch Pediatr Adolesc Med. 2001;155(3):360 –365
14. Arenz S, Ruckerl R, Koletzko B, von Kries R. Breast-feeding and childhood obesity: a systematic
review. Int J Obes Relat Metab Disord. 2004;28(10):1247–1256
15. Zemel MB, Shi H, Greer B, Dirienzo D, Zemel PC. Regulation of adiposity by dietary calcium. FASEB
J. 2000;14(9):1132–1138
16. Kumanyika SK, Whitt-Glover MC, Gary TL, et al. Expanding the obesity research paradigm to reach
African American communities. Prev Chronic Dis. 2007;4(4):A112
17. Hill JO, Wyatt HR. Relapse in obesity treatment: biology or behavior? Am J Clin Nutr. 1999;69(6):
1064 –1065
18. Wing RR, Hill JO. Successful weight loss maintenance. Annu Rev Nutr. 2001;21:323–341
19. Campos P, Saguy A, Ernsberger P, Oliver E, Gaesser G. The epidemiology of overweight and
obesity: public health crisis or moral panic? Int J Epidemiol. 2006;35(1):55– 60
S58
FITZGIBBON and BEECH
SUPPLEMENT ARTICLE
20. Neumark-Sztainer D, Sherwood NE, French SA, Jeffery RW. Weight control behaviors among adult
men and women: cause for concern? Obes Res. 1999;7(2):179 –188
21. Orbach S. Commentary: there is a public health crisis—its not fat on the body but fat in the mind
and the fat of profits. Int J Epidemiol. 2006;35(1):67– 69
22. Institute of Medicine. Preventing Childhood Obesity: Health in the Balance. Washington, DC:
National Academies Press; 2005
23. Brener ND, Burstein GR, DuShaw ML, Vernon ME, Wheeler L, Robinson J. Health services: results
from the School Health Policies and Programs Study 2000. J Sch Health. 2001;71(7):294 –304
24. Chomitz VR, Collins J, Kim J, Kramer E, McGowan R. Promoting healthy weight among elementary
school children via a health report card approach. Arch Pediatr Adolesc Med. 2003;157(8):
765–772
25. Gortmaker SL, Cheung LW, Peterson KE, et al. Impact of a school-based interdisciplinary intervention on diet and physical activity among urban primary school children: eat well and keep
moving. Arch Pediatr Adolesc Med. 1999;153(9):975–983
26. Johnson FL. Speaking Culturally: Language Diversity in the United States. Thousand Oaks, CA:
Sage; 2000
27. Guidry JJ, Fagan P, Walker V. Cultural sensitivity and readability of breast and prostate printed
cancer education materials targeting African Americans. J Natl Med Assoc. 1998;90(3):165–169
28. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee recommendations.
Pediatrics. 1998;102(3). Available at: www.pediatrics.org/cgi/content/full/102/3/e29
29. Himes JH, Dietz WH. Guidelines for overweight in adolescent preventive services: recommendations from an expert committee. The Expert Committee on Clinical Guidelines for Overweight in
Adolescent Preventive Services. Am J Clin Nutr. 1994;59(2):307–316
30. Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention,
assessment, and treatment of child and adolescent overweight and obesity: summary report.
Pediatrics. 2007;120(suppl 4):S164 –S192
31. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods
and development. Vital Health Stat 11. 2002;(246):1–190
32. Story M, Evans M, Fabsitz RR, Clay TE, Holy Rock B, Broussard B. The epidemic of obesity in
American Indian communities and the need for childhood obesity-prevention programs. Am J
Clin Nutr. 1999;69(4 suppl):747S–754S
33. Zephier E, Himes JH, Story M, Zhou X. Increasing prevalences of overweight and obesity in
Northern Plains American Indian children. Arch Pediatr Adolesc Med. 2006;160(1):34 –39
34. Scheier LM. School health report cards attempt to address the obesity epidemic. J Am Diet Assoc.
2004;104(3):341–344
35. US Preventive Services Task Force. Screening and interventions for overweight in children and
adolescents: recommendation statement. Pediatrics. 2005;116(1):205–209
36. Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force. Pediatrics.
2005;116(1). Available at: www.pediatrics.org/cgi/content/full/116/1/e125
37. Ikeda JP, Crawford PB, Woodward-Lopez G. BMI screening in schools: helpful or harmful. Health
Educ Res. 2006;21(6):761–769
38. Johnson A, Ziolkowski GA. School-based body mass index screening program. Nutr Today. 2006;
41(6):274 –279
39. Kantor J. As obesity fight hits cafeteria, many fear a note from school. The New York Times.
January 8, 2007:A14
40. Story M, Kaphingst KM, French S. The role of schools in obesity prevention. Future Child. 2006;
16(1):109 –142
41. Rhee KE, De Lago CW, Arscott-Mills T, Mehta SD, Davis RK. Factors associated with parental
readiness to make changes for overweight children. Pediatrics. 2005;116(1). Available at:
www.pediatrics.org/cgi/content/full/116/1/e94
42. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from
childhood and parental obesity. N Engl J Med. 1997;337(13):869 – 873
43. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become
obese adults? A review of the literature. Prev Med. 1993;22(2):167–177
44. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with
overweight and obesity. JAMA. 1999;282(16):1523–1529
45. Fitzgibbon ML, Stolley MR. Environmental changes may be needed for prevention of overweight in
minority children. Pediatr Ann. 2004;33(1):45– 49
PEDIATRICS Volume 124, Supplement 1, September 2009
S59
46. Resnicow K, Taylor R, Baskin M, McCarty F. Results of Go Girls: a weight control program for
overweight African-American adolescent females. Obes Res. 2005;13(10):1739 –1748
47. Powell AD, Kahn AS. Racial differences in women’s desires to be thin. Int J Eat Disord. 1995;17(2):
191–195
48. Kumanyika S. Obesity, health disparities, and prevention paradigms: hard questions and hard
choices. Prev Chronic Dis. 2005;2(4):A02
49. Abrams KK, Allen LR, Gray JJ. Disordered eating attitudes and behaviors, psychological adjustment, and ethnic identity: a comparison of black and white female college students. Int J Eat
Disord. 1993;14(1):49 –57
50. Akan GE, Grilo CM. Sociocultural influences on eating attitudes and behaviors, body image, and
psychological functioning: a comparison of African-American, Asian-American and Caucasian
college women. Int J Eat Disord. 1995;18(2):181–187
51. Fitzgibbon M, Spring B, Avellone M, Blackman L, Pingitore G, Stolley M. Correlates of binge eating
in Hispanic, black and white women. Int J Eat Disord. 1998;24(1):43–52
52. Chang VW, Christakis NA. Self-perception of weight appropriateness in the United States. Am J
Prev Med. 2003;24(4):332–339
53. Maynard LM, Galuska DA, Blanck HM, Serdula MK. Maternal perceptions of weight status of
children. Pediatrics. 2003;111(5 pt 2):1226 –1231
54. He M, Evans A. Are parents aware that their children are overweight or obese? Do they care? Can
Fam Physician. 2007;53(9):1493–1499
55. Miller JC, Grant AM, Drummond BF, Williams SM, Taylor RW, Goulding A. DXA measurements
confirm that parental perceptions of elevated adiposity in young children are poor. Obesity.
2007;15(1):165–171
56. Crawford D, Timperio A, Telford A, Salmon J. Parental concerns about childhood obesity and the
strategies employed to prevent unhealthy weight gain in children. Public Health Nutr. 2006;9(7):
889 – 895
57. Carnell S, Edwards C, Croker H, Boniface D, Wardle J. Parental perceptions of overweight in 3–5
y olds. Int J Obes (Lond). 2005;29(4):353–355
58. Jeffery AN, Voss LD, Metcalf BS, Alba S, Wilkin TJ. Parents’ awareness of overweight in themselves
and their children: cross sectional study within a cohort (EarlyBird 21). BMJ. 2005;330(7481):
23–24
59. Killion L, Hughes SO, Wendt JC, Pease D, Nicklas TA. Minority mothers’ perceptions of children’s
body size. Int J Pediatr Obes. 2006;1(2):96 –102
60. Adams AK, Quinn RA, Prince RJ. Low recognition of childhood overweight and disease risk among
Native-American caregivers. Obes Res. 2005;13(1):146 –152
61. Rich SS, DiMarco NM, Huettig C, Essery EV, Andersson E, Sanborn CF. Perceptions of health status
and play activities in parents of overweight Hispanic toddlers and preschoolers. Fam Community
Health. 2005;28(2):130 –141
62. Katz ML, Gordon-Larsen P, Bentley ME, Kelsey K, Shields K, Ammerman A. “Does skinny mean
healthy?” Perceived ideal, current, and healthy body sizes among African-American girls and
their female caregivers. Ethn Dis. 2004;14(4):533–541
63. Myers S, Vargas Z. Parental perceptions of the preschool obese child. Pediatr Nurs. 2000;26(1):
23–30
64. Young-Hyman D, Herman LJ, Scott DL, Schlundt DG. Care giver perception of children’s obesityrelated health risk: a study of African American families. Obes Res. 2000;8(3):241–248
65. May AL, Donohue M, Scanlon KS, et al. Child-feeding strategies are associated with maternal
concern about children becoming overweight, but not children’s weight status. J Am Diet Assoc.
2007;107(7):1167–1175
66. Watkins MG, Clark KM, Foster CM, Welch KB, Kasa-Vubu JZ. Relationships among body mass index,
parental perceptions, birthweight and parental weight after referral to a weight clinic. J Natl
Med Assoc. 2007;99(8):908 –913
67. Eckstein KC, Mikhail LM, Ariza AJ, Thomson JS, Millard SC, Binns HJ; Pediatric Practice Research
Group. Parents’ perceptions of their child’s weight and health. Pediatrics. 2006;117(3):681– 690
68. Boutelle K, Fulkerson JA, Neumark-Sztainer D, Story M. Mothers’ perceptions of their adolescents’ weight status: are they accurate? Obes Res. 2004;12(11):1754 –1757
69. Jain A, Sherman SN, Chamberlin DL, Carter Y, Powers SW, Whitaker RC. Why don’t low-income
mothers worry about their preschoolers being overweight? Pediatrics. 2001;107(5):1138 –1146
70. Baughcum AE, Chamberlin LA, Deeks CM, Powers SW, Whitaker RC. Maternal perceptions of
overweight preschool children. Pediatrics. 2000;106(6):1380 –1386
71. Dibley MJ, Goldsby JB, Staehling NW, Trowbridge FL. Development of normalized curves for the
S60
FITZGIBBON and BEECH
SUPPLEMENT ARTICLE
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
international growth reference: historical and technical considerations. Am J Clin Nutr. 1987;
46(5):736 –748
Hamill PV, Drizd TA, Johnson CL, Reed RB, Roche AF, Moore WM. Physical growth: National Center
for Health Statistics Percentiles. Am J Clin Nutr. 1979;32(3):607– 629
Kuchler F, Variyam JN. Mistakes were made: misperception as a barrier to reducing overweight.
Int J Obes Relat Metab Disord. 2003;27(7):856 – 861
Baturka N, Hornsby PP, Schorling JB. Clinical implications of body image among rural AfricanAmerican women. J Gen Intern Med. 2000;15(4):235–241
Airhihenbuwa CO, Webster JD. Culture and African contexts of HIV/AIDS prevention, care and
support. Sahara J. 2004;1(1):4 –13
Airhihenbuwa CO, Kumanyika S, Agurs TD, Lowe A. Perceptions and beliefs about exercise, rest,
and health among African-Americans. Am J Health Promot. 1995;9(6):426 – 429
Hill RB. The Strengths of African American Families: Twenty-Five Years. Lanham, MD: University
Press of America; 1999
Castex G. Providing services to Hispanic/Latino populations: profiles in diversity. Soc Work.
1994;39(3):288 –296
Marin G, Marin BV. Research With Hispanic Populations. Newbury Park, CA: Sage; 1991
Erwin DO, Johnson VA, Trevino M, Duke K, Feliciano L, Jandorf L. A comparison of African American and Latina social networks as indicators for culturally tailoring a breast and cervical
cancer education intervention. Cancer. 2007;109(2 suppl):368 –377
Huff RM, Kline MV. Tips for working with Hispanic populations. In: Huff RM, Kline MV, eds. Promoting Health in Multicultural Populations: A Handbook for Practitioners. Thousand Oaks, CA:
Sage; 1999:189 –197
Kumanyika SK, Morssink C, Agurs T. Models for dietary and weight change in African-American
women: identifying cultural components. Ethn Dis. 1992;2(2):166 –175
Baquet CR, Hunter CP. Patterns in minorities and special populations. In: Greenwald P, Kramer B,
Weed DL, eds. Cancer Prevention and Control. New York, NY: Marcel Dekker; 1995:23– 86
Falicov DJ. Mexican families. In: McGoldrick M, Giordano J, Pearce JK, eds. Ethnicity and Family
Therapy. 2nd ed. New York, NY: Guilford; 1996:169 –182
James DCS. Factors influencing food choices, dietary intake, and nutrition-related attitudes
among African Americans: application of a culturally sensitive model. Ethn Health. 2004;9(4):
349 –367
Mandelblatt JS, Gold K, O’Malley AS, et al. Breast and cervix cancer screening among multiethnic
women: role of age, health, and source of care. Prev Med. 1999;28(4):418 – 425
Kennedy BM, Paeratakul S, Champagne CM, et al. A pilot church-based weight loss program for
African-American adults using church members as health educators: a comparison of individual
and group intervention. Ethn Dis. 2005;15(3):373–378
Sbrocco T, Carter MM, Lewis EL, et al. Church-based obesity treatment for African-American
women improves adherence. Ethn Dis. 2005;15(2):246 –255
Fitzgibbon ML, Stolley MR, Ganschow P, et al. Results of a faith-based weight loss intervention for
black women. J Natl Med Assoc. 2005;97(10):1393–1402
Navarro AM, Senn KL, Kaplan RM, McNicholas L, Campo MC, Roppe B. Por la Vida intervention
model for cancer prevention in Latinas. J Natl Cancer Inst Monogr. 1995;(18):137–145
O’Malley A, Kerner J, Johnson A, Mandelblatt J. Acculturation and breast cancer screening
among Hispanic women in New York City. Am J Public Health. 1999;89(2):219 –227
Navarro AM, Senn KL, McNicholas LJ, Kaplan RM, Roppe B, Campo MC. Por la Vida model intervention enhances use of cancer screening tests among Latinas. Am J Prev Med. 1998;15(1):
32– 41
Altpeter M, Earp JA, Bishop C, Eng E. Lay health advisor activity levels: definitions from the field.
Health Educ Behav. 1999;26(4):495–512
Earp JA, Viadro CI, Vincus AA, et al. Lay health advisors: a strategy for getting the word out about
breast cancer. Health Educ Behav. 1997;24(4):432– 451
Sung JF, Blumenthal DS, Coates RJ, Williams JE, Alema-Mensah E, Liff JM. Effect of a cancer
screening intervention conducted by lay health workers among inner-city women. Am J Prev
Med. 1997;13(1):51–57
Bailey EJ, Erwin DO, Belin P. Using cultural beliefs and patterns to improve mammography
utilization among African-American women: the Witness Project. J Natl Med Assoc. 2000;92(3):
136 –142
Bleich S, Blendon R, Adams A. Trust in scientific experts on obesity: implications for awareness
and behavior change. Obesity. 2007;15(8):2145–2156
PEDIATRICS Volume 124, Supplement 1, September 2009
S61
98. Wasserman J, Flannery MA, Clair JM. Raising the ivory tower: the production of knowledge and
distrust of medicine among African Americans. J Med Ethics. 2007;33(3):177–180
99. Corbie-Smith G, Thomas SB, St George DMM. Distrust, race, and research. Arch Intern Med.
2002;162(21):2458 –2463
100. Coon HM, Kemmelmeier M. Cultural orientations in the United States. J Cross Cult Psychol.
2001;32(3):348 –364
101. Crawford P, Woodward-Lopez G, Ikeda J. Weighing the risks and benefits of BMI reporting in the
school setting. Available at: http://nature.berkeley.edu/cwh/PDFs/BMI㛭report㛭cards.pdf. Accessed March 18, 2009
102. Ikeda JP, Lyons P, Schwartzman F, Mitchell RA. Self-reported dieting experiences of women with
body mass indexes of 30 or more. J Am Diet Assoc. 2004;104(6):972–974
103. Holzman P. Pa. wants schools to battle obesity. Intelligencer Journal. December 10, 2003:A-1
104. Dishongh K. State’s antifat crusade peeves parents, others: report cards to include kids’ body
mass index. Arkansas Democrat-Gazette. August 10, 2003;1A
105. Westwood M, Fayter D, Hartley S, et al. Childhood obesity: should primary school children be
routinely screened? A systematic review and discussion of the evidence. Arch Dis Child. 2007;
92(5):416 – 422
106. Kubik MY, Fulkerson JA, Story M, Rieland G. Parents of elementary school students weigh in on
height, weight, and body mass index screening at school. J Sch Health. 2006;76(10):496 –501
107. Justus MB, Ryan KW, Rockenbach J, Katterapalli C, Card-Higginson P. Lessons learned while
implementing a legislated school policy: body mass index assessments among Arkansas’s public
school students. J Sch Health. 2007;77(10):706 –713
108. Haller EC. The Role of Michigan Schools in Promoting Healthy Weight. Lansing, MI: Department of
Education; 2001
109. California Department of Education. 2005 California Physical Fitness Test: Report to the Governor
and Legislature. Sacramento, CA: California Department of Education; 2005
110. Michigan Department of Education, Department of Community Health. Healthy Kids Healthy
Weight. Lansing, MI: Michigan Department of Education; 2004
111. Kubik MY, Story M, Rieland G. Developing school-based BMI screening and parent notification
programs: findings from focus groups with parents of elementary school students. Health Educ
Behav. 2007;34(4):622– 633
112. Associated Press. School district shows early success in fighting childhood obesity. The Associated Press. January 1, 2005
113. Johnson SH. Dear parents. The Tampa Tribune. November 8, 2004. Available at: http://
tampatrib.com/MGBI0WH3A1E.html. Accessed March 19, 2009
114. Brownell KD. The chronicling of obesity: growing awareness of its social, economic, and political
contexts. J Health Polit Policy Law. 2005;30(5):955–964
115. Ariza AJ, Chen EH, Binns HJ, Christoffel KK. Risk factors for overweight in five- to six-year-old
Hispanic-American children: a pilot study. J Urban Health. 2004;81(1):150 –161
116. Etelson D, Brand DA, Patrick PA, Shirali A. Childhood obesity: do parents recognize this health
risk? Obes Res. 2003;11(11):1362–1368
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