Cultural factors related to childhood and adolescent obesity in Mexico: A systematic review of qualitative studies

Summary Culture and culturally specific beliefs or practices may influence perceptions and decisions, potentially contributing to childhood obesity. The objective of this study is to identify the cultural factors (expressed through decisions, behaviors, individual experiences, perceptions, attitudes, or views) related to childhood and adolescent obesity in Mexico. Ten databases and one search engine were searched from 1995 onwards for qualitative studies. The Sunrise Enabler Model, described within the Cultural Care Theory, guided this review. Sample, the phenomenon of interest, study design, and evaluation data were extracted, and the Critical Appraisals Skills Programme tool was used to assess the quality of the included studies. Twenty‐four studies were included. Of these, 12 studies included children or adolescents, 12 included parents, eight included schoolteachers, four included school staff (other than teachers), four included food vendors, and one included policymakers. Cultural values, beliefs, lifeways (especially food and food costumes), kinship, and social factors (particularly immediate and extended family) strongly influenced childhood and adolescent obesity‐related lifestyles in Mexico. Most cultural factors related to childhood obesity in Mexico identified in this review may be modifiable and amenable to practical interventions.

Qualitative research explores how people perceive and experience certain phenomena. This type of research typically relies on interviews or observations that explore people's perceptions, beliefs, practices, and experiences in connection with their health or health care services use. 8 There can be an increased understanding of a specific phenomenon within a specific context by synthesizing qualitative evidence. Moreover, associations between broader environments and understanding the values, attitudes, and experiences of health conditions and interventions can also be achieved through the synthesis of qualitative literature. 9 Some research has been done on determining factors relevant to childhood obesity through qualitative research synthesis. 3 A previous paper by Chatham and Mixer 3 synthesized qualitative evidence of obesity-promoting factors in ethnic minorities across the United States. Such work added great value to previous research on cultural factors of obesity among Mexican-origin children or adolescents as an ethnic minority in the United States. [3][4][5] Nonetheless, the factors identified so far among Mexican-origin children and adolescents might differ from those decisions, behaviors, individual experiences, perceptions, attitudes or views in children or adolescents living in Mexico because migration and acculturation might shape some health behaviors. 5,10 Obesity rates in Mexico have been alarmingly increasing in the last decades. 11 Such rates have been notoriously high among the < 18 years old population, where it is estimated that by 2018 over 8% of infants (0-4 years), 35% of school-age children (5-11 years), and almost 40% of adolescents (12-19 years) had overweight or obesity. 12 Furthermore, interventions to either prevent 13 or treat 14 obesity among Mexican children and/or adolescents rarely consider cultural factors and focus merely on behavioral change among children and adolescents. Therefore, identifying cultural factors related to obesity among childhood and adolescent within the Mexican culture is indispensable to tackling it effectively. The "Childhood and adolescent Obesity in MexicO: evidence, challenges and opportunities" (COMO) Project intends to synthesize and use data to comprehend the extent, nature, effects, and costs of childhood and adolescent obesity in Mexico. [13][14][15][16] This review of qualitative studies is part of the COMO project and aims to identify the cultural factors (expressed through decisions, behaviors, individual experiences, perceptions, attitudes, or views) related to childhood and adolescent obesity in Mexico.

This project's systematic review was registered in The International
Prospective Register of Systematic Reviews (PROSPERO Registration number CRD42019154132), 17 and it is reported according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. 18 The research question and inclusion/exclusion criteria were defined following the Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) framework for qualitative synthesis. 19 A sensitive search was developed to include index terms, freetext words, abbreviations, and synonyms to combine the key concepts for this review (Table S1). The databases searched included MEDLINE, EMBASE, Global Health Library, LILACS, CINAHL, ERIC, PsycINFO, ScienceDirect, Scopus, AGRICOLA, and SciELO Citation Index. When possible, searches were also done in Spanish to capture relevant references. In addition, the search engine Google Scholar and the COMO project database were also searched. The COMO project database comprises over 950 references related to childhood and adolescent obesity in Mexico. 15 In addition, reference lists of included papers were scrutinized for additional publications. Abstracts were excluded from this review.
Studies published from 1995 onwards were considered in this review.
Original searches were done in January 2020 and updated in January 2022.

| Selection criteria
The eligibility criteria were based on the SPIDER framework: Sample: Studies that included (or referred to) children and adolescents ≤18 years old from any ethnicity living in Mexico were considered. Studies analyzing data on children with severe conditions (e.g., cancer, HIV, and Down syndrome) or pregnant adolescents were excluded. Also, studies of Mexican children living in a different country were excluded to avoid information inherent to the migration phenomena and acculturation.
Studies that included data from direct caregivers of children or adolescents (e.g., parents, teachers, or health professionals), indirect caregivers (e.g., school principals), and/or relevant stakeholders on childhood obesity matters (e.g., school food vendors or policymakers) were also included if the study aimed to comprehend their views and beliefs regarding childhood obesity in Mexico.
Phenomenon of Interest : Childhood and adolescent obesity in the Mexican context.
Design : Studies using any qualitative design, following any framework or theory, were included.
Evaluation : Cultural factors (expressed through decisions, behaviors, individual experiences, perceptions, attitudes, or views) reported through quotes from participants and/or interpretation of findings by study authors.
Research type : Any qualitative or mixed methods studies were considered. However, mixed methods studies were included only if the qualitative methods and results were reported separately from the quantitative analysis.

| Conceptual framework
This systematic review was conducted following the Sunrise's Cultural and Social Structure Dimensions Enabler Model described within Leininger's theory of culture care diversity and universality, also known as the cultural care theory (CCT). [20][21][22] The Sunrise's Cultural and Social Structure Dimensions Enabler Model is a cognitive guide of the theory used to guide our culture care phenomena from a holistic perspective of the multiple factors shaping the well-being of diverse cultures. 22 Such a model illustrates areas that need to be explored regarding the CCT theory principles. 22 Similar to those described by the CDC 23 Table S2).

| Data selection and extraction
Titles, abstracts, and relevant full texts were screened by three reviewers (LL, MGB, MA-M). In addition, two reviewers (MA-M and LL) independently extracted data from relevant studies. A data extraction form was developed based on the CCT theory principles 22 and piloted for this systematic review. From each included study, we recorded quotes from participants and/or interpretation of findings by study authors irrespective of whether participants' quotes supported it. Besides the free codes identified, the participants/stakeholder role was also recorded: Individual (i.e., quotes from children or adolescents); Interpersonal (e.g., quotes from direct caregivers, such as parents and teachers); Community, Institutional, or Industry (i.e., quotes from school principals or school food vendors); Policy (i.e., quotes from policymakers or academics). Papers were initially organized alphabetically and subsequently grouped under themes.

| Data analysis
A thematic synthesis using both inductive and deductive approaches was done. First, to identify the main recurring themes, reviewers conducted a line-by-line coding of the qualitative findings of each of the included studies. Next, guided by the Sunrise's Cultural and Social Structure Dimensions Enabler Model, 20-22 "free codes" (i.e., single quotes) were organized into related areas to construct "descriptive themes", then organized into "analytical themes." If appropriate, free codes were recorded in more than one descriptive or analytical theme.
Finally, codes from studies in Spanish were translated to English using the back-translation method. 26  Results were discussed among five reviewers (MA-M, LLC, NGL, YYGG, and MGB) to ensure consistency across codes and their designations to different themes. Results are reported narratively, and the main results are also tabulated. Analytic and descriptive themes are described in this review based on code density.

| Quality assessment
Methodological rigor and theoretical relevance of included studies were appraised through the Critical Appraisals Skills Programme (CASP) tool, 27 recommended for quality appraisal in qualitative evidence synthesis. CASP appraises the strengths and limitations through questions that focus on different methodological aspects of a qualitative study, such as clarity of the aim, methods appropriateness, or data collection. Included studies were quality-appraised independently by two reviewers (MAM and LLC). Any disagreement was resolved by discussion with a third reviewer (YYGG).

| RESULTS
After searching the different databases, 1097 references were identified, of which 28 were retrieved for full-text review. Of these, 24 studies 28-51 met the inclusion criteria for this review (Figure 1).
Code density of descriptive and analytical themes is presented in Figure 3. The results presented in this section are ordered according to the density of the themes. Those themes with a higher density are presented first. Only those with the higher densities found in more than one study are described in the following section. The complementary list of the themes (including those with a lower density and only presented in one study) can be consulted in Appendix B. In addition, some examples of free codes are presented in Table 1.

| Food and food customs
Across all levels (i.e., individual, interpersonal, community/industry, or policy), food and food customs were the descriptive themes most frequently associated with childhood or adolescent obesity. Overall, the conception of a good diet was limited to consuming fruits and vegetables. 30,33,35,38,41,45,46,48,49 In the narratives, the term "junk food" usually refers to ultra-processed products with high fat, salt, and/or sugar content (e.g., crisps or candies) and were considered "unhealthy products." 33,35,36,42,43 Nevertheless, some discrepancies exist when identifying "junk" products across free codes. For instance, sodas are considered "junk" or "unhealthy products," but most drinks (including sweetened juices and sports or sugary drinks but not sodas) were considered "healthy" by children, parents, and teachers. 33,35,36,[41][42][43] Also, parents often categorize cereals or starchy carbohydrates as "unhealthy," including "tortillas," made of cornflour and the Mexican cuisine base. [33][34][35][36][37]42,47,49 Children and some parents associate food's quantity (rather than quality) with obesity. 32,46,49 Additionally, children prioritize food's flavor over its nutritional value. 30,32,33,35,38,46,48,49,51 The relevance of taste in the children's food decisions was also highlighted by several parents, 33 Some children reported being susceptible to food marketing campaigns, and some parents also acknowledge such susceptibility among children. 39,46,48,49 Parents also trust marketing campaigns or slogans (e.g., "light"), which made them believe products were "healthy" options and could aid obesity prevention. 34,42,43,49,50 Additionally, one study reported that one international soda company had provided resources to reform the school. Hence, teachers at the school promoted the consumption of such products among students to get further benefits from the company. 31

| Illness and death
Overall, childhood and adolescent obesity in Mexico was perceived as an esthetic issue, not a health problem. Most children were unaware of their weight status and the detrimental short-and long-term health issues associated with overweight or obesity. 32 Children only reflected health issues related to obesity with adult relatives, not with themselves or other children. 39,40,45,46,48,49 Some children and adolescents with obesity accept having physical difficulties doing everyday tasks (e.g., agitation or lack of breath). However, these are not considered health issues. 39,40 Some children with obesity did not feel physically bad but emotionally sad because of their appearance or for not fitting in the clothes they liked. 32,39,40,46 Remarkably, several children with obesity show a lack of interest or worry when their weight issue is brought to their attention and seem reluctant to a lifestyle improvement. 30,32,38,40,44 Parents limited childhood obesity to an esthetic problem and did not consider their children's weight status as a reason to seek medical advice. 29,30,32,34,35,37,41,42,47 Most codes from parents showed an unconcern for the risks associated with childhood obesity and appeared to excuse the obesogenic behaviors of their children. 29,30,32,34,35,37,42,47,51 Some parents showed concerns about tooth decay in children with obesity but not to potential comorbidities related to obesity. 34,47,49 Teachers and school principals also normalized overweight among students. 30,35

| Dietary habits
Participants acknowledge a gastronomic transition, and most believe this is an obesity risk factor. Homemade foods are given more value and are believed to be a "healthier" option. 33,35,37,38,46,48,49,51 However, most participants consider some foods sold at school canteens or street food businesses as "homemade type," hence "healthy." 30,32,35,46,[48][49][50] Traditional dishes (e.g., "tacos" or "enchiladas") seem to be valued by children and parents and are considered an ideal option to be provided as family meals. 30,33,41,46,49,51 Only a few parents noticed that traditional dishes are not always the "healthiest" option, especially if eaten away from home. 37,42 No children associated cooking methods with a higher risk of obesity. However, parents and teachers acknowledged that some cooking methods (e.g., steamed) might be "healthier" than others (e.g., fried). Even though cooking methods such as breaded or fried are considered "unhealthy," mothers report using them because it is the only way children accept to eat certain foods (e.g., vegetables or fish). 30,[33][34][35][36]42,43,47,49 In addition, mothers perceive in children selectiveness and resistance towards certain foods (e.g., vegetables), and if served at home, some feel they are providing their children with foods they dislike. 33

F I G U R E 3 Heatmap of identified themes
Children, parents, and teachers recognize sugary drinks as part of the children's daily diets and are often associated with happiness or as a comfort beverage. 35,41,42,46,48,49,51 Some parents and teachers identify sugary drinks as "unhealthy"; however, they kept serving them for acceptability with children. 32,41,43 In most narratives, traditional Mexican  dishes  were  usually  complemented  with  soft drinks. 35,41,42,46,48,49,51 Some parents try to limit these drinks at home but report that children are highly exposed to them in out-of-home environments. 32,34,41,42 Children and mothers acknowledge the importance of different food meals throughout the day (e.g., breakfast, lunch, and dinner).
However, in most of the studies, it was highlighted that children have several opportunities to eat inside the schools (e.g., school canteens), outside the schools (e.g., street food vendors), and at home (or relative's homes) in a single day. 35,36,38,46 However, only parents recognized this as a potentially "unhealthy" lifestyle leading to obesity. 32

| Physical activity
Overall, children consider physical activity a weight management strategy rather than a recreational activity or healthy lifestyle. 36,[38][39][40]45 Children perceive that those peers with obesity might experience some difficulties when exercising because of the excess weight. 39,40,45 Parents also consider physical activity a weight management strategy, 29,34,42,47 and some mentioned challenges while trying to perform physical activities with their children (e.g., children's dislike, costs, safety, or lack of time). 29,34,42,43,47,51 Teachers and health professionals at schools acknowledge the importance of physical activity in obesity prevention. 28 At an interpersonal level, parents and extended family (e.g., grandmothers) believe that a "chubby child" is a healthy child. 29,30,34,37,42 Some believe that children will undergo a "growth spurt" after a weight gain or might have "big-bones." 29,34,37,42 Some mothers believe children should eat more than adults because "they use more energy." 32,37 As a result, parents and extended family (e.g., grandmothers) underestimate childhood obesity. 29,32,34,42,47 Some recognized obesity as a disease (only in adults) and expressed more concerns about avoiding nutrient deficiencies and being underweight among children than having overweight. 42,47 Across all the free codes identified, a pattern was seen where mothers used synonyms with positive connotations when referring to children with obesity (e.g., "he is gaining a little weight," "he is robust, not fat," and "she is a bit chubby"). 29 Unanimously, children and adolescents acknowledge their mothers as primary care and primary food providers. Whether working or unemployed, mothers are recurrently pointed out as the primary provider and decision-makers with the food offered at home. 33,41,45,46,48,49 According to children's descriptions of family dynamics, third parties (e.g., their father or grandparents) consent and indulge children's obesogenic behaviors, counteracting the mother's efforts to provide "healthier" foods. 34,41,42,48,51 Mothers also take full responsibility for providing food to their children. Food decisions are frequently discussed and negotiated by children, who seem to have power in household food decisions. However, it depends on the availability and economic access of the mother or the family to carry them out. 33,41,46 For working mothers or mothers with health issues (e.g., cancer), other female members from the extended family (e.g., daughters, aunts, or grandmothers) help with childcare and food provision. 33,34,38,41,42,46,47,49 Members of the extended families, especially aunts or grandmothers, seem to be more permissible and indulging regarding "junk" food given to children. 33

| Biological factors
Children and some parents believe that having childhood obesity is a consequence of having older family members with obesity. Some children believe that obesity "happens at a certain age" (but not in childhood). 37    The current review found a conflicting narrative between Mexican parents, teachers, school staff, and industry representatives about childhood and adolescent obesity "responsibilities." Parents were usually the ones to "blame" for childhood obesity. Nevertheless, stakeholders (at all levels) need to acknowledge that childhood and adolescent obesity is a shared responsibility that requires action at several levels to achieve meaningful healthy lifestyles and effective health improvements. 24,25,54 Recently, different nationwide strategies to tackle obesity among the general population have been implemented in Mexico. For instance, a 1 peso/liter tax on sugar-sweetened beverages 55,56 and a front-of-pack labeling system have been implemented. 57  givers of children at schools and homes. As shown in Figure 2  All relevant codes are reported in the main manuscript.

Illness and death
All relevant codes are reported in the main manuscript.

Dietary habits
All relevant codes are reported in the main manuscript.

Physical activity
Overall, children consider physical activity a weight management strategy rather than a recreational activity or healthy lifestyle. 2,7,12,19,22 Children perceive that those peers with obesity might experience some difficulties when exercising because of the excess weight. 7,19,22 Parents also consider physical activity a weight management strategy, 10,13,15,24 and some mentioned challenges while trying to perform physical activities with their children (e.g., children's dislike, costs, safety, or lack of time). 10,11,13,15,17,24 Teachers and health professionals at schools acknowledge the importance of physical activity in obesity prevention. 11,12,18 Nevertheless, most report not having a structured physical education class or lacking knowledge on motivating children to engage effectively in physical activities. 11,12,18 Some teachers also mentioned they did not encourage physical activities since children are "at risk of getting injuries" or "generating complaints from parents." 11

Eating rituals
All relevant codes are reported in the main manuscript.

Beliefs about health
All relevant codes are reported in the main manuscript.

Sedentary lifestyles
All relevant codes are reported in the main manuscript.

Kinship and social factors
Family (immediate and extended) All relevant codes are reported in the main manuscript.

Child-feeding practices
All relevant codes are reported in the main manuscript.

Parental role
All relevant codes are reported in the main manuscript.
Friendship, social ties, and social support Children highlight that their weight status and how peers react to it define friendships. 2,19 Some children reported that obesity represented a problem only when bullied at school or home. 2,7,16,19,22 Some free codes at an individual level reveal the cruelty of how children with overweight and obesity can be treated and stigmatized by peers or even family members. 2,7,16,19,22 Some children experience stress from feeling rejected by their peers. 19,22 Social isolation and stigma of children with overweight or obesity were evident in social 2,19,22 and academic situations. 19 Some parents showed concerns about how peers might react to their child's excess weight. 24 One study reported parents witnessing their children's abuse from peers or another family members 10 .

Responsibility of obesity
All relevant codes are reported in the main manuscript.

Gender role
All relevant codes are reported in the main manuscript.

Economic factors
Ability to purchase consumer goods All relevant codes are reported in the main manuscript.
Setting (e.g., housing or school conditions)

Parents and teachers consider that being outside or in open
spaces is the major limitation for children to exercise. Insecurity in the streets and recreation areas, unsafe parks without lighting, lack of indoor spaces, poor infrastructure of public spaces, or lack of hygiene in public spaces were constantly stated by parents as a barrier for children using outdoor public facilities. 4,[11][12][13]15,17 School teachers and staff also acknowledge the lack of suitable spaces or materials for performing physical or recreational activities outside and in school settings. 11,12,18 In addition, the lack of safe water was highlighted by one study as a primary barrier to consuming plain water at schools. 5

Employment type and stability
Children constantly mentioned that working mothers struggle to prepare homemade food, eat at home, or do physical activity. 1,2,8,9,16,17 Similarly, working duties were highlighted by parents as the crucial factor for not cooking 4,12,13,15,21 or performing physical activities with their children. 12,17 Teachers also declare that the lack of time for working parents is a critical factor for feeding children adequately or engaging in physical activity. 11 Cost of living Some children, parents, and teachers know that some healthy behaviors and nutritious foods are linked to the capacity to pay for them. 9,12,13,16,21 Children pointed out that money is indispensable for acquiring nutritional and "good quality" food and for having a "better quality of life." 1,3,9,19 Children's free codes show they associate nutritious food with high prices, justifying the lack of consumption/availability. 21 Children and parents recognize that some physical activities (e.g., team sports like football) usually imply a cost, a significant limitation for enrollment. 12,13,21 Socioeconomic status Some free codes showed that children living in rural marginalized areas (regardless of the city or town) or with low socioeconomic status might experience more difficulties accessing healthy food or safe spaces to perform recreational facilities. 3,[8][9][10]17 Transportation In large cities (e.g., the capital, Mexico City), long commuting times and transportation issues were highlighted by interviewees as a primary factor of lack of time to cook healthy food or exercise with their children. 11,15,17 Food insecurity School teachers were the only stakeholders to perceive food insecurity among children. 4,11,21 They described knowing which children came from financially struggling families and reported that some children either go to school with no breakfast, eat "cheap food," insufficient, or very-inferior quality food. 4,11,21 Health care access, health care quality Parents in one study emphasized the relevance of health care in their children's obesity diagnosis or treatment. 13 However, as most parents do not perceive childhood obesity as a health issue, they find out about the weight-related matters once they take their children to other medical procedures (e.g., vaccination). 13 Technological factors Access to computers/internet, social media, communication All relevant codes are reported in the main manuscript.

Policy
All relevant codes are reported in the main manuscript.

Government
Only one study 20 interviewed academics, deputies, and policymakers, which pointed out the importance (and the lack) of national regulations and governmental actions to protect children's right to healthy eating, necessary for Mexican children and adolescents' growth and proper development.

Access to education
All relevant codes are reported in the main manuscript.

Education disparity
Only one study reported the effects that obesity might have on learning outcomes. The authors concluded that adolescents' stigmatization and social isolation with obesity generate a substantial education disparity. Adolescents with obesity were at a higher risk of missing classes, not working teams, or not returning homework 19 .

Child labor
Only one study 21 stated that children from rural or marginalized areas are essential for the daily subsistence of the household, which requires the work of both parents and, sometimes, of the children making it challenging for families, especially children, to maintain healthy lifestyles.

Biological factors
All relevant codes are reported in the main manuscript.