Immigration and weight gain: Mexican-American women’s perspectives

Obesity increases overall mortality [1-4] and is an important risk factor for chronic conditions such as diabetes and cardiovascular disease.[5-11] In the United States, obesity affects ethnic minority communities at disproportionately high levels.[12-14] Immigrants from Spanish-speaking countries and their descendants are the largest ethnic minority in the United States, a population estimated at over 40 million. Two thirds of the Hispanic population in the United States (26.8 million) are Mexican-Americans. [15] They are among the groups most at risk for obesity and its consequences, with almost 75% of the Hispanic population being overweight and nearly 35% obese.[16]

Relatively little information is available regarding the effectiveness of conventional weight-loss programs among Hispanics. However, the few available studies that provide a comparison have shown that Hispanics tend to lose less weight than non-Hispanic whites, and are more likely to regain weight at follow-up.[17-23] While the results of these interventions may reflect biological characteristics of Hispanic participants, they also reflect treatment variables related to implementation approaches, cultural concerns, and socioeconomic factors.[24;25]

Due to cultural differences, ethnic minorities and health care providers often have opposing views about the desirability of losing weight. For example, weight loss is often viewed in Hispanic cultures as a symptom of illness and a sign of frailty, and may be associated with low sexual attractiveness.[26] Symbolically, an overweight woman may be seen as being well taken care of, and she in turn may be assumed to take good care of her children. In traditional Mexican culture, being overweight may be considered a symbol of maternity and nurturance, a figurative association which increases the cultural acceptability of obesity.[27]

Given the impact of socio-cultural factors on body image and dietary behavior, it is clear that culture must play a central role in the development of weight-loss interventions for ethnic minority populations. Weight-loss interventions targeting Mexican-Americans may need to go beyond simply translating protocols and hand-outs into Spanish, and instead must address the emotional, socioeconomic, and cultural factors that intervene in individuals’ decision to change their dietary behavior, and their ability to adhere to this decision.

However, little information exists on Mexican-American women’s attitudes and beliefs about their dietary habits, weight loss, and the barriers they encounter to dietary change. As a first step in developing culturally-sensitive weight-loss interventions for this population, this study investigated Mexican-American women’s perspectives and experiences regarding weight, diet, and weight loss. These results will be invaluable to researchers and practitioners designing weight loss interventions for Mexican American women.

Methods

Research Design

Focus groups were conducted to obtain information about the attitudes, beliefs and concerns of Mexican-American immigrant women regarding weight, diet, and weight loss. This methodology was selected because it stimulates interaction and participation, [28] and has been recommended as a culturally-appropriate research method in Hispanic populations.[29-31]

Recruitment

Participants were recruited through announcements and flyers distributed at businesses, community centers, and agencies serving the Mexican community in Portland, Oregon. Mexican-born women over the age of 18, able to provide written consent, were invited to participate in the study. No additional screening criteria were used, including overweight status, length of residence in the United States, or language preference.

Participants

With approval from the Kaiser Permanente Northwest’s institutional review board, focus groups were conducted between October of 2006 and February of 2007. Four focus groups were conducted with a total of 25 women, with group sizes ranging from 4 to 10 participants. Following informed consent, the following information was collected from each participant: date of birth, place of residence before moving to the United States, length of residence in the United States, language spoken at home, years of education, occupation, and marital status.

Data collection

We took a phenomenological approach to understand participants’ experiences and perspectives, and avoid imposing external views. Group sessions were facilitated by a bilingual Mexican clinical psychologist and were conducted in Spanish per participants’ preference. Notes were taken at each focus group and all sessions were audiotaped. Analysis of the information was based on audiotapes and field notes. After the focus groups, transcriptions in Spanish were made of the tapes and field notes. Transcripts were analyzed in a systematic manner, with the objective of finding commonly recurring themes, trends, and patterns within group discussions relating to food choices, and weight-loss/weight-gain behaviors. Words used, context, internal consistency, specificity of responses, and overlying themes were considered. Tone and nonverbal communication were assessed using the investigator’s field notes.

Data analysis

Analysis of the information was made following the principles of qualitative research described by Morgan.[32] A matrix of the main topics was created for each focus group. Codes were developed across the focus groups from the matrix; key words and common themes that appeared throughout the group sessions were identified and coded. The analysis process involved consideration of words, tone, content, non verbal communications, and specificity of responses.[33]

Results

Demographics

Twenty-five women participated in the study. Participants were 20 to 63 years of age, with a mean age of 36 years. All participants were born in Mexico, with 76% (N = 19) having emigrated from rural areas and 24% (N = 6) from urban centers. Length of residence in the United States ranged from 2 to 20 years, with a mean length of 7.5 years; many participants had arrived in the United States as young children.

Participants’ level of formal education ranged from 3^rd grade to two years postsecondary education, with a mean of eight years of schooling. Most participants (72%) worked in domestic service-related areas, and the remainder in retail. Most participants were married or living with a partner (64%). Household sizes ranged from 4 to 12, with an average of six people per household.

Major themes

Participants in all focus groups felt that preventing disease was extremely important, and that maintaining a healthy weight was fundamental to disease prevention. Participants were keenly aware of the high prevalence of diabetes in the Mexican-American community, and of a causal link between obesity and diabetes; most of the participants in our study had close relatives with diabetes and many were caregivers to individuals with the disease. Fear of developing diabetes or other illnesses was cited as the most important reason for wanting to lose weight.

“I don’t know anyone with no diabetes in their family. Everyone has two, three or more relatives with diabetes. It almost seems like sooner or later they will tell me I have it. And I don’t want to have it. That’s why I want to lose weight.”

This discussion generated several major recurring themes around the issues of diet, weight, and weight loss.

Theme 1: Adapting to American society

The most consistent theme was the weight gain that “everyone goes through” after moving to the United States. Asked for possible explanations for this weight increase, most women in our groups seemed puzzled at their weight gain, with most of them reporting eating less food than they used to eat in Mexico. When probed, participants explained that breakfast and lunch are not “real sit-down” meals, and thus they consider them as tentempiés (snacks) to “tide them over” until the “real comida (meal).”

Participants also reported consuming more processed foods. They reported that they have come to rely on ready-made processed foods and eating out because of the fast-paced life in the United States, with hectic schedules, little help from extended family, and little time to buy fresh produce and cook.

“You have nobody, really, to help with the kids, or with cooking, like my mother and sister used to help me back home. So you have to do it all, and you have very little time. Things like beans take a long time to cook, and you don’t have time… So you buy things that are already prepared, and some are not good for you... But there is no time to eat properly, anyway…”

Participants also mentioned finding and enjoying new foods. Their dietary horizons have expanded with the discovery of lasagna, Chinese food, and donuts. They reported that living in the United States allows them to eat out or to buy foods that they could not afford in Mexico.

“In Mexico, nobody –really, nobody—ever had ice cream in their freezer at home. You went out for an ice-cream cone on Sundays, when you took a walk... Here, I always have ice cream in the freezer, several flavors...”

Many participants reported that among the biggest changes in their eating habits is stopping at fast-food restaurants for lunch, or on their way to or from work. Participants questioned the quality of the fast food they eat, but they reported enjoying it out of convenience and because, at least initially, it gave them a feeling of being part of American culture. For many, eating “the American way” symbolized becoming part of American society.

“I don’t think about that much, any more. But when I first got here and started going [to fast-food restaurants] I remember thinking that I was doing an American thing, being like everyone else. Eating just like them, you know...? It made me feel good, like I was really living here.”

While exploring the notion of adopting “American ways,” an associated theme emerged regarding the experience of discordant ideas regarding attractiveness, health, and weight between Mexican and American societies. Nearly all participants stated that Mexican standards of attractiveness make a fuller figure desirable, as compared to what they perceive to be American standards. Many questioned the health benefits of what they perceive as the “extremely thin” American ideal body type, compared to what they consider a “healthy-looking” fuller figure.

“They call me gordita, you know. It’s a good thing to look healthy. And men like curves. Here, you are supposed to be so skinny… it’s not healthy.”

Many participants expressed that Mexican and American cultures differ in the importance attached to food. Participants stated that food plays a central role in Mexican culture, both in day-to-day family life as well as in major religious holidays or social events. By contrast, they stated that food has a relatively minor role in American social culture. As one participant summarized:

“Here, it does not seem to matter what one eats, as long as there’s a lot of it! They eat a lot here. We eat a lot here!”

Theme 2: Experiences with weight-loss attempts and need for nutritional information

Most participants reported they were making an effort to improve their health by trying to follow a healthy diet and lose weight. Their health-related changes included drinking more water, eating fewer fried foods, avoiding fast food and sweets, taking vitamins, or eating more raw vegetables. However, in spite of their awareness of the benefits of healthy eating, participants reported not being able to adhere to their plans and feeling frustrated at their inability to lose weight or maintain a healthy weight. For some, weight loss was beginning to feel like an impossible feat; as one participant stated: “Not everyone can be thin, maybe.” All participants reported having attempted to lose weight in the past by modifying their diet (avoiding fat, sweets and bread, eating smaller portions, or skipping some meals). In addition to these dietary changes, many participants reported using non-traditional weight-loss methods, including “sobadas” (traditional Mexican massage), using body-rubs of lemon-based body lotion and sea salt, drinking a small amount of vinegar before meals (“the acid burns off the fat”), or wearing neoprene girdles to “burn fat” while doing regular activities. Most participants also reported using herbal supplements with diuretic or “fat burning” properties, or unspecified “weight-loss pills” from Mexico.

Participants reported spotty methods for dieting, where eating a healthy meal or avoiding a “forbidden” food one day gave them “permission” to eat a fattening meal later. Similarly, several participants reported drinking diet soft drinks only if they had “eaten too much during the day.”

Very few participants reported reading the nutritional information label on food items; most said they find the information confusing and “worthless.”

“Look… [She holds up a box of crackers] ‘Calories from fat... Total fat… saturated fat… I don’t know why they put so many types of fat. And then there are numbers for ‘calories,’ and ‘sugars,’ and ‘fiber’ and who knows what more. Who is going to understand that? Look, the number you really look at is the price! Right…?”

Participants also complained of the difficulties of ‘dieting’ while “living in the Mexican culture of the United States,” and expressed a general feeling of “not being understood.”

“All those diets that you read about, or that you pay to go, they never talk about foods that we eat, like tortillas, or picadillo… We have to stop eating them?

Theme 3: La familia

The importance of the family in the Mexican culture, and the role that the family plays in food choices, was a frequent topic in the discussions. Most participants lived in households involving complex familial relationships and social hierarchies, where there may well be several “women of the house,” playing different roles in decision-making regarding foods and meals. Several participants lived in households that included two inter-related families.

“My mother-in-law cooks but only on Sundays, or for parties. The rest of the week I’m the one who cooks, but she does the shopping. So what we eat depends on what she decides to buy, what my husband and the children want to eat, and what I have time to cook…”

The complex multi-generational social structure of many Mexican-American households makes it difficult for women to simply decide to change their eating habits, as their decisions are likely to have significant repercussions on the entire family network. Many of our participants expressed frustration at not being free to make dietary changes because of the impact they would have on other family members.

Discussion

This study intended to be a first step in the development of culturally sensitive weight-loss interventions for Mexican-American women, shedding some light on the effects of culture on weight management. All study participants perceived that eating a healthy diet and maintaining a healthy weight were very important elements in disease prevention; this finding is in line with a previous study that found Hispanic women to be interested and motivated to increase healthy eating.[34] While generally rejecting the idea of extreme thinness as physically attractive, participants were very concerned about weight-related health problems, particularly diabetes, and all expressed great interest in achieving and maintaining a healthy weight as a way to prevent illness. It is clear that efforts to promote weight loss among Mexican-American women should address these health concerns, emphasizing that even moderate weight reductions are associated with specific health benefits, including reducing the risks of diabetes and hypertension.[35;36]

Participants in our groups believed their weight gain was related to their immigration experience. Their belief is supported by studies that have found a linear relation between obesity and length of residence in the United States among Hispanic immigrants (Dubowitz, Smith-Warner, Acevedo-Garcia, Subramanian, and Peterson, 2007).[37-39] Participants in our study found both positive and negative changes in their diets since coming to the United States: they reported having new food choices and more knowledge about healthy eating, but they also reported adopting unhealthy dietary habits, including reliance on processed foods and fast foods.

Participants’ estimation that frequenting American-style fast-food restaurants is among the biggest changes in their dietary habits is in line with recent findings that the body mass index for Mexican-American individuals tends to be highest for those who eat most often at Anglo-oriented fast-food chains, and lowest for those most frequently selecting Mexican restaurants.[40] Interventions targeting the Mexican-American population must take into consideration the acculturative pressure to integrate to American society and act “like you belong here.” Efforts to educate Hispanic immigrants regarding healthy food choices must take into account the cultural and symbolic significance of many of the food choices made by this population, and the ambivalence many Mexican Americans frequently experience about Mexican and American-style food choices.

Participants in our study had difficulties developing strategies to modify their current diets and maintaining healthy habits. They reported several attempts to “go on a diet,” only to abandon the effort: Social and family pressures to eat like others, to avoid offending others, or to partake in food-centered celebrations are among the difficulties they encounter in making long-term dietary changes. Many participants see dietary change as a personal sacrifice, an unpleasant process with little chance to succeed. Weight loss and healthy eating seem to be an unattainable idea because of the acculturative and interpersonal pressures they encounter, as well as their history of failed attempts at weight loss.

There is a clear need for behavioral interventions that provide nutritional information, as well as culturally-centered behavioral strategies to incorporate dietary changes into the social context in which these women live. Our study found a significant lack of information, and a great deal of misinformation, regarding nutrition and health. This finding supports previous calls for better access to informational resources, including nutritional information in WIC food packages, which might be particularly useful for Spanish-speaking immigrants with lower linguistic acculturation (Dubowitz, Smith-Warner, et al., 2007). Participants in our study expressed great interest in learning about the relative nutritional merits of different foods, and frustration at not being able to easily gather practical nutritional information from food packages. While all participants were aware of the benefits of a healthy diet, they frequently relied on alternative weight-loss methods, including diet pills, and herbal and folk remedies. The unpleasantness inherent in many of these methods contributes to their feeling that weight-loss efforts are necessarily disagreeable and difficult to integrate into their lives.

Family issues were raised as a barrier to dietary change. Women in our study reported lacking family support for the dietary changes they would like to implement, social isolation, and an inability to share their goals and concerns regarding weight and diet with family members. Participants spontaneously talked about the benefits of attempting weight loss en grupo, with other women with similar backgrounds; they reported longing for a supportive group which would “really understand” not only the challenges of weight loss, but also the stress inherent in adapting to a new culture.

The subjective experiences of these participants may not reflect those of other Mexican-Americans. Caution must be used when generalizing these results to other Hispanic subgroups. Despite these limitations, information gleaned from this study can inform weight-loss and dietary-change interventions relevant to Mexican-American immigrant women.