Introduction

Child obesity is one of the most serious public health problems of the 21st century, characterized by the increase in body fat deposits as a result of the consumption of foods rich in carbohydrates and fats, such as bread, pasta and chocolate; it is currently considered a pandemic due to the number of people affected. In Mexico, by 2018, the population aged 5 to 11 years was 18% overweight and it is increasing as age increases ^1,2. Therefore, it is necessary and urgent to address it through actions that focus primarily on the promotion of healthy lifestyles. If we do not intervene, over time, it becomes chronic and causes health consequences and the development of non-transmissible diseases ².

Obesity is a multifactorial disorder that involves genetic, metabolic, psychosocial and environmental factors, but undoubtedly the inadequate parental perception of the nutritional status of their children is a major factor of great impact; not perceiving the obesity and overweight of their children limits actions to modify unhealthy lifestyles ³. On the other hand, there are people who know about the disease and its possible consequences; however, in their families they continue to observe these conditions without modifying deficient eating habits and physical activity, which are essential to intervene to prevent and reduce the disease ⁴. Thus, childhood obesity derives mainly from poor eating habits learned in the family and social environment; however, there are also physical inactivity, poor sleep habits and genetic causes. As a result, obese children tend to suffer from respiratory distress, diabetes, hypertension, fractures, cancer and psychological problems ⁵.

It is important to consider that families in a globalized world have adapted to different ways of acquiring food, especially due to socioeconomic aspects, which, for example, to a certain extent facilitate food quickly and at an economic cost, although most of them are unhealthy ⁶. This, in combination with television advertising and food promotion through information and communication technologies, without underestimating the educational level of parents, influences their decision, thus favoring an unhealthy eating style ⁽⁷. Tarqui-Mamani ⁽⁸ shows that the higher educational level of the head of household is related to obesity in schoolchildren, due to the better purchasing power, which favors children to watch television, access to electronic games and have motorized transport, which together reduce their physical activity. Also, there is the ease of giving them money for the purchase of food that is not supervised. Moreover, the continuous incorporation of women to work outside the home, together with their role as the main responsible for food preparation, influences school children's nutrition by reducing food preparation at home; likewise, by having to resort to processed products rich in refined sugars and fats, which are quick to prepare and consume ^(7,9.

These inadequate dietary practices and the deficit of physical activities cause an increase in childhood overweight and obesity indicators. In the National Health and Nutrition Survey (ENSANUT for its acronym in Spanish “Encuesta Nacional de Salud y Nutrición”) 2018, the prevalence of overweight and obesity in school-age children in Mexico increased by 1.1% compared to 2012; which clearly shows that obesity is still present; likewise, Yucatan, Mexico is among the states with an increase in the prevalence of children with obesity, with 19.1% ⁽¹⁰.

In view of the above, it can be identified that the dietary practices of parents are influenced by environmental, economic and labor conditions, cultural habits, skills, knowledge and beliefs that should be considered when planning nursing care, since they limit or favor its implementation in the family ⁽¹¹.

The nursing role at the community level will always be a fundamental piece for the prevention and promotion of health, since it has the capacity to deal with health situations that require teaching and education of the family or community ⁽¹². One of the tools used by nursing to achieve these objectives are the Nursing Care Plans (PLACE for its acronym in Spanish “Planes de Cuidados de Enfermería”), through which care is provided in a holistic manner and allows decisions to be made about the health-disease process through the assessment, analysis and interpretation of the findings, the decision of the nursing interventions to be carried out and the way to evaluate the results to be obtained ⁽¹³.

The Nursing Theory of the Self-Care Deficit (TEDA for its acronym in Spanish “Teoría Enfermera del Déficit del Autocuidado”) offers the nursing professional the tools for quality care, among which we can highlight the care of sick people, who choose decisions to improve their health, and healthy people who wish to maintain or modify risk behaviors ⁽¹⁴. In his theory, he defines the basic conditioning factors as those that condition the self-care activity of a person at specific times and under specific circumstances; the self-care requirements (universal, developmental and deviation of health), as the expressions of the objectives to be achieved when intentionally dealing with self-care; a nursing system points out how the nursing professional will contribute to overcome the deficit and that the person recovers self-care and, the methods of assistance, are a sequential series of actions that will resolve or compensate for the limitations associated with the health of people, who are committed to perform their self-care; these are: acting or doing on behalf of another, guiding and directing, offering physical or psychological support, providing and maintaining an environment that fosters personal development, and teaching ⁽¹⁵.

Inclusion of the TEDA applied to parents of overweight or obese children through the PLACE, guides them effectively in decision making for the acquisition of knowledge and adequate habits regarding healthy eating and nutrition; as well as to recognize its importance and incorporation in their behavior to achieve adequate self-care in themselves and, therefore, in the other members of their family ⁽¹⁶. The objective of this study was to carry out a PLACE aimed at parents of children with overweight or obesity that could be implemented within the family environment, through nursing actions that would have an impact on the modification or improvement of family nutrition.

Methodology

Methodology proposed for the elaboration of the Nursing Care Plan was used, as established by the current guidelines of the Permanent Nursing Commission (CPE) in Mexico, whose phases are: determination of the problem, construction of the nursing diagnosis, selection of results and selection of nursing interventions ¹⁷. For the delimitation of the problem, first, a nursing assessment was made to 30 parents from Cuncunul, a Mayan community in Yucatan, Mexico, who had overweight or obese children aged 5 to 11 years, who wished to participate voluntarily and gave their informed consent, in order to know the usual diet and frequency of food consumption, feeding practices in the family and beliefs and knowledge about childhood obesity. The degree of obesity of the children was determined by means of the World Health Organization's body mass index table for children aged 5 to 18 years, and the quantification of weight and height by means of a mechanical floor scale with a capacity of 150 kg and a portable stadiometer previously calibrated.

The following instruments were used in the assessment: a) Usual diet and frequency of food consumption ¹⁸, b) Comprehensive Feeding Practices Questionnaire (CFPQ) ¹⁹, c) Obesity Belief Scale in Children (ECOI) ²⁰ and d) Parents'/guardians' perception of nutrition and physical activity in school children ²¹. After the assessment and through the results obtained, for the construction of the nursing diagnoses, an analysis of the assessment was carried out with the TEDA, proposed by the Faculty of Nursing ²² for the identification of the human responses of parents of families with school children with overweight or obesity. This analysis made it possible to identify a) basic conditioning factors and b) self-care requirements (universal, developmental and health deviation) ¹⁵. The diagnoses were written based on the North American Nursing Diagnosis Association (NANDA) taxonomy ²³. The writing of the PLACE, which integrate the selection of nursing outcomes and interventions, was carried out using the Nursing Interventions Classification (NIC) ²⁴ and the Nursing Outcomes Classification (NOC) ²⁵ taxonomies; likewise, the planning of nursing interventions was considered according to the TEDA when specifying the nursing systems: totally compensatory (TC), partially compensatory (PC) and supportive-educational (EA). In this PLACE proposal, the NIC nursing actions were referred to as assistance methods.

The study was based on the Regulations of the General Law of Health (LGS for its acronym in Spanish) on Health Research, title two, chapter 1, Art.13, 14, 16 and 17. According to Article 13, the dignity of the parents/guardians was respected, their rights and welfare prevailed; according to Article 14, paragraph VII, a favorable opinion was obtained from the Ethics and Research Committee of the Faculty of Nursing, with registration number 21/18; the privacy of the research subjects was ensured as stipulated in Article 16 and, according to Article 17, the present research is classified as non-risk research. Furthermore, according to Art. 20, 21 and 22, informed consent was applied in writing and under the requirements proposed by the LGS, free of coercion and under the full knowledge of the participants regarding the activities performed in the research. Finally, Chapter 2, Art. 28 and 29, due to the authorization of health and civil authorities of the community ²⁶.

Results

According to the results of the anthropometric measurements in children, overweight and obesity were identified more frequently in male than in female schoolchildren and, with respect to age, more frequently in boys and girls aged 8 and 11 years, and less frequently in boys and girls aged 6 and 7 years.

The analysis of the nursing assessment with the TEDA allowed the following data to be identified as basic conditioning factors and self-care requirements: the parents had an average age of 33 years, they were women, the developmental stage was the adult stage, nutritional health status was inadequate in all the families, the identified life patterns were the consumption of modern processed foods and physical inactivity.

Among the family system factors were relatives and children with overweight or obesity; among the sociocultural factors, the lack of involvement of the children in the purchase and planning of meals stood out, and the predominant perception was that obese children are healthier than thin children. As for the availability of resources, a low level of schooling, dedication to agriculture, grocery trade, employees, housewives, and lack of healthy foods in the family predominated.

With respect to the self-care requirements affected, among the universal requirements, the maintenance of a sufficient food intake and a balance between activity and rest were identified. In the developmental requirements, preventing or overcoming the effects of conditions and life situations that can negatively affect human development and, finally, in the health deviation requirement, overweight and obesity in school children have been identified.

According to the analysis undertaken, the main nursing diagnoses identified were ineffective role performance, ineffective health maintenance behaviors, deficient knowledge, tendency to adopt health risk behaviors and ineffective preschool and school feeding dynamics, which allowed the elaboration of the proposal of five PLACES that include nursing results and interventions/help methods according to the identified human responses, (Table 1).

Discussion

Based on the objective set forth in order to make a PLACE proposal aimed at parents of overweight and obese children, feasible to implement within the family environment, it was possible to identify that overweight and obesity were more prevalent in boys than in girls; with respect to age, the condition was more prevalent in boys and girls between 8 and 11 years of age. Similar results were found by Castro, et al. ²⁷, who determined that male schoolchildren were those who presented the highest prevalence of obesity in a representative population between 10 and 11 years of age. Naranjo-Orellana, et al., ²⁸ similarly, proved through a study conducted during six years in three public schools in Algaba (Seville) in boys and girls between 6 and 11 years of age that there was a tendency of weight gain in children with some of the criteria used to determine overweight and obesity; which ratifies the results observed in the present study, despite having fewer participants..

In this study, one of the basic conditioning factors that stood out was the participation of the totality of women, which is consistent with Nazar et al. ²⁹, who concluded that, in most of the studies analyzed, the sample included more mothers than fathers, so they share the opinion of considering the involvement of fathers to promote a favorable health status in children. In addition, basic conditioning factors were found to be deficient status of nutritional health in the families, together with parents with low paid jobs; likewise, a maintenance of insufficient food intake, considered in this study, as a universal self-care requirement affected in the families, which favor the lack of healthy food in the homes and the greater consumption of modern processed food, the latter, as a model of life identified in the families evaluated. In this regard, López-Sobaler, et al. ³⁰ argued in their study that some strategies should be implemented to improve the factors associated with obesity, such as low socioeconomic level in families, among others, in order to favor healthier diets and promote more active lifestyles.

In the families of the participants in this study, it was discovered a high consumption of processed foods and, among the most prominent were the daily consumption of tortillas and sugar and, from 1 to 4 times per week, pasta, crackers and sausages. In a study conducted in two communities in Yucatan, Mexico, something similar was observed because processed foods, such as corn tortillas, corn dough, edible oil and sugar, were consumed in a general and frequent manner ³¹. This shows the need to address the factors associated with obesity, as pointed out by López-Sobaler, et al ³⁰. The proposal of interventions through PLACE with parents to reduce and/or eradicate overweight or obesity in children, with a methodological design that nursing professionals should use continuously at the levels of prevention and health care, allow improving healthy lifestyles in the healthy or sick person. The PLACE in this project propose a series of primary interventions aimed at guiding, based on scientific evidence, healthy nutrition in schoolchildren. Arguments that are shared by several researchers, who mention that an inclusive food education is necessary, firstly, to perform a study and diagnosis of the social and food issues, followed by a methodological design to address and/or eradicate or improve them ³².

In the present study, among the basic socio-cultural conditioning factors, the lack of involvement of the children in the purchase and planning of meals was identified. This could be reversed through the intervention proposal of PLACE 1, by considering the design of a program to encourage it. González, et al., ³³ stated that it is necessary to develop programs to improve family habits, so that children acquire a more adequate perception of eating patterns and healthy habits, which will undoubtedly contribute to the current worldwide problem.

Moreover, among the basic conditioning factors of sociocultural type, a perception was obtained from parents who think that obese children are healthier than thin children, identifying that the perception of mothers in relation to the weight of their children has an impact on the development of obesity ³⁴, which allows the intake of much more food than recommended; thus resulting in overweight and obesity in children. For this reason, it is necessary to propose communication strategies between parents and the medical doctor.

The PLACE 3 proposal considered the importance of recognizing food as an element of cultural identity, which is why it is necessary to establish assertive communication between parents and health professionals to create culturally accepted strategies that benefit the nutritional status of children and at the same time rescue culinary eating habits that have been altered by globalization and migration ³⁵.

The feeding style that was reflected in the mothers in this study, due to their family life model, allowed the intake of modern processed foods and promoted the lack of physical activity; in their study Flores-Peña, et al. found that mothers of preschool children with overweight or obesity did not perceive that their children had a poor nutritional status, and that their maternal style of infant feeding was of low demand and responsibility ³⁶. Consequently, they urge to plan interventions that would help mothers to accept when their child is overweight or obese and that this is a disease, as well as to promote in them a maternal style of infant feeding with high demand and responsibility.

It was also identified as a basic conditioning factor, in terms of availability of resources, a low level of schooling in mothers, as well as overweight and obesity in children, a self-care requirement affected by the type of health deviation observed in the families, which predicts the relationship between this conditioning factor; in this regard Anaya-García, et al, ³⁷ in their research, referred that the parents' level of schooling, as well as the economic income, affect the type of food and its accessibility, which can contribute to the nutritional status of children.

In the present study, in addition to the identification of the consumption of modern processed foods, a life pattern of physical inactivity in families was identified and, therefore, the universal self-care requirement affected, called “imbalance between activity and rest”, which evidently contributes to the onset of obesity in children, together with other associated factors such as, for example, genetics, dietary patterns and intestinal microbiota ³⁸.

Through the implementation of the proposed PLACE and the development of a health program with families, other professionals can also be involved in the prevention and decrease of obesity in children, this program should primarily include the promotion of healthy eating habits and physical activity; in this context Pérez-Herrera, et al., ³⁸ expressed the need for the involvement of a multidisciplinary team in the treatment of obesity, such as the government, parents themselves, and health institutions.

In the present study, the diagnoses structured to propose the PLACEs such as ineffective role performance, ineffective health maintenance behaviors, and poor knowledge were similar to the diagnoses identified by Laguado ³⁹ to strengthen the growth and development of children by parents, and even the nursing interventions and outcomes reported were similar in this research, including parenting education and being parents, respectively.

This planning of nursing care was possible by making use of the NANDA, NIC and NOC taxonomies, tools that favor the professional work of nursing from the provision of care, health education, care and knowledge management, as argued by Ramírez, et al. ⁴⁰ by allowing the standardization of the language used in the execution of care, apply critical thinking, obtain security, and professional growth.

Finally, the worldwide COVID-19 pandemic appeared during the time this study was in progress, which caused a modification of the sampling for the participation of mothers in the nursing assessment; nevertheless, it is considered that with the mothers who participated, sufficient data were obtained for the preparation of the proposed PLACEs. The low participation of mothers was probably due to fear and not knowing how to act in the face of the pandemic, even though they were interested in participating when there was no COVID-19 pandemic ⁴¹.

Conclusions

Based on the results obtained in this study, it is possible to confirm the existence of several affected basic conditioning factors and self-care requirements in families, which have contributed to overweight and obesity in their children; these factors give the opportunity to conduct further research on the interventions applicable in the communities, since it is necessary to continuously address the health condition of overweight and obese children, in which parents, particularly the father, should be part of the diagnosis, planning, implementation and evaluation of the care.

In this study, the level of schooling of the mothers, their family income and their perception of their children's illness were key to understanding the poor nutritional health status of the families. Consequently, consumption of modern processed foods, maintenance of insufficient food intake and physical inactivity were identified. Parents, even without basic schooling, should and could be responsible for promoting sufficient and adequate food education to enable them to raise their children correctly, by participating enthusiastically and voluntarily in projects that can be implemented in schools, health institutions and governmental spaces, among others. This in turn will allow them, despite their family income, to plan the purchase of healthy foods they can afford and to value local and regional foods in their communities, as well as to be creators of these, which contribute to sufficient food maintenance in their homes. In addition, they will unlearn erroneous and inculcated knowledge throughout their lives, thus becoming aware of the importance of reducing and/or eradicating obesity in their families, primarily in children, who will transmit the knowledge to new generations.

Finally, it was seen that families do not always involve the participation of their children in the purchase and planning of meals, which is why children, despite obtaining basic knowledge of healthy eating from schools, are not always able to give their opinion, decide and participate in the preparation of meals. Therefore, it is essential to involve children in these household tasks, so that from an early age they can be responsible for what they eat, knowing how to identify healthy and unhealthy foods.

Therefore, the design of the proposed PLACE programs addressed to parents with overweight or obese children, arises from the need to participate with the people who are responsible for the children's health; also, because they are the ones with whom they live most of the time, from whom they acquire the first experiences and the motivation to modify or improve their eating and physical activity habits learned at home.

It is recommended that nursing professionals continue with the development of proposals for individualized and standardized nursing care plans that influence the prevention and nursing treatment of obesity in children, applicable to teachers, community leaders and other family members or individuals in constant interaction with children.

Conflicts of interest

The authors stated that there is no conflict of interest.

Funding

This study was self-funded.